College  of  ^Ijpfiicianfi;  aria  ^urgeonsf 


A  TREATISE 


MEDICAL  AND  SURGICAL  DISEASES 


mFAI^CY  AND  CHILDHOOD, 


BY 


J.   LEWIS   SMITH,  M.D 


CLINICAL    PROFESSOE    OF    DISEASES    OF    CHILDREX,   BELLEVUE    HOSPITAL    :\IEPIIAL    COLLEGE;    PHYSI- 
CIAN TO  CHAPJTY  HOSPITAL;    PHYSICIAN  TO  THE  N.   Y.    FnUNDLINi;    ASYLUM:    PHYSICIAN  TO  THE 
N.   Y.   INFANT  asylum;    CONSULTING  PHYSICIAN  TO  THE  N.  Y.  CITY   HOSPITAL;  CONSULTING 
PHYSICIAN  TO  THE  FRENCH  HOSPITAL;  CONSULTING  PHY"SICIAN  TO  THE  DEPARTMENT 
OF  children's  DISEASES,  BUREAU  FOR  THE  RELIEF  OF  THE  OUT-DOOR  POOR, 
BELLEVUE;    CONSULTING  PHYSICIAN    TO  THE  NURSERY'   AND  CHILD'S 
HOSPITAL,    COUNTRY    BRANCH;    CONSULTING.  PHYSICIAN    TO 
THE  infant's    hospital,   RANDALL'S    ISLAND. 


EIGHTH  EDITION,  THOROUGHLY  REVISED  AND  GREATLY  ENLARGED. 


WITH  TWO  HUNDRED  AND  SEVENTY-THREE  ILLUSTRATIONS 
AND   FOUR    PLATES. 


LEA   BROTHERS   &   CO., 

NEW  YORK  AND  PHILADELPHIA. 

1896. 


Entered  according  to  Act  of  Congress  in  the  year  1896,  hy 

LEA  BROTHERS  &  CO., 

in  the  Office  ol'  the  Librarian  of  Congress,  at  Washington.    All  rights  reserved. 


WESTCOTT    &    THOMSON,  PRESS    OF 

ELECTROTYPERS.     PHiLADA.  WILLIAM  J.    DORNAN,    PHILADA. 


Zo  tbe  /IDemor^ 

OK  XIY  SOX=irsI=LAAV, 


THE   LATE   FREDERIC   M.  WARXER,   M.  D., 


WHO  WAS   A   CO-LABOEER   IX   ITS   PREPARATION, 

THIS    WORK 

IS 

AFFECTIONATELY  DEDICATED. 


Digitized  by  tine  Internet  Archive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/treatiseonmedicaOOsmit 


PREFACE. 


Such  advances  have  recently  been  made  in  our  knowledge  of  the 
etiologv,  pathology,  and  therapeutic  requirements  of  the  diseases  of 
children,  that  in  the  preparation  of  the  eighth  edition  the  rewriting 
of  a  large  part  of  the  book,  with  the  addition  of  new  chapters,  has 
been  necessary.  Hence  an  increase  in  the  number  of  pages  was 
unavoidable,  although  the  material  has  been  condensed  so  far  as  was 
compatible  yvith.  clearness  of  description. 

Fortunately,  Prof.  Stephen  Smith,  whose  large  experience  in  the 
surgical  wards  of  New  York  hospitals  renders  him  eminently  iitted 
for  the  task,  has  added  to  the  text  many  pages  descriptive  of  the  sur- 
gical diseases  of  children.  His  reputation  as  a  surgeon  and  writer 
is  sufficient  to  give  the  impress  of  authority,  and  the  certainty  of 
clearness  and  eifectiveness,  to  whatever  emanates  from  his  pen. 

The  dedication  to  Dr.  Frederic  M.  Warner  becomes  the  more  ap- 
propriate in  view  of  his  lamented  and  untimely  death.  His  large 
clinical  experience,  careful  and  accurate  study  of  symptoms,  and  judi- 
cious selection  of  remedies  especially  fitted  him  for  the  preparation  of 
the  chapters  assigned  to  him,  which  he  was  unable  to  finish.  The 
proofs  of  what  he  had  written  arrived  as  he  was  passing  into  the 
fatal  coma  of  typhoid. 

The  author  o^ratefullv  acknowledo-es  the  assistance  rendered  bv  Dr. 

Joseph  O.  Dwyer,  physician  to  St.  Vincent's  Hospital  and  the  Xew 

York   Foundling  Asylum,  in  preparing  the   Section  on   Intubation ; 

also  the  assistance  of  Dr.  A.  E..  Robinson,  Professor  of  Dermatology 

in  the  Xew  York  Polyclinic,  whose  illustrations,  generously  loaned, 

and  his  contributions  to  the  text,  have  greatly  increased  the  value  of 

the  Section  on  Skin  Diseases. 

J.  LEWIS  SMITH,  M.  D. 

64  West  56th  Steeet,  New  York  City. 


CONTENTS. 


PART  I. 
INFANCY  AND  CHILDHOOD. 


CHAPTEE  I. 

Their  Anatomy  and  Physiology ^'^ 

CHAPTER  II. 
Care  of  the  Mother  in  Pregnancy -IS 

CHAPTER  III. 

Mortality  of  Early  Life  :   Its  Cause  and  Prevention 22 

CHAPTER  IV. 

Weight,  Growth,  Temperature,  Pulse,  Respiration 26 

Wet-nursing :  its  Advantages  and  Hindrances ;  Physical  Conditions  rendering  it 
Impropei^— Colostrum— Human  Milk-Modification  of  Milk  in  Consequence 
of  the  Diet— Modification  of  Milk  from  its  Retention  in  the  Breast— Modifica- 
tion of  Milk  by  Age  and  by  Mental  Impressions— Modification  of  Milk  by  the 
Cataraenial  Function,  Pregnancy,  and  other  Causes-Eflfect  of  Medicine  on  the 
Mother's  Milk— Difierences  in  Women  as  regards  Quantity  and  Quality  of 
Milk— Rules  in  regard  to  Lactation. 

CHAPTER  V. 

42- 
Selection  of  a  Wet-nurse 

CHAPTER  VI. 
Course  of  Wet-nursing— Weaning '^^■ 

CHAPTER  VII. 

Quantity  of  Food  Required  in  Infancy  and  Childhood 47 

CHAPTER  VIII. 

53 
Artificial  Feeding 

CHAPTER  IX. 
Bathing,  Clothing,  Sleep,  Exercise 6o 


vi  CONTENTS. 

CHAPTER  X. 

PAGE 

Diagnosis  of  Infantile  Feeding ^0 

General  Observations— Features ;  External  Appearance  of  the  Head,  Trunk, 
and  Litnbs  in  Disease— Attitude— Movements— The  Voice— Eespiratory  Sys- 
tem—Circulatory System — Animal  Heat — Digestive  System — Nervous  System. 

CHAPTER  XI. 
Therapeutics 80 


PART  II. 
DISEASES   OF   THE   NEWLY-BOEN. 


CHAPTER  I. 

Malformations 82 

Acrania — Meningocele,  Encephalocele,  Hydrencephalocele — Spina  Bifida — 
Congenital  Abnormalities  in  the  Circulatory  System — Cyanosis — Caput  Succe- 
daneum — Cephalhfematoma. 

CHAPTER  II. 

Local  Diseases 101 

Hsematoma  of  the  Sterno-cleido-mastoid  Muscle — Mastitis — Conjunctivitis — 
Ophthalmia  Neonatorum — Umbilical  Vegetations — Umbilical  Hemorrhage — 
Icterus — Septicaemia  of  the  New-born— Thrush. 

CHAPTER  III. 

Diarriicea,  Constipation,  and  Tetanus  of  the  New-born 128 

Diarrhoea  of  the  Newly-born — Constipation  of  the  Newly-born — Tetanus  Neo- 
natorum— Sclerema  Neonatorum — CEdema  Neonatorum — Pemphigus  Neona- 
torum— Osteogenesis  Imperfecta. 


PAET  III. 
CONSTITUTIONAL   DISEASES. 


SECTION  I. 
DIATHETIC   DISEASES. 


CHAPTER  I. 
Rachitis 156 


CONTENTS.  vii 

CHAPTER  II. 

PAGE 
vSCEOFTJLA 186 

CHAPTER  III. 
Tuberculosis .    .    202 

CHAPTER  IV. 
Syphilis , 230 

SECTION  II. 
ERUPTIVE  FEVERS. 

CHAPTER  I. 
Measles 242 

CHAPTER  II. 
ScAELET  Fever 250 

CHAPTER  III. 
Rotheln 298 

CHAPTER  IV. 
Variola — Varioloid 306 

CHAPTER  V. 
Vaccinia  . 316 

CHAPTER  VI. 
Varicella 326 

CHAPTER  VII. 
Diphtheria ,    328 

CHAPTER  VIII. 
Pertussis 381 

CHAPTER  IX. 
Mumps 395 

SECTION   III. 
OTHER  GENERAL  DISEASES. 

CHAPTER  I. 
Intermittent  Fever 399 


viii  CONTENTIS. 

CHAPTER  II. 

PAGE 

Remittent  Fever •   •    ^^^ 

CHAPTER  III. 
Typhoid  Fever ^^'^ 

CHAPTER  IV. 
Cerebro-spinal  Fever 421 

CHAPTER  V. 
Acute  Rheumatism 455 

CHAPTER  VI. 
Erysipelas 463 


SECTION  IV. 
MALFORMATIONS  AND  DEFORMITIES. 


CHAPTER  I. 

The  Digestive  Organs 476 

Lips  and  Palate— The  Tongue— The  Rectum — The  Anus. 

CHAPTER  II. 
The  Urinary  Bladder 489 

CHAPTER  III. 

The  Extremities 490 

The  Upper  Extremities— The  Knee— The  Leg— The  Feet. 


PART  lY. 

SECTION   I. 
DISEASES  OF  THE  BLOOD. 

CHAPTER  I. 

Mel^na  Neonatorum 504 


CONTENTS.  ix 

CHAPTEE  11. 

PAGE 

Simple  or  Secondary  An-emia 507 

CHAPTEE  III. 

Primary  Anemia 511 

LeukEemia  (Leucocythamia) — Pseudo-leukaemia  (Lymphatic  Anaemia;  Hodg- 
kin's  Disease) — Splenic  Ansemia — Pernicious  Anaemia  (Anaemic  Fever,  Idio- 
pathic Anaemia) — Haemophilia — Purpura — Scorbutus  (Scurvy). 


PAET   Y. 
LOCAL  DISEASES. 


SECTION  I. 
INJURIES  AND  DISEASES  OF  THE  OSSEOUS  SYSTEM. 


CHAPTEE  I. 

Caries  of  the  Vertebra 519 

CHAPTEE  II. 
Lateral,  Curvature  of  the  Spine 525 

CHAPTEE  III. 
Injuries  of  Bones 530 

Injuries  of  the  Skull — Injuries  of  Long  Bones. 

CHAPTEE  IV. 
Diseases  op  Bone 538 

CHAPTEE  V. 

Diseases  of  the  Joints 552 

The  Shoulder-joint— The  Elbow-joint— The  Wrist-joint— The  Hip-joint— The 
Knee-joint — The  Ankle-joint — The  Tarsus— The  Foot. 


SECTION  II. 
DISEASES  OF  THE  CEREBRO-SPINAL  SYSTEM. 


CHAPTEE  I. 
Congestion  of  the  Brain 578 


X  CONTENTS. 

CHAPTER  II. 

PAGE 

Intracranial  Hemorrhage  (Meningeal  Hemorrhage,  Cerebral  Hem- 
orrhage)   '^^^ 

CHAPTER  III. 

Congenital  Hydrocephalus 589 

CHAPTER  IV. 

Acquired  Hydrocephalus 595 

CHAPTER  V. 
Meningitis  (Tubercular  and  Non-Tubercular) 596 

CHAPTER  VI. 
Spurious  Hydrocephalus 611 

CHAPTER  VII. 
Eclampsia 614 

CHAPTER  VIII. 
Epilepsy 622 

CHAPTER  IX. 
Internal  Convulsions  (Spasm  of  the  Glottis;  Laryngismus  Stridulus)    634 

CHAPTER  X. 
Tetany 640 

CHAPTER  XL 
Chorea 650 

CHAPTER  XIL 
Paralysis 664 

CHAPTER  XIII. 
Poliomyelitis  Acute  Anterior  ...-....' 664 

CHAPTER  XIV. 
Facial  Paralysis 671 

CHAPTER  XV. 
Psecdo-Hypertrophic  Paralysis 672 

CHAPTER  XVL 
Diseases  of  the  Spinal  Cord  and  its  Coverings 676 

CHAPTER  XVII. 

Congestion  of  the  Spinal  Cord  axd  its  Membranes 677 


CONTENTS.  XI 

SECTION   III. 
DISEASES  OF  THE  DIGESTIVE  APPARATUS. 


CHAPTER  I. 

PAGE 

Simple  Stomatitis,  Ulcerous  Stomatitis,  Follicular  Stomatitis   ....    680 

CHAPTER  II. 

Gangeene  of  the  Mouth 684 

Efflorescence,  Furring,  and  Eruptions  upon  the  Tongue. 

CHAPTER  III. 

Dentition 691 

Ranula — Alveola — Tonsil. 

CHAPTER  IV. 
Catarrhal  Pharyngitis,  Peripharyngeal  Abscess,  (Esophagitis  ....    701 

CHAPTER  V. 

Indigestion,  Congestion  of  Stomach,  Gastritis,  Follicular  Gastritis, 

Diphtheritic  Gastritis 714 

CHAPTER  VI. 
Gastro-intestinal  Bacteria 723 

CHAPTER  VII. 
Simple  Diarrhcea 726 

CHAPTER  VIII. 

Intestinal  Catarrh  of  Infancy  (Entero-Colitis) 730 

Cholera  Infantum,  or  Choleriform  Diarrhoea. 

CHAPTER  IX. 
Enteritis  and  Colitis  in  Childhood 752 

CHAPTER  X. 
Constipation 754 

CHAPTER  XL 
Intestinal  Worms 765 

CHAPTER  XII. 
Intussusception  .... 779 

CHAPTER  XIII. 
Appendicitis  and  Peritonitis 799 


xii  .  CONTENTS. 

CHAPTER  XIV. 

PAGE 

Hernia  of  the  Abdomen 809 

SECTION  IV. 
DISEASES  OF  THE  RESPIRATOEY  SYSTEM. 

CHAPTER  I. 
CORYZA 818 

CHAPTER  11. 
Laryngitis •    ■ 820 

CHAPTER  HI. 
Diseases  of  the  Larynx 828 

CHAPTER  IV. 
PsEUDO-iiEMBRANors  Croup  (True  Croup) 831 

CHAPTER  V. 
IXTrBATION 839 

CHAPTER  VL 
Tracheotomy 848 

CHAPTER  VIL 
Bronchitis 851 

CHAPTER  VIII. 

Atelectasis 861 

CHAPTER  IX. 
Pneumonia 864 

CHAPTER  X. 
Pleurisy 876 

SECTION   Y. 
DISEASES  OF  THE  CIRCULATOEY  SYSTEM. 

CHAPTER  I. 

Diseases  of  the  Heart 912 

Functional  Disorders. 

CHAPTER  IL 
Pericarditis 9]3 


CONTENTS.  xiu 

CHAPTER  III. 

PAGE 

Myocarditis 916 

CHAPTER  IV. 
Endocarditis 917 

CHAPTER  V. 

Ulcerative  Endocarditis 919 

CHAPTER  VI. 
Chronic  Endocarditis    .   .    .■ 920 

CHAPTER  VII. 
Diseases  of  the  Vessels 923 


SECTION   VI. 
DISEASES  OF  THE  GENITO-UEINAEY  ORGANS. 

Calculi ;  Dysuria  ;  Cryptorchia — Vulvitis — Preputial  Dilatation — The  Kidneys — 
The  Urinary  Bladder— The  Urethra— The  Penis— The  Scrotum— The  Testicles    927 


SECTION  VII. 

DISEASES   OF   THE  SKIN. 

Erythema — Urticaria — Prurigo— Eczema — The  Pathogenic  Effects  of  Microbes — 
Parasites  of  the  Skin 949 


THE 


DISEASES  OF  CHILDREN. 


PART  I. 

INFANCY    AND    CHILDHOOD. 


CHAPTER    I. 

THEIE  ANATOMY  AND  PHYSIOLOGY. 

Infancy  and  cliildhood  are,  in  certain  respects,  tte  most  important  and 
interesting  periods  of  life.  To  the  physiologist  they  are  especially  interest- 
ing, because  they  are  the  periods  of  development  and  of  greatest  functional 
activity ;  to  the  pathologist,  because  in  them  many  diseases  occur  which  are 
rarely  or  never  observed  in  the  other  periods,  or  which  present  in  these  periods 
peculiar  features ;  to  the  physician  and  vital  statistician,  because  in  them 
the  greatest  amount  of  sickness  and  the  largest  number  of  deaths  occur. 

Infancy  extends  from  birth  to  the  age  of  two  and  a  half  years,  or 
till  the  completion  of  the  first  dentition.  In  infancy  the  organs  are  delicately 
organized,  containing  a  large  proportion  of  water,  and  hence  are  easily 
injured.  In  this  period  the  brain  is  rapidly  developed — more  so  than  any 
other  organ ;  animal  matter  predominates  in  the  bones ;  the  arteries  are  rel- 
atively large,  the  muscles  small ;  the  superficial  veins  are  small.  Fat  is 
absent  from  the  interior  of  the  body,  but  abundant,  in  well-nourished  infants, 
underneath  the  integument.  The  skin  is  delicate,  and  its  temperature  not 
much  below  that  of  the  blood.  At  birth  it  has  a  reddish  hue  and  is  covered 
with  soft,  fine  hairs  (lanugo).  The  reddish  hue  gradually  fades  into  the 
healthy  tint  of  infancy,  and  the  hairs  fall  out.  In  the  first  two  months  the 
sweat-glands  have  little  functional  activity,  sensible  perspiration  being  quite 
rare.  Subsequently,  perspiration  is  freer,  and  in  certain  diseased  states 
(rachitis,  etc.)  is  abundant.  The  sebaceous  glands  in  the  first  half  of  infancy 
are  active,  particularly  upon  the  scalp,  producing  often  a  pale-yellow  incrusta- 
tion consisting  of  sebaceous  matter  and  epidermic  cells. 

The  secretions  from  the  mucous  surfaces  commence  at  an  early  period. 
At  birth  the  surface  of  the  digestive  tube  is  covered  with  more  or  less 
mucus,  often  in  considerable  quantity.  The  meconium  is  not  considered, 
as  formerly,  to  be  a  product  of  intestinal  secretion.  It  consists  of  flat 
epithelial  cells,  fine  hairs,  oil-globules,  crystals  of  cholesterin,  and  brownish 
or  yellowish  masses  of  coloring  matter,  probably  from  the  liver.  It  is  sup- 
2  17 


18  INFANCY  AND   CHILDHOOD. 

posed  that,  with  the  exception  of  the  coloring  matter,  the  meconium  is 
derived  mainly  from  the  amniotic  fluid  which  the  foetus  has  swallowed. 

The  most  wonderful  change  occurring  in  the  system  at  birth,  through 
the  exigencies  of  the  new  life,  is  that  in  the  circulation.  The  flow  of  blood 
bein"-  interrupted,  thrombi  form  in  the  umbilical  vein  and  arteries,  and  in 
the  ductus  arteriosus  and  ductus  venosus.  and  these  vessels  gradually  atro- 
phy, becoming  Anally  shrivelled  but  permanent  cords.  I  have  many  times 
at  autopsies  removed  the  plug  from  the  ductus  arteriosus  when  death  had 
occurred  as  late  as  the  third  week.  The  foramen  ovale  closes  slowly.  I 
have  ordinarily  found  it  open  till  near  the  end  of  the  first  half  year,  but 
the  valve  covers  fully  the  aperture,  so  that  there  is  no  detriment  to  the  cir- 
culation. Both  the  pulse  and  respiration  are  more  frequent  during  infancy 
than  childhood,  and  are  more  accelerated  by  moral  and  physical  causes. 

The  stomach  has  a  smaller  relative  size  and  emesis  is  more  readily  caused 
than  in  the  adult.  The  liver  is  large,  occupying  at  birth  nearly  half  of  the 
abdominal  cavity,  but  its  proportionate  size  becomes  less  in  subsequent 
months,  from  a  less  rapid  growth.  The  appetite  is  good  and  digestion 
active,  so  that  hunger,  when  appeased,  soon  returns.  The  thymus  gland, 
at  birth  about  the  size  of  an  unexpanded  lung,  slowly  atrophies,  but  it  does 
not  totally  disappear  till  after  infancy. 

The  kidneys,  distinctly  lobulated  at  birth,  gradually  change  their  form, 
so  as  to  present  in  the  last  part  of  infancy  nearly  the  shape  of  the  organ  in 
the  adult.  The  renal  secretion  commences  early,  even  before  birth.  The 
kidneys  seldom  undergo  degenerative  changes  as  in  the  adult,  but  they  are 
liable  to  congestions  and  inflammations.  During  the  first  month,  and  espe- 
cially the  first  fortnight,  crystals  of  uric  acid  and  the  urates  are  often  found 
in  the  urine  in  a  state  of  apparent  health,  causing  more  or  less  fretfulness  in 
their  elimination,  staining  the  diaper,  and  not  infrequently  being  arrested  in 
the  tubules  of  the  pyramids,  where  they  can  be  seen  as  pink-colored  spots  or 
lines  (uric-acid  infarction).  These  deposits  of  uric  acid  and  the  urates  may 
even  occur  in  the  foetus,  producing  obstruction  and  inflammation  of  the  renal 
tubes.  Congenital  cystic  degeneration  of  the  kidneys  is,  in  the  opinion  of 
Virchow,  due  to  them.  In  early  infancy  the  senses  are  imperfectly  devel- 
oped, the  eyes  being  attracted  only  by  blight  objects,  and  the  sense  of  hear- 
ing afi'ected  only  by  loud  noises.  Sleep  is  the  normal  state  in  the  first  weeks 
of  life  :  as  the  age  of  the  infant  increases,  less  and  less  sleep  is  required ;  but 
the  oldest  infants  need  more  than  children  and  several  hours  more  than  adults. 

The  new-born  infant  is  apparently  destitute  of  mental  faculties.  It  seeks 
the  breast  by  instinct,  and  it  exhibits  no  perception  or  refiection.  The  loud 
cries  with  which  it  commences  its  existence  are  not  from  anger  or  sufi"ering  ; 
they  appear  to  be  normal,  like  the  act  of  nursing,  and  providentially  designed 
to  expand  the  lungs.  It  is  not  till  the  close  or  near  the  close  of  the  first 
month  that  the  gray  substance  of  the  brain  begins  to  appear — the  probable 
seat  of  the  mind  and  the  source  of  all  mental  phenomena.  Perception 
and  curiosity  are  early  manifested.  The  infant,  as  Edmund  Burke  has 
remarked,  is  constantly  seeking  new  objects  for  its  amusement,  rejecting  old 
playthings  for  such  as  possess  more  novelty.  Reflection,  a  higher  faculty 
of  the  mind,  appears  at  a  later  period.  The  mind  and  the  bodily  organs  in 
infancy  are,  in  a  high  degree,  impressionable.  Anger  is  excited  by  trivial 
causes,  but  is  easily  appeased,  and  the  various  functions  in  the  system  are 
disturbed  by  agencies  which  in  youth  or  manhood  would  have  no  appreciable 
effect. 

Childhood  extends  from  infancy  to  the  age  of  fifteen  years  or  puberty. 
It  is  a  period  of  great  physical  activity  and  of  rapid  growth.  The  functions 
of  the  various  organs  are  performed  with  more  moderation  than  in  infancy, 


CABE  OF  THE  MOTHER  IN  PREGNANCY.  19 

and  are  less  frequently  deranged.  The  volume  of  the  brain  continues  to 
increase  rapidly,  and  it  becomes  firmer  than  in  infancy.  It  is  estimated  that 
by  the  seventh  year  the  weight  of  this  organ  has  doubled.  The  mind  now 
exerts  a  controlling  influence  over  the  actions  of  the  individual.  The  digestive 
organs  have  changed,  so  that  solid  food  is  required.  Most  of  the  grandular 
organs  are  less  active  than  in  the  greater  part  of  infancy.  The  pulse  and 
respiration  gradually  become  less  frequent  as  the  child  advances  in  age. 


CHAPTER    II. 

CAKE  OF  THE  MOTHER  IN  PEEGNANCY. 

The  frequency  of  miscarriages  and  stillbirths,  and  the  large  number  of 
ill-formed  and  puny  infants  born  to  a  precarious  and  short  existence,  render 
imperative,  on  the  part  of  the  mother,  a  strict  observance  of  the  laws  of 
health,  and  an  avoidance  of  all  exciting  or  perturbating  influences  during 
the  time  when  the  foetus  is  being  developed.  The  diet  should  be  plain  and 
easily  digested,  but  nutritious.  There  is  often  a  craving  in  pregnancy  for 
unusual  articles  of  food.  These  may  sometimes  be  allowed  within  certain 
limits,  provided  that  they  are  such  as  do  not  derange  the  stomach.  Meats 
and  animal  broths,  together  with  vegetables  and  farinaceous  food,  should  con- 
stitute the  ordinary  diet  and  should  be  taken  at  regular  intervals. 

Daily  exercise,  never  violent,  but  moderate  and  gentle,  is  requisite.  No 
exercise  is  better,  none  safer  and  more  likely  to  contribute  to  cheerfulness 
and  healthy  functional  activity  of  the  organs,  than  the  ordinary  household 
duties.  Lifting  heavy  weights  or  work  which,  like  washing  and  ironing, 
causes  great  and  continued  action  of  the  abdominal  muscles,  should  be 
avoided.  Such  exercise  is  highly  injurious,  and  it  may  produce  premature 
labor.  Exercise  in  the  open  air  on  foot  or  by  an  easy  conveyance  conduces 
to  the  health  of  the  mother  and  the  growth  and  development  of  the  foetus. 
On  the  other  hand,  rapid  riding  over  rough  roads  is  one  of  the  most  dangerous 
modes  of  exercise.  It  has  been  known  to  destroy  the  foetus,  which  up  to 
that  time  had  been  apparently  vigorous.  When  such  a  result  occurs  there 
is  probably  more  or  less  detachment  of  the  placenta. 

It  being  a  matter  of  the  utmost  importance  that  the  health  of  the  mother 
should  continue  good  during  gestation,  any  disease  which  she  may  have  in 
this  period,  and  which  affects  her  nutrition  or  the  character  of  her  blood, 
should  be  promptly  cured  if  practicable,  and  with  the  least  possible  reduction 
of  the  vital  powers.  Intermittent  fever,  occurring  during  gestation,  should 
never  be  allowed  to  continue.  It  seriously  retards  foetal  development  and 
may  produce  miscarriage.  Unless  it  be  controlled  by  proper  measures,  the 
offspring,  though  born  at  term,  is  puny  and  emaciated.  Syphilis  in  the  preg- 
nant woman  also  requires  treatment.  This  disease,  readily  transmitted  from 
the  mother  to  the  foetus  through  the  ovum  or  the  uterine  circulation,  may  be 
eradicated  by  antisyphilitic  treatment  of  the  mother,  or  at  least  so  modified 
that  the  infant  is  born  vigorous  and  healthy. 

The  pregnant  woman  should  avoid  all  causes  of  undue  mental  excite- 
ment. This  is  almost  as  necessary  as  the  avoidance  of  great  physical  exer- 
tion. There  is,  during  pregnancy,  unusual  susceptibility  to  mental  impres- 
sions, and  this  should  be  borne  in  mind  not  only  by  the  woman  herself,  but 
by  those  who  associate  with  her. 


20  MFANCY  AND  CHILDHOOD. 

Strong  emotions,  whether  of  joy,  sorrow,  or  anger,  affect  primarily  the 
nervous  system,  but  indirectly  most  of  the  organs  of  the  body.  Observa- 
tions have  long  established  the  fact  that  such  emotions  influence  the  state 
and  functions  not  only  of  the  digestive  and  glandular,  but  also  of  the  mus- 
cular, organs,  as  the  heart  and  uterus.  Physicians  are  familiar  with  cases 
in  which  vivid  mental  impressions  produced  uterine  contractions,  and  even 
miscarriage,  or  have  disturbed  the  catamenial  function.  Therefore,  the  asso- 
ciations and  care.s  of  pregnant  women  should  be  such  as  conduce  to  cheerful- 
ness and  equanimity. 

It  is  the  popular  belief  and  the  belief  of  many  physicians  that  vivid 
mental  impressions  sometimes  have  a  direct  effect  on  the  development  of 
the  ftetus.  Many  cases  are  on  record  in  which  infants  were  born  with  marks 
or  deformities  corresponding  in  character  with  objects  which  had  been  seen 
and  had  made  a  strong  impression  on  the  maternal  mind  at  some  period  of 
gestation.  Whether  the  mind  of  the  mother  exerts  a  controlling  influence 
on  the  form  and  color  of  the  foetus  is  a  subject  of  great  interest  to  the  psy- 
chologist as  well  as  the  physiologist  and  physician,  since  it  involves  no  less  a 
question  than  the  power  and  scope  of  the  human  mind.  Violent  emotions, 
it  is  admitted,  may  affect  directly  most  of  the  important  organs  in  the  system. 
They  may  derange  the  liver,  causing  jaundice,  accelerate,  or  for  a  moment 
suspeiid,  the  heart's  action,  stimulate  the  kidneys,  causing  diuresis,  or  even 
the  intestinal  follicles,  causing  watery  evacuations.  But  with  all  these  organs 
the  brain  is  connected  by  nerves  which  anatomy  reveals.  On  the  other  hand, 
the  mother  and  f(jetus  have  a  distinct  existence  as  regards  their  nervous  sys- 
tems, and  even  their  blood.  Still,  the  multitude  of  facts  which  have  accumu- 
lated justify  the  belief  that  deformity  or  other  abnormal  development  of  the 
fo'tus  is,  at  times,  due  to  the  emotions  of  the  mother.  Some  of  the  cases 
related  by  Dr.  Whitehead  in  his  work  on  hereditary  diseases  are  very  strik- 
ing and  difficult  to  explain  on  the  ground  of  coincidence.  I  have  met  the 
following  cases :  An  Irish  woman  of  strong  emotions  and  superstitions  was 
passing  along  a  street  in  the  first  months  of  her  gestation,  when  she  was 
accosted  by  a  beggar,  who  raised  her  hand,  destitute  of  thumb  and  fingers, 
and  in  ''  (rod's  name  "  asked  for  alms.  The  woman  passed  on,  but  reflecting 
in  whose  name  money  was  asked,  felt  that  she  had  committed  a  great  sin  in 
refusing  assistance.  She  returned  to  the  place  where  she  had  met  the  beggar, 
and  on  different  days,  but  never  afterward  saw  her.  Harassed  by  the  thought 
of  her  imaginary  sin,  so  that  for  weeks,  according  to  her  statement,  she  was 
made  wretched  by  it,  she  approached  her  confinement.  A  female  infant  was 
born,  otherwise  perfect,  but  lacking  the  fingers  and  thumb  of  one  hand.  The 
deformed  limb  was  on  the  same  side  as,  and  it  seemed  to  the  mother  to 
resemble  precisely,  that  of  the  beggar.  In  another  case  which  I  met  a  very 
similar  malformation  was  attributed  by  the  mother  of  the  child  to  an  accident 
occurring  to  a  near  relative  which  necessitated  amputation  during  the  time  of 
her  gestation.  I  examined  both  of  these  children  with  defective  limbs,  and 
have  no  doubt  of  the  truthfulness  of  the  parents.  In  May,  1868,  I  removed 
a  supernumerary  thumb  from  an  infant  whose  mother,  a  baker's  wife,  gave 
me  the  following  history:  No  one  of  the  family  and  no  ancestor,  to'her 
knowledge,  presented  this  deformity.  In  the  early  months  of  her  gestation 
she  sold  bread  from  the  counter,  and  nearly  every  day  a  child  with  double 
thumb  came  in  for  a  penny  roll,  presenting  the  penny  between  the  thumb  and 
the  finger.  After  the  third  month  she  left  the  bakery,  but  the  malformation 
was  so  impressed  upon  her  mind  that  she  was  not  surprised  to  see  it  repro- 
duced in  her  infant.    Mrs.  S ,  West  Fiftieth  street,  New  York,  when  in  the 

seventh  week  of  gestation,  saw  a  child  with  fingers  united,  so  that  they  resem- 
bled the  palm  of  the  hand  extended.     She  was  much  excited  at  the  appear- 


CABE  OF  THE  MOTHER  IN  PREGNANCY.  21 

ance,  and  clutched  tlie  window-sill  with  such  force  as  to  cause  abrasion  of 
the  fingers.  The  malformation  of  the  child  made  a  deep  and  lasting  impres- 
sion on  her  mind,  and  her  child,  born  at  term,  had  the  index,  middle,  and  ring 
fingers  of  the  left  hand  webbed  and  ending  with  the  first  phalanges,  while  the 

little   finger   was   normal.     Mrs.   D ,  Eighth  avenue,  New   York,   seven 

months  before  the  birth  of  her  child,  when  visiting  at  a  distance,  accident- 
ally broke  the  plate  of  a  full  set  of  upper  teeth.  The  line  of  fracture  was 
antero-posterior  and  through  the  centre  of  the  plate.  Being  away  from  home, 
she  was  much  annoyed  by  the  accident,  and  retained  the  fragments  of  the 
plate  in  situ  by  pressure  with  the  tongue.  As  she  could  not  open  her  mouth 
without  the  plate  falling  out,  except  it  was  retained  by  pressure  with  the  tongue, 
her  mind  was  dwelling  almost  constantly  on  the  accident  during  the  few  days 
of  her  visit.  Her  boy,  born  seven  months  subsequently,  had  a  hare-lip  and 
cleft  palate.  The  mother  stated  that  the  deficiency  in  the  lip  and  palate  cor- 
responded precisely  to  the  location  of  the  fracture  in  the  plate.  Dr.  G-reenley 
relates  five  similar  cases  in  which  infants  at  birth  presented  marks  or  arrested 
development  corresponding  in  appearance  with  objects  which  produced  strong 
mental  impressions  in  the  mothers  (^Amer.  Prac.  and  News,  Oct.  29,  1887). 

Dr.  William  A.  Hammond  of  Washington,  in  an  interesting  paper  on  the 
"Influence  of  the  Maternal  Mind,"  etc.  \Quarterly  Journal  of  Physiological 
Medicine,  January,  1868),  says:  "  The  chances  of  these  instances,  and  others 
which  I  have  mentioned,  being  due  to  coincidence  are  infinitesimally  small, 
and  though  I  am  careful  not  to  reason  upon  the  principle  of  POST  HOC,  ERGO 
PROPTER  HOC,  I  cannot,  nor  do  I  think  any  other  person  can,  no  matter  how 
logical  may  be  his  mind,  reason  fairly  against  the  connection  of  cause  and 
eff'ect  in  such  cases.  The  correctness  of  the  facts  can  only  be  questioned ; 
if  these  be  accepted,  the  probabilities  are  thoiisands  of  millions  to  one  that 
the  relation  between  the  phenomena  is  direct."  Professor  Dalton  also  says 
(^Huvian  Physiology') :  "  There  is  now  little  room  for  doubt  that  various  deform- 
ities and  deficiencies  of  the  foetus,  conformably  to  the  popular  belief,  do  really 
originate  in  certain  cases  from  nervous  impressions,  such  as  disgust,  fear,  or 
anger,  experienced  by  the  mother."  The  observations  on  which  this  belief  is 
based  relate  both  to  man  and  the  lower  animals.  A  very  strong  argument  in 
its  support  is,  as  Professor  Hammond  remarks,  the  popular  opinion,  which 
dates  back  to  the  time  of  Jacob  (Genesis  xxx.).  An  almost  universal  senti- 
ment, running  through  centuries,  is  rarely  wholly  fallacious.  It  has  some 
truth  for  its  foundation,  especially  when,  as  in  this  instance  the  subject  is 
one  of  observation. 

If  maternal  emotions  affect  the  development  of  the  exterior  of  the  foetus, 
as  observations  show  and  physiologists  admit,  the  presumption  is  strong  that 
they  may  affect  also  the  proper  development  and  adjustment  of  the  parts  of 
the  brain,  an  organ  so  complex  and  delicate,  and  may  therefore  give  rise  to 
idiocy.  Dr.  Seguin  (Idiocy  and  its  Treatment,  etc.,  New  York,  1866)  thus 
remarks  on  this  point :  "  Impressions  will  sometimes  reach  the  foetus  in  its 
recess,  cut  off  its  legs  or  arms  or  inflict  large  flesh  wounds  before  birth,  .... 
from  which  we  surmise  that  idiocy  holds  unknown  though  certain  relations 
to  maternal  impressions  as  modifications  to  placental  nutrition." 

In  volume  i.  of  the  Cyclopedia,  of  Diseases  of  Children  (Philadelphia, 
1889)  Dr.  W.  C.  Dabney  has  published  the  statistics,  of  90  cases  showing 
that  both  mental  and  bodily  defects  in  the  infant  sometimes  result  from 
vivid  mental  impressions  in  the  mother  during  the  early  months  of  her  ges- 
tation. These  cases  are  mostly  collated  from  recent  medical  literature,  and 
many  of  them  are  striking  instances  showing  the  effect  of  maternal  impres- 
sions in  causing  malformations  in  the  foetus,  not  only  in  the  human  race,  but 
also  in  quadrupeds.     Dr.  Dabney  also  relates  the  remarkable  statement  of 


22  INFANCY  AND  CHILDHOOD. 

Baron  Larrey.  that  92  enceinte  -women  who  had  experienced  extreme  mental 
and  physical  suffering  at  the  siege  of  Landau  in  1793  brought  forth  infants 
with  the  following  result :  born  dead,  16  ;  born  alive,  but  dying  in  ten  months, 
33 ;  born  idiotic,  8 ;  born  with  bones  ununited  or  in  a  fragmentary  state,  2. 

It  is  an  interesting  fact  that  abnormalities  of  structure  occurring  from 
whatever  cause  are  sometimes  propagated  to  descendants.  Dr.  Carpenter 
and  others  relate  instances  among  the  lower  animals,  and  similar  instances 
of  transmission  have  now  and  then  been  observed  in  the  human  race.  Thus, 
in  the  issue  of  Nature  for  March  7,  1878,  it  is  stated  on  the  authority  of  M. 
Leno-len,  a  physician  of  Arras,  that  a  certain  M.  Gamelon  in  the  last  century 
had  two  thumbs  on  each  hand  and  two  great  toes  on  each  foot :  this  peculi- 
aritv  did  not  appear  in  the  son,  but  it  reappeared  in  the  three  succeeding 
generations,  so  that  some  of  the  great-great-grandchildren  possessed  it  in  as 
marked  a  degree  as  their  ancestors. 

In  view  of  such  important  facts  the  duty  of  the  pregnant  woman  is  ren- 
dered the  more  imperative  to  avoid  the  presence  of  disagreeable  and  unsightly 
objects,  as  well  as  all  causes  of  excitement,  and  to  remove,  as  soon  as  possible, 
yivid  and  unpleasant  impressions  by  quiet  diversion  of  the  mind. 


CHAPTER   III. 

MOKTALITY  OF  EAELY   LIFE:    ITS   CAUSES  AND  PEEVEXTIOK 

Xo  fact  is  better  known  in  the  profession  than  that  the  first  years  of  life 
constitute  the  period  of  greatest  mortality. 

In  Ensland.  where  there  is  an  accurate  registration  of  births  and  deaths, 
statistics  show  fifteen  deaths  in  every  hundred  infants  in  the  first  year  of  life, 
and  between  four  and  five  deaths  in  the  first  month.  Statistics  on  the  Con- 
tinent correspond  with  those  in  England  as  regards  the  periods  of  greatest 
mortality.  Quetelet  says  :...."  There  die  during  the  first  month  after  birth 
four  times  as  many  children  as  during  the  second  month  after  birth,  and 
almost  as  many  as  during  the  entirety  of  the  two  years  that  follow  the  first 
year,  although  even  then  the  mortality  is  high.  The  tables  of  mortality 
prove,  in  fact,  that  one-tenth  of  children  born  die  before  the  first  month  has 
been  completed." 

In  this  country,  in  consequence  of  deficient  registration  of  births,  the  per- 
centage of  deaths  to  births  cannot  be  accurately  ascertained.  In  New  York 
City  53  per  cent,  of  the  total  number  of  deaths  occur  under  the  age  of  five 
years,  and  26  per  cent,  under  the  age  of  one  year.  According  to  the  census 
of  1865.  there  were  in  Xew  York  City  95,020  children  under  the  age  of  five 
years,  and  during  the  five  years  ending  with  1865,  49,000  children  five  years 
old  and  under  had  died.  Therefore,  according  to  these  statistics,  more  than 
one-third  of  all  the  infants  born  in  this  city  die  under  the  age  of  five  years. 
An  error,  however,  occurs  from  the  fact  that,  while  the  death-statistics  were 
complete,  it  is  known  that  there  were  more  children  in  the  city  than  were  em- 
braced in  the  census  returns.  Still,  it  may,  I  think,  be  safely  stated  that  one- 
fifth  of  the  children  born  in  New  York  City  die  before  the  age  of  five  years. 

In  less-crowded  cities  and  the  rural  districts  it  is  known  that  the  percent- 
age of  deaths  in  the  first  years  of  life  to  the  total  number  of  deaths  is  con- 
siderably less  than  in  New  York  City,  but  it  is  nevertheless  large. 

As  the  child  advances  toward  puberty  the  liability  to  sickness  and  death 


3I0ETALITY  OF  EARLY  LIFE.  23 

gradually  diminislies,  but  even  the  last  years  of  childhood  present  a  con- 
siderably larger  percentage  of  deaths  to  the  population  than  does  youth  or 
manhood. 

The  causes  of  this  great  mortality  of  infants  and  children,  and  the  means 
of  diminishing  it.  deserve  careful  consideration. 

Some  of  the  causes  which  conspire  to  produce  it  are  to  a  considerable 
extent  unavoidable.  Such  are  congenital  vices  of  formation  of  internal 
organs.  Many  of  the  internal  malformations  necessarily  occasion  an  early 
death.  Cases  of  anencephalus,  most  cases  of  congenital  hydrocephalus,  of 
spina  bifida,  of  cyanosis,  are  fatal  before  the  close  of  infancy.  These  defects 
of  formation  we  cannot  detect  before  birth,  and  their  causes  are  often  obscure. 
Some  of  them  seem  to  result  from  inflammation,  believed  to  be,  occasionally, 
syphilitic,  developed  at  some  period  of  foetal  existence.  Other  internal  mal- 
formations are  attributable  to  perturbating  influences  operating  temporarily 
on  the  mother  during  gestation.  But  in  a  large  proportion  of  cases  we  can- 
not assign  the  cause.  Obviously,  only  partial  success  attends  our  efforts  as 
regards  prevention  in  these  cases,  and  almost  no  success  as  regards  the  use 
of  remedial  measures. 

Another  obvious  cause  of  the  great  mortality  of  early  life  is  natural  fee- 
bleness of  system,  especially  in  infancy.  The  younger  the  patient  prior  to 
the  middle  period  of  life,  the  sooner  are  the  vital  powers  exhausted  by  dis- 
ease. Hence  a  larger  proportion  of  infants  succumb  to  the  same  malady 
than  children,  and  a  larger  proportion  of  children  than  adults.  This  state- 
ment is  true  of  infancy  and  childhood  in  general.  It  is  a  law  in  nature,  and 
cannot  be  changed  by  art.  But  there  are  many  infants  born  with  hereditary 
disease  or  a  strong  predisposition  to  disease  through  a  fault  which  is,  in  a 
degree,  curable  in  the  system  of  one  or  both  parents  ;  as,  for  example,  the 
syphilitic,  scrofulous,  or  tubercular  diathesis.  Parents  seriously  afi"ected  by 
such  diseases  cannot,  without  corrective  treatment,  have  healthy  ofi'spring. 
Their  children  are  among  the  first  to  droop  and  die,  either  directly  from  the 
inherited  disease  or  from  feebleness  of  con=^titution  which  such  disease  entails, 
and  which  renders  them  an  easy  prey  to  other  diseases.  The  duty  of  the 
physician  as  regards  such  parents  is  obvious.  He  may,  by  therapeutic  and 
hygienic  measures,  secure  a  more  healthy  progeny,  and  so  far  as  he  can  do 
this  he  aids  in  diminishing  the  infantile  mortality.  He  may  sometimes,  by 
timely  measures  directed  to  the  infant,  establish  a  better  state  of  health. 

The  subject  of  hereditary  disease  is  one  of  great  interest  and  importance, 
especially  as  regards  the  city  population.  Inherited  aflFections  are  less  com- 
mon in  the  country,  but  in  the  city  they  contribute  largely  to  the  number  of 
deaths  in  early  life. 

Another  important  cause  of  the  great  mortality  of  children  is  the  fact 
that  they  are  peculiarly  liable  to  certain  severe  and  fatal  maladies.  I  allude 
particularly  to  the  acute  communicable  diseases,  which,  as  a  rule,  occur  but 
once,  and  then  in  childhood.  Some  of  them,  as  scarlet  fever,  greatly  increase 
the  number  of  deaths.  They  extend  and  become  epidemic  through  the  inter- 
course of  children.  We  are  constantly  witnessing  in  Xew  York  the  spread 
of  the  acute  contagious  diseases,  especially  of  whooping  cough,  measles,  scar- 
let fever,  and  diphtheria,  through  the  schools.  Measures  employed,  thus  far, 
by  Boards  of  Health  or  other  local  authorities  to  prevent  the  dissemination  of 
these  and  kindred  diseases  have  been  but  partially  successful,  except  in  regard 
to  small-pox.  In  the  large  public  schools  especially  these  maladies  are  most 
frequently  contracted,  and  from  them  they  radiate  over  the  school  districts ; 
for  if.  as  is  now  common,  at  least  in  Xew  York  City,  a  child  comes  to  school 
wearing  clothes  which  at  home  have  lain  in  a  room  where  a  brother  or  sister 
has  been  sick  with  diphtheria  or  scarlet  fever,  or  if  he  enter  the  class  with  a 


24  INFANCY  AND   CHILDHOOD. 

mild  pertussis  or  measles,  certain  of  liis  classmates  will  probably  return  home 
infected  with  the  virus  of  the  disease.  The  same  remarks  are  applicable, 
though  with  less  force,  to  private  schools.  From  both  such  schools  I  have 
over  and  over  again  witnessed  the  dissemination  not  only  of  the  maladies 
mentioned,  but  also  of  the  milder  infectious  diseases,  as  mumps  and  varicella. 
The  Health  Board  of  New  York  City  has  recently,  by  stringent  enactments 
regulating  the  schools,  accomplished  much  in  suppressing  this  source  of  the 
infectious  diseases. 

In  hospitals  and  asylums  for  children  much  can  be  done  to  prevent  the 
occurrence  of  the  infectious  diseases  by  strict  surveillance  and  prompt  isola- 
tion of  all  suspicious  cases.  Without  such  care  scarcely  a  year  passes  in 
which  these  institutions  are  not  scourged  by  one  or  more  of  these  maladies. 
Much  has  been  said  of  the  crowding  of  families  in  tenement-houses  so  com- 
mon in  New  York  and  other  large  cities,  by  which  a  large  number  of  children 
are  brought  under  one  roof,  of  the  uncleanliness  of  person  and  apartment  to 
which  it  leads,  and  of  the  insufficient  air  and  space  which  it  allows  to  each. 
But  one  of  the  strongest  objections,  in  my  opinion,  to  the  present  plan  of 
building  and  crowding  tenement-houses  is  the  facility  which  it  aflfords  for  the 
spread  of  the  contagious  diseases  of  childhood ;  and  it  is  in  such  houses,  as 
shown  by  statistics,  that  these  maladies  are  the  most  frequent  and  fatal.  The 
much-needed  enactments  or  rules  in  relation  to  the  construction  and  occu- 
pancy of  such  houses  would,  among  other  salutary  eifects,  greatly  diminish 
the  death-rate  from  the  infectious  maladies. 

Over  the  most  loathsome,  and  formerly  the  most  fatal,  malady  of  man- 
kind— namely,  small-pox — -we  now  have,  or  can  have,  complete  control  by 
statutory  enactments  enforcing  vaccination.  It  is  only  by  carelessness  or 
the  lack  of  sufficiently  stringent  regulations  relating  to  the  matter  that  small- 
pox is  not  "stamped  out."  Again,  some  of  the  most  fatal  inflammatory 
diseases  of  life  occur  chiefly  in  childhood,  as  croup  and  capillary  bronchitis. 
These  and  kindred  diseases  can  only  be  prevented  by  proper  hygienic  man- 
agement on  the  part  of  families,  and  measures  calculated  to  educate  fam- 
ilies in  reference  to  the  management  of  children  cannot  fail  to  diminish  the 
number  of  cases  of  such  inflammations,  and,  consequently,  of  the  deaths  from 
them. 

Another  obvious  and  important  cause  of  the  mortality  of  early  life  is  the 
antihygienic  condition  or  state  in  which  many  children  live  in  consequence 
of  the  poverty  or  gross  negligence  of  parents. 

Residence  in  insalubrious  localities,  personal  and  domiciliary  uncleanliness, 
exposure  without  proper  protection  to  vicissitudes  of  weather,  are  fertile 
causes  of  sickness  and  death.  Hence  one  reason  for  the  great  infantile 
mortality  among  the  city  poor,  who  live  in  damp  and  dark  alleys  and  in 
crowded  and  filthy  tenement-houses,  breathing  night  and  day  an  atmosphere 
loaded  with  noxious  gases.  All  physicians  are  aware  how  the  most  fatal 
diseases,  such  as  Asiatic  cholera,  cholera  infantum,  diphtheria,  and  scarlet 
fever,  seek  the  quarters  of  the  city  poor,  and  what  terrible  havoc  they  make 
there.  All  are  aware,  also,  what  wonderful  recoveries  result  when  feeble  and 
attenuated  infants,  gradually  sinking  with  chronic  diseases,  induced  in  great 
measure  by  the  foul  air,  are  transferred  from  such  localities  to  the  pure  air 
of  the  country. 

Careless  management  of  young  children  as  regards  dress  increases  greatly 
the  liability  to  local  diseases,  such  as  commonly  occur  from  exposure  to  cold. 
These  ai-e  inflammatory  afi"ections  seated  chiefly  upon  the  mucous  surfaces, 
but  sometimes  in  parenchymatous  organs.  Adults,  aware  of  the  efi'ect  of 
sudden  change  of  temperature  from  warm  to  cold  or  of  exposure  to  currents 
of  air,  protect  themselves  by  additional  clothing.     Such  precautionary  meas- 


MORTALITY  OF  EARLY  LIFE.  25 

ures  are  often  lacking  in  the  management  of  young  children,  and  hence  one 
cause  of  their  liability  to  local  affections,  both  of  the  respiratory  and  diges- 
tive organs. 

Routh,  in  his  excellent  treatise  on  Infant  Feeding,  says  :  "  Among  the 
most  pernicious  influences  to  young  children,  however,  we  may  include  cold ; 
the  change  of  temperature  from  45°  to  four  or  five  below  zero,  as  before 
stated,  producing  an  increase  of  mortality  in  London  alone  of  three  to  five 
hundred.  As  out  of  100  deaths,  however,  from  all  specified  causes,  nearly 
24  occur  to  children  under  one  year,  and  36  to  children  under  five,  the  great 
increase  of  mortality  to  children  by  cold  is  thus  at  once  made  obvious. 
Indeed,  it  is  a  household  word  among  us,  which  takes  its  origin  from  the 
Registrar-Grenerars  returns,  that  a  very  cold  week  always  increases  the 
mortality  of  the  very  young  and  the  very  aged." 

Lastly,  a  very  important  cause  of  mortality  in  early  life  is  the  use  of 
improper  food.  In  infants  artificial  feeding  in  place  of  the  aliment  which 
nature  has  provided  for  them,  and  in  children  the  use  of  innutritions  or  indi- 
gestible articles  of  diet,  give  rise  to  diarrhoeal  maladies,  emaciation,  and  death 
in  numerous  instances.  Sometimes,  also,  defective  alimentation  is  the  cause 
of  scrofulous  or  tuberculous  ailments,  and  sometimes  it  gives  rise  to  a 
cachexia  or  feebleness  of  system  which,  without  engendering  any  positive 
disease,  renders  those  thus  aff"ected  less  able  to  support  disease  induced  by 
other  causes.  A  committee,  of  which  Professor  Austin  Flint,  Jr.,  was  chair- 
man, appointed  in  1867  to  revise  the  "  dietary  table  of  the  children's  nurseries 
on  Randall's  Island,"  states  with  2uuch  truth  and  force :  "  Children  .... 
are  not  capable  of  resisting  bad  alimentation,  either  as  regards  quantity, 
quality,  or  variety.  At  that  age  the  demands  of  the  system  for  nourishment 
are  in  excess  of  the  waste,  the  extra  quantity  being  required  for  growth  and 
development.  If  the  proper  quantity  and  variety  of  food  be  not  provided, 
full  development  cannot  take  place,  and  the  children  grow  up,  if  they  sur- 
vive, into  puny  men  and  women,  incapable  of  the  ordinary  amount  of  labor 
and  liable  to  diseases  of  various  kinds." 

Improper  feeding,  like  other  causes  of  mortality,  is  much  more  injurious, 
much  more  frequently  the  cause  of  death,  in  the  city  than  in  the  country. 
Statistics  in  Europe,  as  well  as  on  this  side  of  the  Atlantic,  establish  this  fact. 
It  is  in  infancy,  and  especially  in  the  first  year,  that  the  use  of  unwholesome 
food  entails  the  most  serious  consequences.  No  artificially-prepared  food  is 
a  good  substitute  for  the  mother's  milk,  and  hence  artificial  feeding  of  the 
infant,  unless  under  the  most  favorable  circumstances,  results  disastrously. 
In  the  country,  where  salubrious  air  and  sunlight  conspire  to  invigorate  the 
system,  where  a  robust  constitution  is  inherited,  and  where  cow's  milk,  fresh 
and  of  the  best  quality,  is  readily  obtained,  lactation  is  not  so  necessary  for 
the  well-being  of  the  infant ;  but  in  the  city  its  importance  cannot  be  toa 
strongly  urged. 

The  foundlings  of  cities  afi'ord  the  most  striking  and  convincing  proof  of 
the  advantages  of  wet-nursing.  In  some  cities  foundlings  are  wet-nursed, 
while  in  others  they  are  dry-nursed,  and  the  result  is  always  greatly  in  favor 
of  the  former.  Thus,  on  the  Continent,  in  Lyons  and  Parthenay,  where 
foundlings  are  wet-nursed  almost  from  the  time  that  they  are  received,  the 
deaths  are  33.7  and  35  per  cent.  On  the  other  hand,  in  Paris,  Rheims,  and 
Aix,  where  the  foundlings  were  wholly  dry-nursed  at  the  date  of  the  statis- 
tics, their  deaths  were  50.3,  63.9,  and  80  per  cent. 

In  New  York  City  the  foundlings,  amounting  to  several  hundred  a  year,, 
were  formerly  dry-nursed,  and,  incredible  as  it  may  appear,  their  mortality 
with  this  mode  of  alimentation  nearly  reached  100  per  cent.  Now  wet-nurses 
are  employed  for  a  portion  of  the  foundlings,  with   a  much  more  favorable 


26  INFANCY  AND   CHILDHOOD. 

result.  Several  years  ago,  before  the  New  York  Foundling  Asylum  existed, 
the  foundlings  of  New  York  were  taken  care  of  by  the  pauper  women  of  the 
almshouse,  and  the  medical  board  of  Charity  Hospital  assigned  me  to  the 
service  in  the  almshouse.  Foundlings  were  received  nearly  every  day,  and 
were  given  cow's  milk  prepared  by  these  pauper  women.  When  my  duties 
commenced  in  the  almshouse  the  deaths  corresponded  with  the  admissions : 
only  one  infant  was  pointed  out  that  had  survived  the  first  half  year  in 
the  almshouse. 

These  facts,  to  which  others  might  be  added  from  the  experience  of 
European  cities,  show  the  importance  of  wet-nursing  as  a  means  of  reducing 
infantile  mortality  in  the  cities.  What  has  been  stated  as  regards  the  result 
of  artificial  feeding  of  foundlings  is  true,  in  great  measure,  in  reference  to  all 
city  infants.  The  ill-eff"eet  of  artificial  feeding  is  well  known  in  city  families, 
and  it  is  the  common  practice  to  employ  a  hired  wet-nurse  if,  for  any  reason, 
the  mother's  milk  is  insufiicient. 

AVhen  the  infant  has  reached  the  age  at  which  it  is  proper  to  wean,  the 
digestive  organs  are  less  frequently  deranged  by  errors  of  diet.  More  sub- 
stantial food,  and  considerable  variety  in  it,  may  now  be  not  only  safely 
allowed,  but  are  required  by  the  wants  of  the  system. 


CHAPTER    lY. 

WEIGHT,  GEOWTH,  TEMPERATUEE,  PULSE,  EESPIEATION. 

Dr.  K.  Parker,  resident  physician  of  the  New  York  Infant  Asylum 
when  these  observations  were  made,  weighed,  immediately  after  birth,  170 
infants — 89  male  and  81  female — born  consecutively  and  at  term,  with  the 
following  result : 

Average  male  weight 7  lbs.  11  oz. 

"        female  "       7    "      4  " 

Fifty  of  these,  who  were  wet-nursed  and  apparently  well  taken  care  of,  were 
weighed  when  one  week  old,  with  the  following  result : 

Increase  of  weight  in 32  cases. 

Loss  of  weight  in 13     " 

Average  gain A^^  oz. 

"        loss 3|    " 

Greatest  gain 12       " 


Average  Gain. 

From  birth  to  age  of  4  months  (25  cases) 4  lbs.  8f  oz. 

"     3  to    6  months  (6  cases) 3  "     31   " 

"     6  to    9      "  "  2  "     7i   " 

"     9  to  12      "  "  1   "  15*   " 


WEIGHT,    GROWTH,   TEMPERATURE,   PULSE,   RESPIRATION.     27 


Statistics  of  Temperature,  Pulse,  and  Respiration  of  Healthy  In- 
fants, OBTAINED   BY  DrS.  PaRRY  AND  HODGE,  N.  Y.  InPANT  AsYLUM. 


Under  6  mos. 
6  to  12  mos. 
12  to  18  mos. 
18  to  30  mos. 


Table  I. —  Temperature  in  Health. 
f  Rectal  average  of  313  observations  in  14  cliildren 


\  Axillary 
f  Eectal  " 
\  Axillary 
f  Rectal 
\  Axillary 
f  Rectal 
\  Axillary 


144 
55 
39 
70 
35 

102 
54 


in  14  cliilc 

Iren,  98.5° 

"14 

98.3° 

"    2 

98.6° 

"    2 

98.3° 

u    2 

98.4° 

"    2 

98.3° 

u    3 

98.9° 

u    3 

98.1° 

The  difference  in  the  temperature  of  healthy  infants  in  the  morning  and 
evening  was  found  to  be  trivial,  as  is  seen  by  the  following  statistics : 


6  to  12  mos. 
12  to  18  mos 


Average  Pulse. 

When  awake.  When  asleep. 

141.77 128.23 

136.2 120.37 

129.8 110.71 


Under  6  mos 

6  to  12      " 

12  to  18    " 

18  to  30    " 131.6 108.35 


Morning  and  Evening  Temperatures. 

/Rectal  average,  A.  M.,  98.44  (observations,  436).  No.  of  infants,  6 

t       "          "         P.  M.,  98.56  (          "    _        414  .  "           "        6 

f  Rectal  average,  A.  jr.,  98.43  (observations,  185).  " 

t       "          "         P.  M.,  98.34  (           "   _         181).  " 

TO  ^    oA            f  Rectal  average,  A.  M.,  98.34  (observations,  206).  " 
18  to  30  mos.  I       <.          "        P.M.,  98.59  (           "            199). 

Table  II. — Pulse  in   Qidet,  Healthy  Infants. 

Under  6  mos..  observations  90,  No.  of  infants  27,  average  125 
6  to  12       "    '  "  11,      '■  "        2,        "       124 

12  to  18     "  "  23,       "  "        4,        "       115.5 

18  to  30     "  "         37,       "  "       7,        "       111.8 

Respirations. 

Under  6  mos.,  observations  90,  No.  of  infants  27,  average  44.8 
6  to  12      "  "  11,       "  "  2,        "       34.8 

12  to  18    "  "  24,       "  "         4,        "       35.4 

18  to  30    "  "  37,      "  "         7,        "      29.8 


Respirations. 


Under  6  mos. 
6  to  12       " 
12  to  18     " 
18  to  30     " 


Awake.  Asleep. 

.  53.47 40.23 

.  41.66 32.13 

.  38.25 26.18 

.  39.33 25.49 


Lactation. — It  is  desirable  that  the  infant  as  soon  as  it  requires  nutriment 
should  receive  breast-milk.  If  it  be  fed  for  a  few  days  with  the  bottle  or 
spoon,  it  may  be  difficult  finally  to  induce  it  to  take  the  breast ;  therefore  it 
is  well  to  determine  early  whether  the  mother  will  be  able  to  wet-nurse  her 
infant,  so  that,  if  unable,  suitable  provision  may  be  made. 

The  matter  of  determining  beforehand  the  capability  of  the  mother  for 
wet-nursing  has  been  investigated  by  Dr.  Donne  of  Paris,  and  in  his  treatise 
on  Mothers  and  Infants  he  describes  the  mode  in  which  it  may  be  ascertained. 
The  desired  information,  in  his  opinion,  may  be  acquired  by  examining  the 


28  INFANCY  AND  CHILDHOOD. 

colostrum,  wliicli  is  secreted  in  small  quantity  in  the  last  months  of  gesta- 
tion, and  which  can  be  squeezed  from  the  breast  in  sufl&cient  quantity  for 
inspection. 

In  some  women,  according  to  Dr.  Donne,  the  colostrum  is  so  scanty  that 
only  a  drop  or  half  a  drop  can  be  obtained  from  the  nipple  by  careful  pres- 
sure. This  will  be  found  by  the  microscope  to  contain  but  few  milk-glob- 
ules, ill  formed,  and  a  few  granular  bodies,  such  as  the  colostrum  ordinarily 
contains.  Such  women  almost  invariably  furnish  poor  milk  and  in  small 
quantity.  In  other  women  the  colostrum  is  abundant,  but  thin,  resembling 
gum-water ;  it  lacks  the  yellow  streaks  and  viscous  character  of  ordinary 
colostrum,  and  it  flows  readily  from  the  nipple.  The  milk  of  such  women 
is  sometimes  scanty,  sometimes  abundant,  but  it  is  watery  and  deficient  in 
nutritive  principles.  In  a  third  class  of  women  the  colostrum  is  pretty  abun- 
dant, and  it  contains  yellowish  streaks  of  more  or  less  consistence,  which  are 
found  to  be  rich  in  milk-globules  of  good  size.  Women  furnishing  such 
colostrum  in  the  last  weeks  of  gestation  will  have  sufficient  milk  and  of 
good  quality.     These  latter  women  make  the  best  wet-nurses. 

Wet-nursing:  its  Advantages  and  Hindrances;  Physical  Condi- 
tions rendering  it  Improper. 

During  the  first  year  of  the  infant's  life  the  natural  mode  of  alimenta- 
tion— that  by  the  mother's  milk — should  always  be  recommended,  except 
in  those  instances  in  which  mothers  are  incapacitated  by  physical  ailments 
or  mental  derangement.  The  practice  common  in  New  York,  and  probably 
in  other  cities,  of  employing  wet-nurses,  in  the  belief  that  suckling  their 
infants  deprives  mothers  of  social  enjoyments  and  by  the  drain  upon  the 
system  impairs  their  general  health,  should  be  discouraged.  Wet-nursing 
by  the  mother,  if  properly  regulated,  with  sufficient  undisturbed  sleep  at 
night,  and  with  the  maintenance  of  good  appetite  and  digestion,  does  not 
impair  her  health,  but,  on  the  other  hand,  tends  to  promote  her  physical 
well-being.  But  there  are  unavoidable  conditions  which  render  wet-nursing 
by  the  mother  injudicious  or  impossible.     These  will  be  considered  hereafter. 

The  primipara  often  experiences  difficulty  in  wet-nursing  in  consequence 
of  a  depressed  state  of  the  nipple.  It  is  not  sufficiently  prominent  to  be 
readily  grasped  by  the  mouth,  and  after  ineffectual  attempts  the  infant 
becomes  fretful  when  applied  to  the  breast,  and  perhaps  for  a  time  refuses 
it  altogether.  Multipar^e  occasionally  experience  the  same  inconvenience, 
but  it  is  not  common  when  there  has  once  been  successful  lactation.  By 
calmness  and  perseverance  on  the  part  of  the  mother  the  nursling  can  usually 
be  made  to  seize  the  nipple  in  the  course  of  a  week. 

Depression  of  the  nipple  is,  to  a  certain  extent,  the  result  of  pressure 
upon  it  by  the  dress  during  gestation.  The  state  of  the  nipple  should 
indeed,  in  those  who  have  never  suckled,  receive  early  attention,  even  before 
the  birth  of  the  infant.  Tightness  of  dress  around  the  breast,  as  also  vipon 
every  part  of  the  body,  should  be  avoided,  and  from  time  to  time  gentle 
traction  should  be  made  upon  the  nipple  if  it  be  depressed.  It  may  be 
drawn  out  by  the  fingers  of  the  mother  several  times  each  day,  or  by  a  com- 
mon breast-pump,  or  by  suction  with  a  tobacco-pipe,  the  edge  of  the  bowl 
having  been  smoothed.  Occasionally,  in  these  cases  of  depressed  nipple 
the  mother,  fatigued  and  discouraged  by  her  frequent  ineffectual  attempts 
to  induce  the  infant  to  nurse,  becomes  feverish  and  excited,  so  that  the  quan- 
tity of  her  milk  is  sensibly  diminished.  The  physician  should  assure  her,  as 
he  usually  can  with  confidence,  that  in  a  few  days,  as  the  baby  becomes  a  little 
stronger,  there  will  be  no  difficulty  in  its  nursing.     Some  women  are  unre- 


WET-NUESING.  29 

mitting  in  their  endeavors  to  procure  nursing.  This  should  be  forbidden, 
since  the  lack  of  sleep  and  the  nervousness  which  such  constant  endeavor 
produces  tend  to  defeat  the  object  which  they  have  in  view,  by  diminishing 
the  secretion  of  milk.  Sufficient  sleep,  freedom  from  anxiety,  and  no  more 
frequent  application  of  the  infant  to  the  breast  than  is  required  in  success- 
ful lactation  should  be  enjoined.  Occasionally,  we  can  best  succeed  in  pro- 
curing lactation  under  these  circumstances  of  discouragement  by  the  aid  of 
another  infant  older,  more  vigorous,  and  better  able  to  seize  the  nipple.  An 
exchange  of  infants  a  few  times  may  remedy  the  difficulty. 

Occasionally,  suckling  is  rendered  difficult  and  painful  by  too  long  delay 
before  applying  the  infant  to  the  breast.  When  the  mother  has  rested  a  few 
hours  after  her  confinement — about  six  in  ordinary  cases — lactation  may  com- 
mence. There  is  at  first  but  very  little  milk,  often  only  a  few  drops,  but  the 
secretion  is  promoted  by  nursing,  so  that  the  requisite  amount  is  sooner 
obtained  than  when  the  infant  is  kept  from  the  breast  till  the  second  or  third 
day.  If,  as  some  physicians  advise,  suckling  be  deferred  till  the  breasts  are 
full  and  tender,  and  if,  as  is  often  the  case  with  primiparje,  the  nipples  are 
also  tender,  many  mothers  lack  the  fortitude  required  to  allow  their  infants 
to  obtain  a  sufficient  amount  of  milk.  Excoriated  and  fissured  nipples  con- 
stitute a  serious  impediment  to  wet-nursing.  They  are  very  sensitive  on  pres- 
sure, and  are  long  in  healing.  They  are  fully  described  in  works  which  relate 
to  female  diseases,  and  their  treatment  pointed  out.  Occasionally,  fissured 
nipples  do  harm  to  the  infant  by  the  blood  which  escapes  and  is  swallowed 
with  the  milk.  A  case  is  related  in  which  positive  indigestion  was  caused 
in  this  way,  the  infant  vomiting,  after  each  nursing,  milk  mixed  with  blood. 
The  local  hindrances  to  lactation  described  above  can  in  most  instances  be 
relieved  in  the  course  of  a  few  weeks.  To  what  extent  menstruation  and 
pregnancy  are  detrimental  to  the  nursing,  and  therefore  contraiudicate  lacta- 
tion, will  be  considered  in  another  section. 

There  is  occasionally  a  constitutional  state  of  the  mother  which  necessi- 
tates either  the  employment  of  a  hired  wet-nurse  or  weaning.  This  is  the 
case  when  there  is  a  strong  tendency  to  tuberculosis.  If  the  complexion  be 
pallid,  the  system  at  all  emaciated,  and  suckling  be  attended  by  more  or  less 
exhaustion,  and  if  with  fair  trial  of  wine  and  tonics  no  improvement  follow, 
the  physician  is  justified  in  forbidding  further  attempts  at  wet-nursing.  If, 
under  such  circumstances,  an  hereditary  tendency  to  tuberculosis  exist,  it  is 
his  duty  positively  to  interdict  nursing.  The  opinion  of  the  physician  in  such 
a  matter  should  be  formed  after  mature  deliberation.  There  are  many  women 
who,  suffering  temporarily  from  illness  and  discouraged,  are  ready  at  once  to 
abandon  their  infants  to  the  care  of  others  with  the  least  encouragement  on 
the  part  of  the  physician  to  do  so,  but  who,  by  attention  to  their  own  health, 
and  especially  by  taking  more  sleep,  soon  recover  from  their  depression  and 
become  good  wet-nurses.  On  the  other  hand,  night-sweats,  a  cough,  and  pro- 
gressive decline  in  health  show  the  need  of  immediate  suspension  of  wet- 
nursing. 

Sometimes  women  prior  to  pregnancy  present  indubitable  evidence  of 
tuberculosis,  but  by  the  improved  general  health  which  attends  pregnancy 
the  disease  is  temporarily  arrested.  Such  women  should  never  suckle  their 
infants.  If  they  do,  they  soon  lose  all  that  was  gained  and  the  disease 
advances  rapidly.  These  objections  to  wet-nursing  in  such  a  state  of  health 
apply  to  the  mother.  There  are  also  objections  as  regards  the  infant.  The 
milk  of  those  in  decidedly  infirm  health  is  deficient  in  nutritive  principles. 
Their  infants,  therefore,  are  ill-nourished,  and  if  they  have  inherited  a  pre- 
disposition to  tuberculosis,  there  is  great  danger  that  this  disease  will  be 
developed  in  them  ;  whereas  with  healthy  wet-nursing  even  a  strong  predis- 


30  INFANCY  AND   CHILDHOOD. 

position  may  remain  latent.  M.  Donne  relates  the  following  instructive  cases, 
which  show  the  danger  which  sometimes  attends  suckling  and  the  imperative 
necessity  which  may  arise  of  discontinuing  it :  "A  very  light-complexioned 
young  mother,  in  very  good  health  and  of  a  good  constitution,  though  some- 
what delicate,  was  nursing  for  the  third  time,  and,  as  regarded  the  child, 
successfully.  All  at  once  this  young  woman  experienced  a  feeling  of 
exhaustion.  Her  skin  became  constantly  hot ;  there  were  cough,  oppression, 
night-sweats ;  her  strength  visibly  declined,  and  in  less  than  a  fortnight  she 
presented  the  ordinary  symptoms  of  consumption.  The  nursing  was  immedi- 
ately abandoned,  and  from  the  moment  the  secretion  of  milk  had  ceased  all  the 
troubles  disappeared."  "A  woman  of  forty  years  of  age,  ....  having  lost, 
one  after  another,  several  children,  all  of  whom  she  had  put  out  to  nurse, 
determined  to  nurse  the  last  one  herself.  ....  This  woman,  being  vigorous 
and  well  built,  was  eager  for  the  work,  and,  filled  with  devotion  and  spirit, 
she  gave  herself  up  to  the  nursing  of  her  child  with  a  sort  of  fury.  At 
nine  months  she  still  nursed  him  from  fifteen  to  twenty  times  a  day. 
Having  become  extremely  emaciated,  she  fell  at  once  into  a  state  of  weak- 
ness from  which  nothing  could  raise  her,  and  two  days  after  the  poor  woman 
died  of  exhaustion." 

A  very  similar  case  recently  occurred  in  my  practice.  A  young  and 
healthy  woman  from  the  country,  suckling  her  second  infant,  on  coming  to 
the  city  lived  in  a  dark  and  very  imperfectly  ventilated  room  on  the  first  floor 
and  in  the  rear  of  a  crowded  tenement-house.  She  soon  lost  her  appetite, 
but  continued  suckling  for  three  months,  when  she  became  so  ansemic  and 
feeble  that  she  was  compelled  to  seek  medical  advice.  She  died  without  local 
disease,  notwithstanding  the  most  nutritious  diet  and  free  use  of  stimulants 
and  tonics. 

Constitutional  syphilis  in  the  mother  does  not  contraindicate  wet-nursing. 
It  is  probable  that  the  infant  also  has  it.  The  mother  should  take  antisyph- 
ilitic  remedies,  which  will  eradicate  the  disease  in  herself,  and  also,  if  it  be 
present,  in  the  infant.  Febrile  affections  also  do  not  in  general  contraindicate 
wet-nursing.  They  may,  however,  for  a  time  diminish  the  quantity  of  milk 
or  impair  its  quality.  If,'  however,  the  mother  be  in  a  critical  state  or  much 
reduced,  whatever  the  disease,  suckling  should  cease.  Whether  or  not  the 
infant  should  be  taken  from  the  breast  if  the  mother  be  suffering  from  one 
of  the  essential  fevers  depends  on  the  severity  of  the  malady  and  the  degree 
of  her  exhaustion.  Twice  I  have  known  newly-born  infants  to  be  suckled  by 
mothers  while  the  latter  had  scarlet  fever  without  contracting  it,  but  suffer- 
ing immediately  afterward  from  protracted  and  severe  eczema.  In  rural 
localities,  where  artificially-fed  infants,  as  a  rule,  do  well,  it  might  be  best  to 
wean  if  the  mother  have  such  a  disease ;  but  in  the  city  eczema  is  less  dan- 
gerous than  the  diarrhoeal  affections  which  early  weaning  is  likely  to  entail. 
In  most  cases  of  typhus  and  typhoid  fevers  weaning  or  procuring  a  wet- 
nurse  is  necessary,  on  account  of  the  depression  of  the  vital  powers  which 
these  diseases  produce.  Mothers  with  organic  diseases,  of  whatever  kind, 
which  impair  the  general  health  or  diminish  the  appetite,  should  never  be 
allowed  to  wet-nurse  their  infants.  Wet-nursing  under  such  circumstances  is 
likely  to  aggravate  the  disease,  and  the  milk  which  such  mothers  furnish, 
even  if  sufficient  in  quantity,  is  deficient  in  nutritive  properties. 

Inflammatory  affections,  unless  of  a  dangerous  character,  do  not  ordinarily 
interfere  with  wet-nursing,  except  that  the  quantity  of  milk  is  somewhat  dimin- 
ished. In  severe  inflammation  it  may  be  so  necessary  to  husband  the  strength 
or  to  keep  the  patient  perfectly  quiet  that  suckling  her  infant  would  be  inju- 
dicious. It  should  then  be  transferred  to  a  wet-nurse  or  weaned.  Inflam- 
mation of  the   breast   often  presents   an  impediment  to  lactation.     It  is  a 


HINDRANCES  TO  LACTATION.  31 

common  and  painful  affection,  suspending  or  greatly  diminishing  the  secre- 
tion of  milk  in  the  affected  gland.  Wet-nursing  should  cease  as  soon  as  there 
are  evident  signs  of  inflammation,  unless  it  be  limited  to  a  small  part  of  the 
gland.  General  heat  of  the  breast,  with  tenderness  and  induration  extending 
over  a  considerable  part  of  it,  indicates  the  need  of  the  immediate  removal 
of  the  infant  from  it.  Suckling  must  be  restricted  to  the  unaffected  side. 
It  is  often  the  case  that  the  volume  of  the  inflamed  gland  is  considerably 
increased  from  the  afflux  of  blood  to  it  and  from  the  interstitial  exudation, 
while  it  contains  little  or  no  milk,  and  attempts  at  suckling  under  such  cir- 
cumstances are  injurious  to  the  mother  as  well  as  to  the  infant.  The  cause 
of  the  swelling  should  be  explained  to  the  mother,  who  commonly  attributes 
it  to  the  accumulation  of  milk,  and  worries  herself  and  the  infant  by  attempts 
to  make  it  nurse.  As  the  inflammation  abates  by  resolution,  or  more  com- 
monly by  suppuration,  and  the  normal  secretion  returns,  the  first  milk,  which 
is  usually  thick  and  stringy,  should  be  rejected,  after  which  the  infant  may 
nurse  as  usual.  Occasionally,  the  abscess  which  has  formed  in  the  breast 
connects  with  a  lactiferous  tube,  so  that  pus  may,  on  suction,  escape  from 
the  nipple.  If  this  occur,  of  course  nursing  should  be  interdicted  until  pure 
milk  is  obtained.  Pus  in  the  milk  can  sometimes  be  detected  by  the  naked 
eye.  It  presents  a  yellowish  or  greenish  color,  occurring  in  streaks  when  not 
intimately  mixed  with  the  milk.  When  it  is  intimately  mixed  and  in  small 
quantity,  it  cannot  be  detected  by  the  naked  eye,  but  the  microscope  reveals 
the  pus-globules.  M.  Donne  relates  a  case  in  which  he  discovered  these 
globules  by  the  microscope,  although  there  were  at  first  no  other  evidences 
of  an  abscess,  and  doubts  were  expressed  in  reference  to  the  accuracy  of  his 
observation.     Finally,  an  abscess  pointed  and  discharged. 

Sometimes  when  the  inflammation  abates  the  secretion  does  not  return, 
and,  worse  still,  occasionally  the  inflammation  has  occurred  so  near  the  nipple 
that  the  lactiferous  tubes  are  permanently  closed  by  it,  so  that,  though  milk 
form  in  the  breast,  there  is  no  escape  for  it.  Thenceforth  only  one  breast  can 
be  used. 

If  erysipelas  occur  in  the  mother,  the  infant  should  be  immediately  taken 
from  her  breast  and  from  her  arms.  If  this  disease  should  not  be  communi- 
cated to  the  infant  through  the  milk  or  through  flssures  in  the  nipple,  of 
which  there  is  danger,  still  the  milk  usually  undergoes  such  a  change  in  con- 
sequence of  the  erysipelas  as  to  endanger  the  health  of  the  child.  Thus,  one 
of  the  wet-nurses  in  the  New  York  Infant  Asylum  sickened  with  severe  facial 
erysipelas  on  the  24th  of  April,  1875,  eight  days  after  the  death  of  her  baby. 
She  was  wet-nursing  a  foundling,  aged  seven  weeks,  at  the  time  of  the  com- 
mencement of  the  erysipelas,  and,  as  it  was  very  important  that  her  milk 
should  be  preserved  for  the  coming  hot  months,  it  was  deemed  best  to  allow 
the  nursing  to  continue,  the  infant  being  placed  in  a  crib  at  a  little  distance 
as  soon  as  it  dropped  the  nipple.  On  the  27th  the  baby  was  troubled  with 
diarrhoea.  April  28th  its  morning  temperature  was  irjl°,  and  that  of  the 
evening  103°,  the  diarrhoea  continuing.  It  was  now  removed  entirely  from 
the  breast  and  was  given  artificial  food.  On  the  29th  there  was  a  decided 
general  icteric  hue  of  the  infant's  surface,  which  continued  till  its  death  on 
May  1st.  The  stools  numbered  about  eight  daily  till  April  30th,  when  they 
ceased.  The  record  which  I  preserved  does  not  state  whether  there  was 
vomiting,  but  it  had  probably  been  slight  on  account  of  the  speedy  pi'ostra- 
tion.  Death  occurred  from  exhaustion.  At  the  autopsy  from  half  an  ounce 
to  one  ounce  of  pus  was  found  in  the  peritoneal  cavity,  newly-formed  fibrin 
was  observed  upon  the  spleen  and  liver,  and  the  peritoneum  generally  had 
lost  much  of  its  lustre :  a  careful  microscopic  examination  of  the  liver  and 
its  ducts,  made  by  Dr.  Heitzmann,  revealed  no  anatomical  change  which  would 


32 


INFAJS'CY  AND   CHILDHOOD. 


explain  the  icteric  hue,  and  it  seemed  propable  that  this  was  due  to  the  altered 
state  of  the  blood.  The  mucous  membrane  of  the  intestines  exhibited  vascular 
streaks  and  its  follicles  were  distinct.  The  lesions,  therefore,  indicated  intes- 
tinal catarrh.  Nothing  unusual  was  observed  in  the  heart  and  lungs  of  the 
infant.      Its  life  had  been  apparently  sacrificed  by  the  unhealthy  nursing. 


Colostrum. 

The  milk  secreted  during  gestation  and  immediately  after  the  birth  of  the 
infant  ordinarily  differs  in  its  gross  appearance,  as  well  as  chemical  and 
microscopical  characters,  from  that  which  is  subsequently  secreted.  It  is 
termed  colostrum.  It  has  a  turbid  and  yellowish  appearance,  and  is  some- 
what viscid.  It  is  decidedly  alkaline,  and  undergoes  lactic-acid  fermentation 
more  readily  than  common  milk,  and  it  also  contains  more  solid  matter.  It 
has  an  excess  of  fat,  of  salts,  and,  according  to  Simon,  also  of  sugar.  It 
appears  from  Simon's  analysis  that  the  solid  matter  of  colostrum  is  about 
17  per  cent.,  while  that  of  the  ordinary  breast-milk  is  about  11   per  cent. 

Examined  by  the  microscope,  the  colostrum  is  seen  to  contain  oil-globules 
and  a  viscid  substance  which  often  assumes  an  ovoid  or  globular  form,  but 
which  also  exists  in  irregular  masses  of  considerable  size.  This  substance 
has  been  thought  by  some  to  be  mucus,  but  it  is  dissolved  by  acetic  acid  and 
potash  and  is  tinged  yellow  by  a  watery  solution  of  iodine.  It  is  therefore 
to  be  regarded  as  albuminous.  Imbedded  in  this  substance  are  oil-globules, 
which  are  for  the  most  part  of  small  size,  while  the  free  oil-globules  of  colos- 
trum are  larger  than  those  occurring  in  healthy  milk.  The  viscid  substance, 
with  the  imprisoned  oil-globules,  constitutes  what  has  been  designated  the 
"  colostrum-corpuscles." 

The  colostrum  is  replaced  by  milk  of  the  normal  character  in  six  to  eight 


Fig.  1. 


Milk-globules. 


Colostrum-corpuscles. 


days,  sometimes  as  early  as  the  third  or  fourth  day  after  delivery.  In  excep- 
tional instances  the  colostrum  does  not  disappear  for  several  weeks,  and  it 
may  reappear  at  any  time  subsequently  as  a  consequence  of  derangement  of 
the  system  or  from  disease.  It  is  assimilated  with  difficulty  by  the  digestive 
organs  of  the  infant,  producing  usually  a  laxative  effect.  It  therefore  aids 
in  the  removal  of  the  meconium,  and,  being  a  normal  production,  it  is  to  be 
regarded  as  beneficial  in  the  first  week  of  the  infant's  life.  Continuing  longer 
than  the  first  week,  its  effect  is  deleterious.  It  produces  evident  derange- 
ment of  the  digestive  organs,  and  the  infant  that  habitually  nurses  it  never 
thrives.  It  has  diarrhoea  or  vomiting,  becomes  more  or  less  emaciated,  and 
suffers  from  colicky  pains.  Sometimes  an  extreme  degree  of  exhaustion  is 
reached  before  the  cause  is  suspected,  for  if  the  milk  be  pretty  abundant  the 


HUMAN  MILK.  33 

admixture  of  colostrum  with  it  cannot  be  detected  by  tbe  naked  eye.  The 
microscope  alone  reveals  it.  The  following  is  an  interesting  example  of  this 
fact :  In  1868  an  infant  six  weeks  old  was  brought  to  me  with  the  following 
history :  The  mother  had  for  several  years  been  troubled  with  dyspeptic 
symptoms,  but  had  otherwise  been  in  good  health.  The  infant  at  birth  was 
fleshy  and  strong,  but  after  the  first  week  it  had  never  thrived  like  other 
infants.  It  nu.rsed  regularly,  and  the  quantity  of  milk  was  apparently  suf- 
ficient, but  it  vomited  as  soon  as  it  ceased  nursing ;  it  was  much  emaciated 
and  the  bowels  were  habitually  constipated.  The  digestive  organs  of  the 
infant  had  been  in  this  unhealthy  state,  with  little  variation,  from  the  first 
week,  and  it  was  very  evident,  from  the  emaciation  and  exhaustion,  that  it 
must  soon  perish  unless  some  change  were  efi'ected.  The  milk  of  the  mother 
presented  the  usual  appearance  to  the  naked  eye,  but  under  the  microscope 
colostrum-corpuscles  were  observed.  A  wet-nurse  was  immediately  obtained, 
and  from  that  moment  the  gastro-intestinal  symptoms  disappeared,  with  a 
rapid  recovery.  This  case  shows  at  once  the  evil  effects  of  the  colostrum 
and  the  need  of  a  microscopic  examination  of  the  milk  whenever  the  nursling- 
suffers  from  indigestion. 

Human  Milk. 

In  the  normal  state  milk  is  the  sole  nutriment  during  the  first  months  of 
infancy,  and  during  the  entire  periods  of  infancy  and  childhood  it  contributes 
more  than  any  other  food  to  healthy  development  and  growth.  It  contains 
nitrogenous  elements  designed  for  tissue-formation,  along  with  carbohydrates, 
fats,  saline  substances,  and  abundant  water,  designed  for  sustaining  the  heat, 
producing  cell-formation,  and  the  various  secretions  and  excretions.  All  the 
ingredients  of  milk  are  useful  in  one  way  or  another  in  the  economy,  so  that 
there  is  no  waste  as  in  other  kinds  of  food. 

Foster  states  that  milk  is  the  result  of  the  activity  of  certain  protoplasmic 
cells  forming  the  epithelium  of  the  mammary  gland.  "So  far  as  we  know, 
the  fat  is  formed  in  the  cell  through  metabolism  of  the  protoplasm.  Micro- 
scopically, the  fat  can  be  seen  to  be  gathered  in  the  epithelium  cell  in  the 
same  way  as  in  a  fat-cell  of  the  adipose  tissue,  and  to  be  discharged  into  the 
channels  of  the  gland,  either  by  a  breaking  up  of  the  cells  or  by  a  contractile 
extrusion  very  similar  to  that  which  takes  place  when  an  amoeba  ejects  its 
digested  food."  Foster  also  states  that  there  is  evidence  that  the  casein  and 
sugar  are  formed  from  the  protoplasm  in  the  mammary  cells,  and  not  by 
appropriation  of  the  casein  and  sugar  introduced  into  the  system  in  the  food. 
Therefore,  if  the  food  contain  no  fat,  casein,  or  sugar,  still,  these  substances 
are  produced  by  the  cell-agency  in  the  mammary  gland  {Arch,  fur  Phys.., 
1886,  539). 

According  to  MM.  Vernois  and  Becquerel,  the  average  specific  gravity 
of  human  milk  in  89  observations  was  1032,  the  minimum  being  1025  and 
the  maximum  1046.  The  specific  gravity  of  cream  from  milk  having  the 
sp.  grav.  1032  is  1024;  of  the  milk  skimmed,  1046.  Of  course  many  cir- 
cumstances cause  modifications  in  human  milk,  as  irregularities  in  the  mode 
of  life,  excesses,  lack  of  requisite  sleep,  food  too  highly  stimulating  or  defi- 
cient in  nutritive  properties,  etc. 

The  analysis  of  human  milk  has  been  made  with  great  care  by  different 
chemists.  Its  composition  of  course  varies  considerably  in  different  females 
according  to  the  diet,  health,  mode  of  life,  etc.,  but  the  following  table,  pre- 
pared by  Robin  and  accepted  by  Prof.  Austin  Flint  in  his  elaborate  treatise 
on  physiology,  gives  the  most  reliable  exhibit  of  its  composition  yet  pub- 
lished : 


34  INFANCY  AND  CHILDHOOD. 

Composition  of  Human  Milk. 

Water 902.717  to  863.149 

Casein  (desiccated) 29.000  "  39.000 

Lacto-proteine 1.000  "  2.770 

Albumin traces  "  0.880 

(   Mari^arine 17.000  "  25.840 

Butter  25  to  28  \   Oleine       _._.    .  7.500"  11.400 

(_  Butyrine,  Caprine,  Caproine,  Capriline  .     0.500  "  0.760 

Sugar  of  milk  (lactose) 37.000  "  49.000 

Lactate  of  soda  (?)      0.420  "  0.450 

Chloride  of  sodium 0.240"  0.340 

Chloride  of  potassium 1.440  "  1.830 

Carbonate  of  soda 0.053  "  0.056 

Carbonate  of  lime 0.069  "  0.070 

Phosphate  of  lime 2.310"  3.440 

Phosphate  of  magnesia 0.420  "  0.640 

Phosphate  of  soda 0.225"  0.230 

Phosphate  of  iron  (?)      0.032"  0.070 

Sulphate  of  soda 0.074"  0.075 

Sulphate  of  j^otassa     .    .        a  trace 

I   Oxygen,  1.29  ] 

Gases  in  solution  \   Nitrogen,  12.17    >-  30  parts  per  1000  volume. 

(  Carbonic  acid,  16.54  J 

Modification  of  Milk  in  Consequence  of  the  Diet. 

The  relative  proportion  of  the  diiferent  ingredients  of  the  milk  varies 
according  to  the  diet.  If  the  diet  be  poor,  the  amount  of  water  increases 
and  that  of  butter  and  casein  diminishes.  Lehmann  says  (^Pliys.  Chemistry, 
vol.  ii.  p.  65) :  "  From  experiments  made  on  bitches  it  vrould  appear  that  a 
vegetable  diet  renders  the  milk  richer  in  butter  and  sugar,  while  the  solid 
constituents  are  augmented  when  a  sufficient  quantity  of  mixed  food  is  given. 
Peligot  found  the  milk  of  an  ass  most  rich  in  casein  when  the  animal  had 
been  fed  on  beet-root,  while  it  was  richest  in  butter  when  the  food  had  con- 
sisted of  oats  and  lucerne.  Boussingault  found  the  milk  of  a  cow  richer  in 
casein  when  the  animal  had  been  fed  on  potatoes  than  when  other  food  was 
taken.  Reiset  found  that  the  milk  of  cows  which  were  at  grass  was  much 
richer  in  butter  than  when  the  animals  had  stood  all  night  in  their  stall  with- 
out food ;  but  Playfair  found,  on  the  contrary,  that  the  quantity  of  butter  in 
the  milk  increased  during  the  night  as  much  as  during  their  stall-feeding,  but 
that  the  quantity  of  butter  in  the  milk  was  considerably  diminished  by  the 
motion  of  the  animals  in  the  fields."  ^  Simon  made  the  following  analysis  of 
the  milk  of  a  poor  woman.  She  was  suddenly,  during  the  period  of  lactation, 
deprived  of  the  means  of  support,  so  that  her  food  was  insufficient  in  quantity 
and  of  poor  quality.  The  amount  of  her  milk  was  not  diminished  by  priva- 
tion, but  the  solid  constituents  were  reduced  to  86  parts  in  1000.  After  this, 
for  a  time,  her  diet  was  nutritious  and  abundant,  the  quantity  of  milk  was 
increased,  and  the  solid  constituents  amounted  to  119  parts  in  1000.  Her 
diet  was  again  reduced,  with  a  reduction  of  the  solid  elements  to  98  in  1000, 
and  at  a  later  period  the  diet  was  again  nutritious,  with  an  increase  of  the 
solid  elements  to  126.  The  chief  variation  observed  in  the  milk  of  this 
woman  was  in  the  amount  of  butter. 

Modification  of  Milk  from  its  Retention  in  the  Breast. 

M.  Peligot  has  clearly  demonstrated  that  the  longer  milk  is  retained  in 
the  breast  the  more  watery  it  becomes.     This  is  explained  on  the  supposition 

^Animal  Chem.,  Sydenham  Soc's  Trans.,  vol.  ii.  p.  55. 


MODIFICATION  OF  MILK  BY   VARIOUS  CAUSES.  35 

that  the  solid  portion  is  first  absorbed.  Therefore,  the  milk  is  richer  the  more 
frequently  it  is  removed  from  the  breast.  A  similar  fact,  which  has  the  same 
explanation,  has  long  been  known — namely,  that  the  first  milk  taken  from  the 
breast  is  thinnest,  while  that  which  flows  last  is  richest.  That  first  removed 
has  remained  longest  in  the  gland,  while  that  which  comes  last  is  but  recently 
secreted. 

A  knowledge  of  this  fact  is  of  considerable  practical  importance.  The 
milk,  as  M.  Donne  has  shown,  may  be  too  rich,  so  as  to  cause  indigestion, 
with  more  or  less  enteralgia,  in  the  infant.  Some  nurslings,  if  the  milk  be 
too  rich  and  abundant,  reject  a  part  of  it  by  vomiting,  but  others  do  not,  and 
sufi"er  the  consequence  of  derangement  of  the  digestive  organs.  For  such 
cases  the  remedy  is  to  give  the  breast  less  frequently,  by  which  a  less  amount 
of  milk  is  taken  and  milk  of  a  poorer  quality.  On  the  other  hand,  if  there 
be  poverty  of  the  milk  and  the  infant  be  insufficiently  nourished,  the  milk  is 
more  nutritious  if  the  nursing  be  at  short  intervals. 

Modification  of  Milk  by  Age  and  by  Mental  Impressions. 

The  composition  of  milk  varies  also  according  to  the  age  of  the  infant. 
Simon  analyzed  the  milk  of  a  woman  at  intervals  for  the  period  of  about  six 
months.  In  this  case  the  amount  of  casein  at  first  was  small,  but  the  quan- 
tity increased  during  the  two  months  succeeding  delivery,  after  which  it  was 
nearly  stationary.  A  similar  increase  was  observed  in  reference  to  the  saline 
substances.  The  sugar,  on  the  other  hand,  diminished  in  quantity  as  the 
infant  grew  older,  its  maximum  amount  being  in  the  first  and  second  months. 
The  quantity  of  butter  in  the  milk  varies  from  day  to  day  more  than  the 
other  elements. 

Many  observations  have  been  published  which  show  that  the  composition 
of  the  milk  may  be  materially  changed  by  mental  impressions.  The  infant 
has  died  suddenly  in  the  act  of  nursing  after  its  mother  had  been  violently 
excited.  Such  a  case  is  related  by  Tourtnal.  The  infant  ceased  nursing, 
gasped,  and  died  in  the  mother's  lap.  In  other  cases  convulsions  have 
occurred.  MM.  Becquerel  and  Vernois  made  the  chemical  analysis  of  the 
milk  of  a  woman  in  a  state  of  nervous  excitement,  and  found  that  the  solid 
constituents  were  diminished  to  91  parts  in  1000,  the  most  marked  diminu- 
tion being  in  the  butter,  which  was  only  about  5  parts.  In  a  case  related  by 
Parmentier  and  Deyeux  the  milk  became  watery  and  viscid,  and  remained  so 
till  the  nervous  attacks  from  which  the  patient  sufi'ered  had  ceased.  Dairy- 
men are  well  aware  how  ill-treatment  and  the  separation  of  the  calf  from  the 
cow  diminish  the  milk  which  she  yields.  A  new  milkman  seldom  obtains  as 
much  milk  as  one  with  whom  the  cow  is  familiar.  Bouchut,  alluding  to  the 
influence  of  the  moral  afi"ections  on  the  secretion  of  milk,  makes  the  follow- 
ing remark,  the  truth  of  which  most  mothers  will  acknowledge :  "  It  is  also  a 
fact  that  the  sight  of  the  nursling,  the  idea  of  seeing  it  at  the  breast,  and  the 
joy  which  certain  mothers  thence  experience,  exercise  a  moral  influence  over 
the  secretion  of  the  milk  entirely  independent  of  their  will.  They  feel  the 
draught  of  milk  as  soon  as  they  behold  their  child  or  think  of  it  too  deeply ; 
and  in  a  woman  who  saw  her  child  fall  to  the  ground  the  flow  of  milk  ceased, 
and  did  not  reappear  until  the  child,  having  quite  recovered,  attempted  to 
take  the  breast." 

Rotch  states  that  a  primipara  of  an  excitable  and  nervous  temperament 
was  in  a  marked  degree  anxious  and  despondent  in  reference  to  her  infant, 
which  she  was  wet-nursing.  The  infant  began  to  suff"er  from  indigestion,  so 
that  the  mother's  milk  was  analyzed  with  the  following  result :  water,  89.17  ; 
fat,  0.62  ;  sugar,  5.80  ;  albuminoids,  4.21  ;  ash,  0.20.     This  marked  variation 


36  INFANCY  AND   CHILDHOOD. 

from  normal  milk  was  apparently  due  to  the  emotions  of  the  mother.  A  wet- 
nurse  was  procured  and  the  infant  did  well. 

Modification  of  Milk  by  the  Catamenial  Function,  Pregnancy, 

and  Other  Causes. 

The  eatamenia  reappear  in  most  women  before  the  close  of  lactation,  often 
by  the  fifth  or  sixth  month  after  delivery.  If  this  function  be  re-established 
in  the  normal  manner — that  is,  without  any  derangement  of  the  system,  with- 
out pain  or  undue  profuseness — ^no  unfavorable  result  ordinarily  occurs  with 
the  infant.  On  the  other  hand,  if  the  mother  sulFer  any  disturbance  of  the 
system  or  if  the  menses  be  profuse,  the  lacteal  secretion  may  be  so  changed 
that  the  infant  is  injuriously  affected  by  it.  The  symptoms  produced  are 
those  of  indigestion,  such  as  abdominal  pains,  more  or  less  vomiting,  and 
diarrhoea.  This  result  is,  however,  in  my  experience,  quite  exceptional.  In 
rare  instances  more  dangerous  symptoms  occur  in  the  infant.  A  case  has 
been  reported  to  me  in  which  at  each  catamenial  period  the  nursling  was 
seized  with  convulsions. 

Charles  Marchand  found  in  three  chemical  analyses  of  the  milk  during 
menstrviation  a  diminution  of  2  to  4  parts  in  the  butter,  of  2  to  5  parts  in 
the  sugar,  and  a  diminution  in  the  casein  and  albumen  of  2  to  5  parts.  This 
seems  but  a  trifling  change  when  we  recollect  that  human  milk  in  the  state 
of  health  contains,  according  to  the  analysis  of  M.  Robin  and  others,  25  to 

37  parts  of  butter,  37  to  49  parts  of  sugar,  and  29  to  39  parts  of  casein  in 
1000  of  milk.  Rotch  has  made  the  following  analyses  of  the  milk  of  two 
women  during  the  eatamenia.  Their  infants  exhibited  symptoms  of  indi- 
gestion during,  but  not  before  or  after,  the  catamenial  flow : 

First  Case.  Second  Case. 

Fat 0.62  1.37 

Sugar 5.80  6.10 

Albuminoids. 4.21  2.78 

Ash .20  0.15 

Solids 10.83  10.40 

Water 89.17  89.60 

(Cyclop,  of  Diseases  of  Children,  1889.) 

In  these  two  instances  the  albuminoids  were  increased.  But  even  if  the 
infant  suffer  from  indigestion  during  the  catamenial  period,  its  duration  is  so 
short  and  the  milk  so  soon  returns  to  its  normal  state  that  the  occurrence  of 
the  eatamenia  does  not  indicate  the  need  of  weaning  if  the  infant  be  under 
the  age  of  ten  months.  But  if  the  menses  reappear  with  regularity  when 
the  infant  has  attained  the  age  of  ten  or  twelve  months,  they  should  be  con- 
sidered as  designed  to  supersede  the  secretion  of  milk,  which,  indeed,  usually 
begins  to  diminish.  Weaning  is  then  proper.  If  the  menses  return  early  in 
the  period  of  lactation  and  give  rise  to  symptoms  in  the  infant  in  consequence 
of  the  altered  quality  of  the  milk,  it  is  best  to  allow  but  little  nursing  during 
the  eatamenia,  and  to  employ  artificial  feeding  instead  until  the  flow  of  blood 
ceases. 

The  change  produced  in  the  milk  by  pregnancy  is,  in  general,  more  inju- 
rious to  the  nursling  than  that  caused  by  the  reappearance  of  the  menses. 
The  milk  of  the  pregnant  woman  frequently  contains  more  or  less  of  the 
viscid  substance  which  characterizes  colostrum.  Still,  the  milk  of  pregnancy 
does  not  ordinarily  derange  the  digestive  function  as  much  as  colostrum  in 
the  first  weeks  of  lactation,  for  pregnancy  rarely  occurs  till  after  the  infant 
is  five  or  six  months  old,  when  the  organs  of  digestion  are  less  readily  dis- 
turbed.    The  injurious  effect  of  pregnancy  on  the  infant  is  shown  by  vomit- 


MODIFICATION  OF  MILK  BY  VARIOUS  CAUSES.  37 

ing  or  diarrhoea,  by  restlessness  and  occasional  abdominal  pains ;  in  fine,  by 
symptoms  of  indigestion.  In  many  cases,  however,  these  symptoms  do  not 
occur,  and  the  infant,  though  nursing  regularly,  continues  to  thrive.  No 
doubt,  as  a  rule,  the  nursling  should  be  weaned  when  there  are  clear  evi- 
dences of  pregnancy,  but  under  certain  circumstances  weaning  is  injudicious. 
I  have  on  different  occasions  been  called  to  infants  in  midsummer  dangerously 
sick  with  diarrhoeal  attacks  induced  by  this  cause.  These  infants  were  per- 
haps doing  well  or  suffering  but  little  from  indigestion,  when  the  mothers, 
suspecting  themselves  pregnant,  at  once  withdrew  them  from  the  breast,  and 
severe  and  dangerous  intestinal  catarrh  was  the  result.  No  infant  in  the 
city  should  be  weaned  in  the  hot  months.  It  is  much  safer,  though  there  be 
indubitable  signs  of  pregnancy,  that  it  continue  nursing  till  the  cool  weather. 
The  better  method  is,  however,  under  such  circumstances  to  employ  a  wet- 
nurse  or  to  remove  the  infant  to  the  country  and  wean  it  there.  In  cool 
weather  it  is  usually  safe  to  wean  an  infant  in  the  city  after  it  has  reached 
the  age  of  five  or  six  months. 

Sometimes  a  young  mother  devotes  hei'self  unremittingly  to  the  care  of 
her  infant,  giving  it  the  breast  every  hour  or  oftener  through  the  day  and 
frequently  through  the  night.  She  gives  the  infant  little  rest,  and  has  but 
little  herself.  This  devotion,  praiseworthy  as  it  is,  is  nevertheless  very 
injurious  to  both  parties  concerned.  The  rule  should  be  repeated  and  remem- 
bered, that  while  an  infant  may  nurse  hourly  during  the  first  month,  except 
in  the  hours  which  the  mother  requires  for  sleep,  in  which  it  should  not  nurse 
more  than  once  or  twice,  after  the  first  month  nursing  should  be  restricted  to 
intervals  of  two  hours  till  the  third  or  fourth  month,  and  in  older  infants, 
with  greater  capacity  of  the  stomach,  to  intervals  of  three  or  four  hours. 
Too  frequent  nursing  produces  indigestion  with  its  usual  fretfulness  and 
diarrhoea,  and  it  deprives  the  mother  of  the  mental  composure  and  rest  which 
are  required  for  successful  lactation  ;  but  the  more  the  infant  frets,  in  many 
instances,  the  oftener  the  mother  applies  it  to  the  breast,  which  only  inci*eases 
the  indigestion.  Worriment  and  lack  of  sleep  tend  not  only  to  diminish  the 
milk,  but  also  to  impair  its  quality. 

Effect  of  Medicine  on  the  Mother's  Milk. 

This  important  subject  has  been  investigated  by  Fehling  (^Arcli.  f.  Gyn.., 
xxvii.  p.  332).  According' to  him,  one  or  two  grammes  of  salicylate  of 
sodium,  taken  by  a  woman  who  is  wet-nursing,  may  be  in  part  recovered 
in  the  child's  urine.  Rheumatism  in  the  nursing  child  may  therefore  be 
treated  by  the  ordinary  doses  of  this  agent  administered  to  the  mother. 
Rheumatism  occurs  more  frequently  in  the  nursing  infant  than  is  commonly 
supposed,  since  its  symptoms  as  regards  the  joints  are  usually  mild  and 
likely  to  be  overlooked,  and  it  often  causes  endocarditis  and  permanent 
valvular  disease  when  its  presence  is  not  suspected  and  no  physician  is 
called.  Schaeffer  relates  the  case  of  an  infant  born  with  rheumatism. 
Iodide  of  potassium  also,  says  Fehling,  given  to  the  mother,  can  be  detected 
in  large  quantity  in  the  infant's  urine.  We  have  Fehling's  authority  for  the 
following  statements  :  After  applying  iodoform  to  perineal  lacerations,  iodine 
was  found  in  the  milk  and  urine  of  the  mother,  but  no  apparent  harm  has 
resulted  from  applying  iodoform  to  wounds  or  sores  in  the  nursing  mother. 
Mercury  taken  by  the  mother  did  not  appear  in  the  milk,  and  the  same  was 
true  of  acetic,  hydrochloric,  and  citric  acids.  Therefore  acid  foods  probably 
do  not  render  the  milk  acid.  Laudanum  given  by  the  mouth  in  no  instance 
caused  drowsiness  in  the  infant,  and  morphia  given  hypodermically  did  not, 
as  a  rule,  affect  the  child.     On  the  other  hand,  atropine  taken  by  the  mother 


38  INFANCY  AND  CHILDHOOD. 

caused  dilation  of  the  infant's  pupils.  Hydrate  of  chloral  taken  by  the 
mother  did  not  affect  the  child.  The  effect  on  the  nursing  child  of  medi- 
cines administered  to  the  mother  needs  further  investigation.  The  observa- 
tions relating  to  it  published  in  the  journals  are  as  yet  too  meagre  for  the 
valid  and  reliable  deductions  which  are  required  by  the  profession  to  ensure 
safe  and  proper  medication  of  nursing  women. 

Diiferences  in  Women  as  regards  Quantity  and  Quality  of  Milk. 

There  is  a  great  difference  in  different  women  as  regards  the  quantity  and 
quality  of  their  milk,  and  even  the  mode  in  which  it  is  secreted.  The  best 
wet-nurses  are  usually  robust  without  being  corpulent.  Their  appetite  is 
good,  and  their  breasts  are  distended  from  the  number  and  large  size  of  the 
blood-vessels  and  milk-ducts.  There  is  but  a  moderate  amount  of  fat  around 
the  gland,  and  tortuous  veins  are  observed  passing  over  it.  Such  nurses  do 
not  experience  a  feeling  of  exhaustion  and  do  not  suffer  from  lactation. 

The  nutriment  which  they  consume  is  equally  expended  in  their  own  sus- 
tenance and  the  supply  of  milk.  There  are  other  good  wet-nurses  who  have 
the  physical  conditions  which  I  have  described,  but  whose  breasts  are  small. 
Still,  the  infant  continues  to  nurse  till  it  is  satisfied,  and  it  thrives.  The  milk 
is  of  good  quality,  and  it  appears  to  be  secreted  mainly  during  the  time  of 
suckling.  Other  mothers  evidently  decline  in  health  during  the  time  of 
lactation.  They  furnish  milk  of  good  quality  and  in  abundance,  and  their 
infants  thrive,  but  it  is  at  their  own  expense.  They  themselves  say,  and 
with  truth,  that  what  they  eat  goes  to  milk.  They  become  thinner  and  paler, 
are  perhaps  troubled  with  palpitation,  and  are  easily  exhausted.  They  often 
find  it  necessary  to  wean  before  the  end  of  the  usual  period  of  wet-nursing. 
There  is  another  class  whose  health  is  habitually  poor,  but  who  furnish  the 
usual  quantity  of  milk  without  the  exhaustion  experienced  by  the  class 
which  I  have  just  described.  The  milk  of  these  women  is  of  poor  quality. 
It  is  abundant,  but  watery.  Their  infants  are  pallid,  having  soft  and  flabby 
fibre.  All  these  kinds  of  wet-nurses  are  met  in  practice,  and  they  require 
general  sustaining  measures,  but  the  treatment  must  be  more  or  less  diverse 
according  to  the  exigencies  of  each  case. 

Rules  in  regard  to  Lactation. 

Newly-born  infants  should  be  applied  to  the  breast  about  twelve  times  in 
twenty-four  hours.  The  suckling  should  be  mostly  in  the  day-time,  and  only 
once  or  twice  during  the  hours  required  by  the  mother  for  sleep.  After  the 
third  or  fourth  week  the  infant  should  take  the  breast  at  intervals  of  two 
hours  during  the  day-time,  and  only  once  during  the  seven  or  eight  hours  of 
sleep  which  the  mother  must  have  in  order  that  her  health  be  preserved  and 
her  milk  be  of  good  quality.  A  healthy  infant  empties  the  breast  in  ten  to 
fifteen  minutes  of  nursing,  when  it  should  be  removed,  and  if  in  good  condi- 
tion it  falls  asleep,  and  may  not  awaken  until  the  next  suckling,  or  if  it 
remain  awake  it  is  cheerful  and  contented. 

Insufficient  Feeding  of  the  Newly-horn. — Not  a  few  young  infants  perish 
from  want  of  food,  even  in  well-to-do  families  who  are  solicitous  for  the  wel- 
fare of  their  children  and  are  abundantly  able,  pecuniarily,  to  provide  the 
nutriment  which  they  require.  During  the  last  two  or  three  years  I  have 
been  called  to  four  or  five  new-born  babies  whose  mothers  were  primiparge, 
young  and  inexperienced — babies  that  were  said  to  be  hearty  nursers  until 
they  became  too  weak  to  draw  the  breast.  The  history  received  was,  that 
they  never  seemed  satisfied,  fretted  almost  constantly,  quiet  when  drawing 
the  breast  for  a  short  time,  but  crying  and  sleepless  immediately  afterward, 


RULES  IN  REGARD   TO  LACTATION.  39 

losing  in  weight  and  strength  each  day.  The  urine  was  scanty  and  the  stools 
infrequent.  The  condition  was  one  of  gradual  starvation.  When  summoned 
to  these  cases  I  have  found  in  one  instance  no  pulse  at  the  wrist  of  the  baby 
on  the  fourth  day  after  birth,  and  in  another  instance  the  baby  greatly  wasted 
on  the  ninth  day,  its  skin  lying  in  folds,  the  milk  placed  in  its  mouth  running 
out  from  inability  to  swallow  ;  in  fine,  death  impending.  The  physician  and 
nurse  could  not  believe  that  the  mother  had  an  insufficient  supply  of  milk, 
but  on  applying  the  breast-pump  not  more  than  half  a  dozen  drops  of  thin 
milk  could  be  obtained.  A  wet-nurse  was  promptly  procnred,  but  death  of 
the  infant  occurred  in  a  few  hours.  It  is  not  improbable  that  the  breast-milk, 
insufficient  from  the  first,  became  more  scanty  from  the  extreme  grief,  loss  of 
sleep  and  appetite  of  the  mother.  An  insufficient  secretion  of  milk  with  its 
disastrous  consequences  to  the  new-born  in  well-to-do  families,  anxious  and 
pecuniarily  able  to  provide  everything  needed  for  the  comfort  and  well-being 
of  their  olfspring,  is  still  more  common  among  the  poor  in  tenement-houses, 
and  is  most  common  when  the  mothers  are  insufficiently  fed  and  are  obliged 
to  work  for  a  livelihood,  which  often  necessitates  absence  from  home  and 
separation  from  the  infant.  Insufficient  food  may  render  the  milk  more 
watery,  as  has  already  been  stated,  or  it  may  cause  diminution  in  its  quantity. 
The  mother  thus  situated  is  pallid.  She  is  subject  to  palpitation  and  attacks 
of  faintness.  Her  condition,  indeed,  is  that  of  angemia.  Working  women 
have  scantiness  of  milk,  not  only  in  consequence  of  hardships,  but  also 
because,  as  stated  above,  they  are  usually  separated  for  hours  from  their 
infants.  Age  is  also  a  cause  of  scantiness  of  milk.  Mothers  at  the  age  of 
forty  years  ordinarily  furnish  less  milk  than  between  twenty  and  thirty. 
Those  who  have  not  borne  children  till  late  in  life,  and  whose  mammary 
glands  have  therefore  long  been  inactive,  have  less  milk  than  those  who  com- 
mence bearing  children  at  the  usual  period. 

Routh  speaks  of  hyperaemia  as  a  cause  of  defective  lactation.  "  This  is 
a  variety,"  says  he,  "  which  I  have  chiefly  observed  among  hired  wet-nurses 

selected  from  the  poorer  classes  and  admitted  into  wealthier  families 

When  feeding  at  the  expense  of  a  master  or  mistress  the  amount  they  devour 
surpasses  all  moderate  imagination.  They,  in  fact,  gormandize.  If  in  such 
instances  a  wet-nurse  be  given  all  she  asks  for,  she  will  be  found  often  to 
to  eat  quite  as  much  as  any  two  men  with  large  appetites  ;  and  as  a  result  she 
becomes  gross,  turgid,  often  covered  with  blotches  or  pimples,  and  generally 
too  plethoric  to  fulfil  the  duties  of  her  position.  The  plethora,  as  first 
induced,  is  of  the  sthenic  variety,  but  it  soon  assumes  an  asthenic  character, 
and  as  the  immediate  result  the  breast  no  longer  secretes  its  quantity  of 
milk.  There  may  be  good  milk  secreted,  but  it  is  in  small  quantity,  and  this 
quantity  diminishes  daily.  The  breast  may  also  enlarge,  but  it  is  from  a 
deposition  of  fatty  tissue  in  and  about  it,  as  in  other  parts  of  the  body.  The 
veins  on  the  surface  become  less  apparent — always  a  bad  feature  in  a  suckling 
breast — till  finally  the  flow  of  milk  ceases  altogether."  But  the  gormandiz- 
ing habit  referred  to  by  Dr.  Routh  does  not  often  in  this  country  cause  dimi- 
nution or  impair  the  quality  of  the  milk,  provided  that  the  nursling  is  faith- 
fully and  properly  applied  to  the  breast.  By  frequent  suckling  the  glands 
continue  actively   secreting. 

xltrophy  of  the  breast  from  the  employment  of  iodine  or  from  long  disuse 
is  also  a  cause  of  insufficiency  of  milk. 

It  is  so  necessary  for  the  health  and  development  of  the  infant  that  the 
milk  should  be  in  proper  quantity  as  well  as  quality  that  it  is  best  in  a  work 
of  this  kind  to  consider  the  treatment  of  insufficient  secretion,  and,  on  the 
other  hand,  of  excessive  secretion  and  loss  of  milk,  or  galactorrhoea  ;  and  first 
of  insufficient  or  scanty  secretion. 


40  INFANCY  AND  CHILDHOOD. 

The  most  efficient  mode  of  increasing  the  lacteal  secretion  is  that  which 
is  also  natural — namely,  suction  from  the  nipple.  There  are  many  cases  on 
record  in  which  this  has  produced  the  flow  of  milk  in  women  who  have  never 
borne  children,  and  even  in  men.  Baudelocque  mentions  the  case  of  a  girl 
eight  years  old  who  suckled  her  brother  for  a  month,  and  cases  at  the  opposite 
extreme  of  life  have  been  reported — one  of  a  women  of  seventy  years  who 
wet-nursed  a  grandchild  twenty  years  after  her  last  confinement. 

The  following  case,  which  was  under  my  observation,  is  interesting  in  this 

connection :  Lizzie  S was  confined  with  her  first  child  on  May  30,  1876. 

When  the  baby  was  a  few  days  old,  and  before  she  had  left  the  bed,  she  had 
inflammatory  symptoms  which  proved  to  be  due  to  pelvic  cellulitis.  Its 
course  was  tedious ;  her  milk  diminished,  and  its  secretion  soon  ceased.  On 
or  about  the  1st  of  August  she  began  to  sit  up,  and  on  August  11th  she 
was  admitted  into  the  Sixty-first  street  branch  of  the  Infant  Asylum,  pale 
and  wasted,  but  with  returning  appetite.  She  had  no  mammary  secretion  for 
eleven  weeks,  and  her  breasts  were  small  and  flabby.  She  had  two  fistulous 
openings,  one  vaginal  and  the  other  low  down  in  the  back,  near  the  lower 
end  of  the  sacrum  or  the  coccyx.  The  baby  was  in  a  fair  condition,  having 
been  wet-nursed  by  other  women.  Experiences  in  this  and  other  institutions 
show  that  infants  having  breast-milk  do  far  better  and  are  much  more  likely 
to  live  than  those  without  breast-milk,  and  the  mother  was  therefore  advised 
by  one  of  the  managers — himself  a  physician — to  suckle  her  baby,  although 
there  was  not  a  drop  of  milk  in  her  breast  and  nursing  had  been  suspended 
eleven  weeks.  To  the  surprise  of  the  mother  and  of  the  nurses  in  the 
house — to  whom  the  procedure  seemed  very  ridiculous — milk  began  to  appear 
in  a  few  days.  The  mother  left  the  institution  October  8th,  but  before  her 
departure  she  was  able  to  furnish  perhaps  two-thirds  the  quantity  of  milk 
which  her  infant  required.  This  case  affords  practical  illustration  of  the  fact 
that  frequent  suckling  is  the  most  efficient  galactagogue.  Mothers  sometimes, 
having  little  breast-milk,  suckle  their  babies  at  long  intervals,  and  finally, 
discouraged  at  the  unproductive  state  of  their  breasts,  resort  to  weaning, 
when  by  patience  and  more  frequent  use  of  their  breasts  they  might  become 
good  wet-nurses.  In  the  cities  and  during  the  summer  season,  in  which 
breast-milk  is  so  much  required,  the  history  of  cases  like  the  above,  and  the 
more  remarkable  cases  in  which  men  and  grandparents  have  had  secretion  of 
milk  and  have  suckled  infants,  should  induce  the  physician  to  withhold  his 
consent  to  premature  weaning,  which  the  disheartened  mother  is  apt  to  sug- 
gest, unless  indeed  he  perceives  other  reasons  for  weaning  apart  from  scanti- 
ness of  milk. 

Travellers  among  barbarous  nations  or  tribes  have  often  observed  these 
cases  of  unnatural  lactation.  Humboldt  saw  a  man  thirty-two  years  old 
who  gave  the  breast  to  his  child  for  five  months,  and  Captain  Franklin  in 
the  Arctic  regions  met  a  similar  case.  Dr.  Livingstone  in  his  African  trav- 
els says  that  he  has  examined  several  cases  in  which  a  grandchild  has  been 
suckled  by  a  grandmother,  and  equally  remarkable  instances  of  wet-nursing 
occur  among  the  negroes  of  the  Southern  and  Middle  States.  Professor 
Hall  presented  to  his  class  in  Baltimore  a  male  negro,  fifty-five  years  old, 
who  wet-nursed  all  the  children  of  his  mistress.  In  these  cases  of  abnormal 
lactation,  so  far  as  we  have  accurate  records  of  them,  it  is  ascertained  that 
the  breasts  were  torpid,  and  even  sometimes,  as  in  old  people,  atrophied,  till 
the  nursing  commenced.  Titillation  or  pressing  of  the  nipple  caused  an  afflux 
of  blood  to  the  gland  and  developed  its  functional  activity,  so  that  milk  was 
produced  for  the  sustenance  of  the  nursling.  Therefore,  in  case  of  scanty 
secretion  of  milk  the  mother  may  increase  the  quantity  by  applying  the 
infant  often  to  the  breast.     If,  dissatisfied  with  the  small  amount  of  nutri- 


RULES  IN  REGARD   TO  LACTATION.  41 

ment  which  it  receives,  it  refuse  to  make  the  necessary  suction,  any  other 
mode  of  gentle  traction  or  pressure  may  be  employed  in  addition.  The  occa- 
sional employment  of  another  infant  or  a  pup,  milking  the  breast  with  the 
thumb  and  fingers,  or  the  gentle  suction  of  a  breast-pump  aids  in  stimulat- 
ing the  secretion.  Forcible  rubbing  or  traction  of  the  breast  defeats  the  pur- 
pose for  which  it  is  employed.  It  produces  too  much  irritation  and  tender- 
ness. The  best  mode  of  stimulation  is  by  nursing,  as  it  is  the  natural  mode, 
and  the  effect  of  the  infant  at  the  breast  upon  the  maternal  instincts  aids  in 
promoting  the  secretion. 

Another  mode  of  increasing  the  functional  activity  of  the  mammary  glands 
is  by  the  electrical  current.  The  fact  is  established  by  physiological  exj)eri- 
ments  that  glandular  organs  can  be  made  to  secrete  more  actively  by  the 
stimulus  of  electricity,  and,  accordingly,  this  agent  has  been  successfully 
employed  to  promote  the  secretion  of  milk.  In  Routh's  Infant  Feeding' 
several  cases  are  related  which  show  the  beneficial  effects  of  this  agent 
(page  149  et  seq.').  Among  them  are  six  reported  by  Dr.  Skinner  of  Liver- 
pool. In  all  these  one  or  two  applications  of  the  electrical  current  sufficed 
to  restore  the  secretion.  The  following  is  Dr.  Skinner's  mode  of  employing^ 
this  treatment : 

"  1.  Direct. — Both  poles  must  terminate  in  cylinders,  with  sponges 
moistened  in  tepid  water.  The  positive  pole  is  pressed  deep  into  the  axilla^ 
while  the  negative  is  lightly  applied  to  the  nipple  and  the  areola,  the  current 
being  no  stronger  than  is  agreeable  to  the  patient's  feelings.  The  poles  are 
kept  in  this  position  for  about  two  minutes. 

"  2.  Intraniammary. — The  poles  are  to  be,  as  it  were,  imbedded  in  the 
mamma  and  moved  about,  raising  and  depressing  both  poles  at  once  in  and 
around  the  organ  for  the  space  of  another  two  minutes.  The  same  is  to  be 
done  to  both  breasts  daily  until  the  secretion  is  properly  established.  Hith- 
erto one  or  two  sittings  have  always  sufficed  in  my  hands"  (^Communication 
of  Dr.  Skinner  to  Dr.  Routli). 

In  all  cases  of  scanty  secretion  of  milk  the  regimen  of  the  mother  is  a 
matter  of  importance.  Personal  and  domiciliary  cleanliness  is  essential  for 
successful  wet-nursing.  A  certain  amount  of  exercise  in  the  open  air  is  con- 
ducive to  the  health  of  the  mother  and  to  the  secretion  of  abundant  and 
healthy  milk.  A  case  is  related  to  show  the  effect  of  fresh  air  and  out-door 
exercise  on  the  lacteal  secretion.  A  lady  of  cleanly  habits,  living  in  London, 
had  a  very  scanty  supply  of  milk.  She  removed  to  the  pure  air  of  the  sea- 
shore, and  immediately  the  quantity  became  abundant  and  continued  so  for 
months.  Such  cases  are  not  infrequent.  A  mode  of  life  that  contributes  to 
the  general  health  of  the  mother  will  not  fail  to  augment  the  quantity  of  her 
milk  if  it  be  scanty,  and  to  improve  its  quality. 

Much  has  been  written  in  reference  to  the  diet  of  women  who  suckle.  It 
is  a  popular  belief  that  certain  articles  of  food  promote  the  secretion  of  milk 
much  more  than  other  articles,  though  equally  nutritious.  No  doubt  writers 
have  erred  in  recommending  exclusively  this  or  that  kind  of  food  as  most  likely 
to  produce  milk.  The  exact  kind  of  food  which  is  preferable  in  a  certain  case 
depends  partly  on  the  physique  of  the  individual  and  partly  on  the  character- 
of  the  food  to  which  she  has  been  accustomed.  A  mixed  diet  contributes 
most  to  the  sustenance  of  the  mother  and  to  an  abundant  secretion  of  milk. 

There  are  certain  kinds  of  food  which  do  appear  to  have  a  galactagogue- 
effect  with  most  wet-nurses.  Oatmeal  gruel  is  one  of  these.  Wet-nurses- 
often  remark,  after  taking  a  bowl  of  this,  that  they  feel  the  flow  of  milk. 
Cow's  milk  with  some  has  a  similar  effect.  Porter  or  ale,  taken  once  or  twice 
a  day,  also  promotes  the  secretion  of  milk,  especially  in  those  who  have  poor 
appetites  and  whose  systems  are  somewhat  reduced. 


42  INFANCY  AND  CHILDHOOD. 

A  great  variety  of  medicines  have  been  used  for  their  supposed  galacta- 
gogue  effect.  Medicines  which  improve  the  general  health  are  no  doubt 
sometimes  useful  for  this  purpose,  such  as  the  vegetable  and  ferruginous 
tonics  and,  perhaps,  cod-liver  oil.  But  there  are  other  medicines  which  it  is 
claimed  have  a  specific  effect  on  the  mammary  gland,  promoting  its  secretion. 
Lettuce,  wintergreen,  fennel,  the  broom  tops  (scoparius),  and  marshmallow 
have  been  used  for  this  purpose.  There  can  be  no  doubt  that  the  aromatic 
stimulants,  as  fennel,  anise,  and  carraway  seed,  given  in  soups,  sometimes 
stimulate  the  lacteal  secretion.  Another  medicine  which  has  been  recom- 
mended to  the  profession  as  a  galactagogue  is  castor  oil  and  the  plant  from 
which  it  is  derived.  Recently  a  medicine  designated  nutrolactis,  prepared 
from  the  galega  or  goat's  rue,  which  the  laity  in  the  country  where  it  grows 
believe  promotes  the  mammary  secretion,  has  been  employed  in  two  of  the 
New  York  maternity  services,  and  confidence  in  it  for  this  purpose  has  been 
fully  established  by  those  who  have  witnessed  its  effect.  The  dose  is  one 
tablespoonful  three  times  daily. 


CHAPTER  V. 

SELECTION  OF  A  WET-NUKSE. 

In  the  cities  cases  are  frequent  in  which  mothers,  with  all  possible  care 
or  endeavor,  find  themselves  unable  to  suckle  their  infants.  Their  health  is 
too  poor  or  the  milk  possesses  the  properties  of  colostrum,  or  it  is  no  longer 
secreted  on  account  of  nervous  excitement  or  exhaustion  or  inflammation  of 
the  breasts.  The  number  of  such  cases  in  the  city  would  surprise  physicians 
who  are  familiar  only  with  the  healthy  and  robust  mothers  of  the  country. 
The  infant  thus  deprived  of  the  mother's  milk  should,  if  practicable,  be  fur- 
nished with  a  wet-nurse. 

The  selection  of  a  wet-nurse  often  devolves  upon  the  physician,  and  is  a 
duty  of  great  responsibility.  We  have  stated  elsewhere  why  it  is  better  to 
select  one  between  the  ages  of  twenty  and  thirty  years.  Those  who  have 
previously  suckled  and  had  charge  of  infants  are  obviously  more  competent 
to  serve  as  wet-nurses  than  are  primiparae.  The  milk  of  a  wet-nurse  whose 
infant  is  under  the  age  of  six  months  will  ordinarily  agree  with  a  new-born 
infant.     If  above  that  age  it  sometimes  agrees,  but  often  does  not. 

The  most  difficult  and  responsible  task  imposed  on  the  physician  in  the 
selection  of  a  nurse  is  to  ascertain  the  exact  condition  of  her  health  and  the 
quantity  and  quality  of  her  milk.  Constitutional  syphilis  is  common  in  the 
class  of  women  who  present  themselves  for  wet-nursing ;  it  is  often  latent  or 
its  symptoms  are  easily  concealed,  and  it  is  communicable  by  lactation.  The 
virus  may  be  received  by  the  infant  from  fissures  or  excoriations  of  the  nip- 
ple. The  nursling  tainted  by  syphilis  may,  on  the  other  hand,  communicate 
the  disease  to  the  nurse  through  the  same  source.  It  is  not  fully  ascertained 
whether  the  syphilitic  virus  may  be  conveyed  to  the  infant  by  the  milk.  But 
the  cases  which  have  accumulated  in  the  records  of  medicine  are  numerous  in 
which  infants  born  of  healthy  parents  have  contracted  syphilis  from  the 
breasts  of  diseased  nurses,  (See  article  Syphilis.)  These  infants  have  some- 
times led  a  short  and  miserable  existence,  and  have  occasionally  increased  the 
misery  of  the  household  by  imparting  the  disease  to  others.  The  duty  is 
therefore  imperative  on  the  part  of  the  physician  to  examine  carefully  the 


SELECTION  OF  A    WET-NURSE.  43 

wet-nurse  in  reference  to  any  evidences  of  the  syphilitic  taint.  Acquainted 
with  the  symptoms  of  syphilis,  he  may  usually,  by  shrewd  questioning  and 
by  careful  examination  of  the  present  appearance  and  condition  of  the 
woman,  ascertain  with  considerable  certainty  whether  her  system  has  ever 
been  infected.  References  should  also  be  obtained  and  consulted,  and, 
if  practicable,  the   physician  who  has  attended  her  be  communicated  with. 

It  is  safer  to  employ  a  wet-nurse. two  months  after  her  confinement  than 
previously,  for  if  she  have  the  syphilitic  taint  it  will  by  this  time  show  itself 
in  the  innutrition,  coryza,  and  anal  sores  of  her  infant. 

There  are  also,  among  the  women  who  present  themselves  for  wet-nursing 
in  the  cities,  many  of  a  scrofulous  habit  and  many  who  possess  an  hereditary 
tendency  to  tuberculosis,  if  indeed  they  do  not  already  have  the  incipient 
disease.  Such  applicants  should  be  rejected  on  account  of  the  poverty  of 
their  milk  and  the  probability  that  they  will  not  be  able  to  endure  the  debil- 
itating effect  of  wet-nursing. 

The  milk  should  be  examined  in  order  to  ascertain  its  richness  and  quan- 
tity and  whether  it  contain  colostrum.  If  there  be  colostrum  after  the  eighth 
day,  it  is  probable  that  there  is  some  fault  in  the  health  or  digestion  of  the 
wet-nurse,  and  that  her  milk  may  disagree  with  the  infant.  It  is  not  neces- 
sary that  the  breast  should  be  large  in  order  to  furnish  a  sufficient  quantity 
of  milk,  since,  as  has  been  already  stated,  in  some  the  secretory  function  is 
active  during  the  time  of  each  nursing,  so  that,  although  the  breasts  are  of 
moderate  size,  a  sufficient  amount  of  milk  is  furnished. 

By  examination  of  the  milk  its  degree  of  richness  can  be  readily  ascer- 
tained. A  quantity  of  it  should  be  placed  in  a  test-tube,  and  the  cream 
which  rises  to  the  top  indicates,  approximately,  the  character  of  the  milk. 
Good  milk  furnishes  3  per  cent,  of  cream,  and  the  casein  and  sugar  usually 
correspond  in  quantity  with  the  cream.  An  instrument  has  been  invented, 
called  the  lactometer,  by  which  the  exact  amount  of  the  cream  can  be  ascer- 
tained. It  is  simply  a  tube  graded  into  one  hundred  divisions.  It  is  placed 
upright  and  filled  with  milk,  and  the  number  of  divisions  occupied  by  the 
cream  indicates  its  proportion  in  one  hundred  parts. 

Examination  of  the  milk  by  the  microscope  not  only  enables  us  to  deter- 
mine whether  there  are  abnormal  corpuscular  or  granular  elements,  but  also 
its  richness.  It  should  be  examined  before  the  cream  has  separated.  Oil- 
globules  of  small  size  and  few  indicate  poverty  of  the  milk ;  very  large  oil- 
globules  are  said  to  indicate  milk  which  is  liable  to  be  indigestible,  especially 
in  feeble  infants.  Such  are  the  free  globules  of  the  colostrum.  Numer- 
ous oil-globules  of  medium  size  indicate  nutritious  milk.  In  examining  the 
milk  by  the  microscope  or  otherwise  in  order  to  determine  its  richness,  the 
important  fact  should  be  borne  in  mind  that  milk  removed  from  the  breast 
at  short  intervals  is  richer  or  more  concentrated  than  that  removed  at  long 
intervals,  as  we  have  stated  elsewhere.  A  larger  percentage  of  water  is 
present  if  the  interval  be  four  hours  than  if  it  be  two  hours.  Another  im- 
portant fact  which  should  be  borne  in  mind  in  testing  the  milk  is  that  that 
first  drawn  from  the  breast  is  more  watery,  or  not  so  rich,  as  that  last  re- 
moved or  the  stripping,  as  is  seen  by  the  following  analysis,  made  by  Har- 
rington and  published  by  Rotch  in  his  interesting  paper  on  infant  feeding  in 
the  Oi/clopsedia  of  Diseases  of  Children  : 


Fat. 

Foremilk 3.88 

Middle  milk.    .    .    .6.74 
Strippings 8.12 


Total 
solids. 

Water. 

Ash. 

13.34 

86.66 

0.85 

15.40 

84.60 

0.81 

17.13 

82.87 

0.82 

44  IXFAXCT  AND  CHILDHOOD. 

The  increase  in  the  solid  constituents  of  the  milk  near  the  close  of  a 
nursing  is  said  to  be  chiefly  of  fat,  but  partly  of  the  albuminoids.  It  is 
evident,  therefore,  that  the  milk  obtained  from  a  breast  that  is  emptied  at 
short  intervals  is  richer  than  that  obtained  when  the  breast  is  drawn  at  long 
intervals. 

Kotch  publishes  the  following  analysis  made  by  Harrington,  in  which  this 

fact  is  clearly  shown  : 

:Milk  drawn  at  two  Milk  drawn  at  twelve 

hours'  intervaL  hours'  interval. 

Total  solids  ....  15.32  10.14 

Water ■  84.68  89.86 

100.00  100.00 

Vogel  in  1850  made  the  discovery  of  vibriones  in  human  milk.  The  fact 
is  established  that  these  animalcules  may  be  generated  in  the  milk  within  the 
breast,  though  such  cases  are  not  frequent.  Dr.  Gibb  describes  a  case  which 
he  met  (^Ranking' s  Abstract,  vol.  xxxiv.) :  An  infant  seven  weeks  old,  wet- 
nursed  by  its  mother,  who  had  the  appearance  of  perfect  health,  was,  never- 
theless, ill-nourished  and  emaciated.  It  had  no  diarrhoea  or  other  apparent 
disease,  and  the  milk  was  therefore  examined.  Vibriones  were  discovered  in 
the  milk  immediately  after  it  was  obtained  from  the  breast.  The  milk  had 
the  usual  amount  of  cream,  and  seemed  to  the  naked  eye  of  good  quality. 
According  to  Dr.  Gibb,  two  genera  of  microscopic  organisms  occur  in  the 
milk — namely,  vibriones  and  monads.  It  is  believed  that  the  monads  occur 
in  consequence  of  fermentation  of  the  sugar  and  the  production  of  lactic  acid. 
Yogel  also  attributed  the  production  of  the  vibriones  to  fermentation  occur- 
ring in  consequence  of  heat  and  congestion  of  the  breast  connected  with  sexual 
excitement.  This  explanation  is  probably  not  correct,  because  vibriones  some- 
times occur  when  there  is  no  unusual  heat  of  breast  and  no  evidence  of  fer- 
mentation. The  fact  that  such  organisms  may  be  found  in  milk  which  seems 
of  good  quality  to  the  naked  eye  aifords  additional  proof  of  the  usefulness  of 
the  microscope  in  the  selection  of  a  wet-nurse. 

Many  wet-nurses  have  a  return  of  the  menses  as  early  as  the  fourth  or 
fifth  month  after  delivery.  The  re-establishment  of  this  function  in  some 
women  impairs  the  quality  of  the  milk,  so  as  to  render  it  less  nutritious,  and 
perhaps  less  digestible,  during  the  time  of  the  catamenial  flow,  as  we  have 
stated  in  a  preceding  paragraph.  In  the  selection  of  a  wet-nurse,  then,  pref- 
erence should  be  given  to  one  who  does  not  have  the  periodical  sickness ;  but 
if  she  be  already  employed  and  give  satisfaction,  the  reappearance  of  the  cata- 
menia  does  not  indicate  the  need  of  the  change  of  nurse,  unless  the  digestion 
of  the  infant  be  disordered  or  its  nutrition  be  impaired. 

In  the  selection  of  a  wet-nurse  attention  should  also  be  given  to  her  mental 
and  moral  traits.  Cheerfulness,  afi'ection,  veracity,  and  a  proper  appreciation 
of  the  responsibility  of  her  situation  enhance  greatly  the  value  of  a  wet-nurse. 
Not  less  important  are  habits  of  temperance  and  cleanliness.  I  could  cite 
cases  of  the  most  melancholy  results  from  the  absence  of  these  traits.  In  one 
case  idiocy  resulted  from  an  infant  falling  upon  the  pavement  from  the  arms 
of  a  reckless  or  intemperate  wet-nurse. 

In  most  cases  the  mode  of  examination  indicated  above  suffices  to  show 
the  character  of  a  wet-nurse,  so  far  as  her  health  and  milk  are  concerned.  It 
should  be  borne  in  mind,  however,  that  the  microscope  does  not  always  reveal 
deleterious  properties  in  the  milk.  Elements  which  are  in  a  state  of  solution, 
and  are  invisible,  may  occur  in  excess,  so  as  to  impair  the  quality  of  the  milk 
and  render  it  indigestible.  The  following  case,  in  which  the  saline  ingredients 
seem  to  have  been  in  excess,  is  related  by  Dr.  Hartman  (British  and  Foreign 
Medical  Review,  vol.  xii.)  :  "  An  infant  whose  mother  was  in  good  health  and 


COURSE  OF   WET-NURSING— WEANING.  45 

had  borne  several  children  exhibited  a  healthy  appearance  for  the  first  five 
weeks  after  birth.  The  alvine  evacuations  then  became  copious,  fluid,  and 
discolored,  and  the  child  lost  flesh  and  strength.  After  the  usual  remedies 
had  been  vainly  administered  for  a  fortnight,  the  mother  remarked  that  the 
child  did  not  take  the  right  breast  willingly,  and  so  much  did  the  unwilling- 
ness increase  that  at  length  the  mere  application  of  the  nipple  to  the  child's 
lips  occasioned  loud  crying.  On  examination  it  was  found  that  the  milk  of 
the  right  breast  had  a  distinctly  saline  taste,  whereas  the  milk  of  the  opposite 
breast  was  of  the  ordinary  sweetness ;  no  difi'erence  of  consistence  or  color 
was  discoverable.  From  that  time  the  child  was  only  allowed  to  nurse  the 
left  breast,  and  in  a  few  days  all  diarrhoea  and  sickliness  of  appearance 
vanished."  In  this  case  there  was  no  appreciable  disease  of  the  breast, 
although  its  secretion  was  perverted.  The  deleterious  character  of  the  milk 
was  discovered,  not  by  any  change  in  its  appearance,  but  by  the  taste. 

It  is  obviously  very  necessary,  before  recommending  a  wet-nurse,  to  ascer- 
tain whether  she  will  probably  furnish  sufficient  milk  ;  for,  however  excellent 
she  may  otherwise  be.  if  she  do  not  satisfy  the  wants  of  the  infant  she  obvi- 
ously should  not  be  employed.  If  the  infant  of  the  nurse  be  well  nourished, 
and  if  it  seem  satisfied  after  nursing  ten  or  fifteen  minutes,  she  probably  has 
sufficient  milk.  The  more  exact  method  of  weighing  the  infant  before  and 
after  it  nurses,  and  observing  whether  the  difi'erence  corresponds  with  that 
given  in  Chapter  VII.,  enables  us  to  determine  more  accurately  the  capabil- 
ities of  the  wet-nurse. 


CHAPTER    YI. 
COUESE  OF  WET-XUESING— WEAXING. 

After  the  birth  of  the  infant  the  mother  needs  rest  a  few  hours— four  or 
five  or  a  little  longer  in  tedious  and  exhaustive  cases — and  then  it  should  be 
applied  to  the  breast.  There  is  frequently  a  little  milk  at  this  time,  and  the 
act  of  nursing  promotes  the  secretion  and  increases  the  quantity.  The  full 
secretion  is  not,  however,  established  before  the  third  day,  and,  though  the 
infant  be  applied  to  the  breast  often,  it  obtains  but  little  milk.  Infants  are 
so  constituted  that  they  require  but  little  food  until  it  is  naturally  provided 
for  them,  and  the  common  practice  of  feeding  them  to  repletion  with  various 
sweetened  mixtures  almost  as  soon  as  life  begins,  because  they  obtain  little 
breast-milk,  is  to  be  deprecated.  Filling  their  stomachs  in  this  way  has  a 
tendency  to  prevent  their  drawing  upon  the  nipples  with  the  avidity  which 
is  required  to  stimulate  a  free  fiow  of  milk.  Besides,  as  I  have  many  times 
observed,  indigestion,  diarrhoea,  and  sprue  are  common  results  of  this  inju- 
dicious feeding.  If,  therefore,  the  infant  be  applied  to  the  breast  every  second 
hour  when  the  mother  is  awake  till  the  third  day,  and  be  fed  nothing  besides, 
there  need  be  no  anxiety  as  regards  its  nutrition.  If  on  the  third  day  the 
breasts  do  not  begin  to  fill  and  the  secretion  be  delayed,  a  little  fresh  Pas- 
teurized cow's  milk,  diluted  with  double  its  quantity  of  warm  water,  and 
slightly  sweetened,  should  be  given  every  fourth  hour,  but  should  be  with- 
held as  soon  as  the  fiow  of  milk  occurs. 

Infants  under  the  age  of  one  month  should  take  the  breast  about  every 
hour  and  a  half  by  day  and  at  longer  intervals  by  night,  or  about  twelve 
times  in  twenty-four  hours,  for  the  stomach  of  the  new-born  holds  but  little, 
and  therefore  receives  but  little  at  each  nursing,  and  its  digestion  is  active. 


46  INFANCY  AND  CHILDHOOD. 

The  interval  should  be  longer  at  night  than  in  the  day-time,  so  as  to  allow 
the  mother  more  sleep.  In  the  second  month  and  subsequently  the  interval 
should  be  about  two  hours. 

The  infant  should  be  habituated  to  nursing  at  regular  intervals,  and  when 
it  is,  it  will  ordinarily  awaken  at  about  the  proper  time.  The  practice  on  the 
part  of  the  mother  of  applying  the  babe  to  the  breast  whenever  it  frets  and 
as  a  means  of  quieting  it.  although  it  have  but  just  nursed,  is  pernicious 
and  should  be  forbidden.  Giving  the  stomach  no  time  to  rest  or  filling  it  to 
repletion  tends  to  produce  indigestion  and  diarrhoea  and  to  increase  its  fret- 
fulness.  The  cause  of  the  fretfulness  should  be  sought  for,  that  the  proper 
measures  may  be  applied.  Frequently  it  is  due  to  insufficient  breast-milk, 
and  more  or  less  supplementary  feeding  may  be  required. 

While  regularity  in  nursing  is  required,  still,  as  M.  Donne  has  said, 
mathematical  exactness  in  this  matter  would  be  ridiculous.  Quiet  natural 
sleep  of  a  well-nourished  infant  should  not  be  interrupted  in  order  to  give  it 
the  breast,  unless  the  sleep  be  unusually  protracted.  It  will  usually  awaken 
when  the  system  requires  more  nutriment.  Ill-nourished  infants  often  sleep 
but  little,  making  known  their  want  by  crying  and  fretfulness,  until  they 
become  wasted  and  prostrated,  when  they  are  drowsy  in  consequence  of  pas- 
sive congestion  of  the  brain.  This  drowsiness  is  evidently  a  pathological 
symptom.  It  shows  the  need  of  increased  nutrition.  It  is  due  to  scantiness 
of  milk  or  milk  of  poor  quality,  and  the  infant  should  be  aroused  frequently 
for  the  purpose  of  giving  it  nutriment  or  even  stimulants.  The  breast-milk 
is  sufficient  for  its  nutrition  till  the  age  of  six  or  eight  months,  provided  that 
it  is  abundant  and  of  good  quality.  Therefore,  if  the  mother  be  strong  and 
experience  no  exhaustion,  no  other  nutriment  need  be  given  till  that  age. 

Many  mothers,  however,  by  the  third  or  fourth  month  of  wet-nursing  find 
that  they  have  not  sufficient  milk  to  meet  the  wants  of  the  infant.  The  con- 
stant drain  upon  their  systems  sensibly  impairs  their  health.  In  such  cases 
it  is  proper  to  commence  with  a  little  feeding  from  the  spoon  or  bottle,  and 
increase  the  quantity  given  as  the  infant  grows  older.  Great  care  is,  how- 
ever, requisite  in  the  preparation  of  food  for  so  young  an  infant,  whose 
digestive  organs  are  still  feeble  and  easily  deranged.  In  the  country,  where 
diarrhoeal  affections  and  the  so-called  gastric  derangements  are  not  frequent, 
the  danger  from  artificial  feeding  is  less  than  in  the  city,  and  in  the  cool 
months  in  the  city  the  danger  is  less  than  in  the  summer  season.  Infants  of 
the  city  between  the  months  of  May  and  October  have  a  strong  predisposition 
to  diarrhoeal  attacks,  the  result  of  antihygienic  influences  which  surround 
them.  Errors  of  diet  in  their  case  readily  provoke  disease  or  derangement 
of  the  digestive  organs,  often  of  a  severe  and  dangerous  form.  Moreover, 
experience  has  shown  that  artificial  feeding  during  the  period  when  nature 
designed  that  they  should  be  nourished  at  the  breast  very  commonly  produces 
in  the  hot  months  more  or  less  vomiting  and  diarrhoea,  followed  by  emacia- 
tion and  other  evidences  of  malnutrition.  Therefore  an  exception  must  be 
made  in  case  of  the  city  infant  as  regards  the  commencement  of  artificial 
feeding.  If  it  be  under  the  age  of  one  year,  it  should  be  nourished  exclu- 
sively, or  almost  exclusively,  at  the  breast  during  the  hot  months  when  prac- 
ticable, even  if  the  mother  suffers  somewhat  in  her  health  from  the  constant 
drain  upon  her  system.  It  should,  however,  receive  the  amount  of  nutriment 
which  it  requires,  and.  if  there  be  not  sufficient  breast-milk,  it  will  be  neces- 
sary to  supply  the  deficiency  by  artificial  feeding.  The  reader  is  referred  to 
Chapter  VIII.  for  facts  relating  to  the  subject  of  artificial  feeding. 

Weaning  ought  to  take  place,  as  a  rule,  between  the  ages  of  ten  and 
twelve  months.  It  is  well,  if  the  mother's  health  be  good  and  her  milk 
sufficient,  to  defer  weaning  till  the  canine  teeth  appear.     The  infant,  then 


QUANTITY  OF  FOOD  REQUIRED  IN  INFANCY  AND  CHILDHOOD.    47 

possessing  sixteen  teeth,  is  able  to  masticate  the  softer  kinds  of  solid  food. 
Weaning  should  be  gradual.  Mothers  often  speak  of  weaning  on  a  certain 
day.  They  have  given  but  little  artificial  food  and  have  suckled  at  regular 
intervals,  till  at  a  fixed  time  they  have  denied  the  breast  altogether.  This 
abrupt  change  of  diet  should  be  discouraged.  It  should  only  be  recom- 
mended under  peculiar  circumstances.  It  is  likely  to  derange  the  digestive 
organs,  and  it  causes  fretfulness  and  sleeplessness  on  the  part  of  the  infant 
for  a  week  or  more.  Weaning  should  commence  by  feeding  with  a  spoon  a 
little  oftener  through  the  day,  and  nursing  less,  and  by  discontinuing  the 
practice  of  suckling  at  night.  The  infant  tolerates  this  gradual  change  of 
diet,  while  it  rebels  against  sudden  weaning,  and  by  its  fretfulness  increases 
greatly  the  care  and  trouble  of  the  mother.  Nurslings  in  the  city  should 
not  be  weaned  in  warm  weather  nor  within  a  month  immediately  preceding 
it.  If  the  mother's  health  fail  or  her  milk  become  deficient  in  the  summer 
months,  so  that  she  cannot  continue  suckling,  a  wet-nurse  should  be  employed, 
or  the  infant  should  be  sent  to  some  rural  locality  and  weaned  there.  Wean- 
ing in  the  city  in  hot  weather  should,  if  practicable,  be  avoided  on  account 
of  the  liability  to  the  summer  diarrhoea  produced  by  change  of  diet,  although 
I  believe  there  is  less  danger  from  this  than  formerly,  since  we  now  under- 
stand better  how  to  feed  infants. 


CHAPTER    VII. 
QUANTITY  OF  FOOD  REQUIEED  IN  INFANCY  AND  CHILDHOOD. 

Infantile  Feeding. 

Over-feeding -More  than  half  a  century  has  elapsed  since  the  most  dis- 
tinguished New  England  physician  of  his  day,  Dr.  James  .Jackson  of  Boston, 
wrote  in  his  Letters  to  a  Young  Physician  that  a  certain  ailment  of  the  diges- 
tive system  of  infants  had  often  puzzled  him  when  a  young  practitioner.  It 
was  characterized  by  the  occurrence  of  green  and  unhealthy  stools,  showing 
imperfect  digestion.  The  stools  contained  an  unusual  amount  of  mucus,  and 
were  passed  more  frequently  than  the  normal  stools  of  a  healthy  infant. 
After  observing  many  infants  thus  affected,  and  ascertaining  the  manner  and 
frequency  of  their  feeding,  the  truth  gradually  dawned  upon  him  that  their 
unhealthy  evacuations  were  due  to  over-feeding.  By  diminishing  the  amount 
of  nutriment  given  and  lengthening  the  intervals  between  the  feedings  these 
infants  were  soon  cured. 

Suction  by  the  lips  of  the  infant  seems  to  be  to  a  great  extent  automatic, 
so  that  if  its  mother  or  wet-nurse  have  a  copious  supply  of  milk,  it  is  liable 
to  over-nurse,  or,  if  it  be  bottle-fed,  is  liable  to  take  more  from  the  bottle 
than  it  requires  for  its  nutrition.  Some  infants  if  over-fed  regurgitate  the 
surplus  food,  but  others  do  not,  and  the  portion  which  is  not  digested  under- 
goes fermentation  and  acts  as  an  irritant  to  the  stomach  and  intestines. 
Acids,  as  the  butyric  and  lactic,  and  gases  which  distend  the  stomach  and 
intestines  and  cause  colicky  pains,  form  from  the. fermentation.  An  infant 
thus  suff"ering  from  overtaxed  digestion,  and  from  the  presence  of  irritating 
acids  and  gases  in  the  stomach  and  intestines,  is  usually  fretful  and  its  sleep 
is  disturbed  and  broken.  The  cause  of  its  restlessness  is  often  misunder- 
stood by  the  mother,  who  thinks  it  may  be  due  to  insufficient  nutriment,  and 


48  INFANCY  AND   CHILDHOOD. 

accordingly  it  is  applied  more  frequently  to  the  breast,  or,  if  it  be  bottle-fed, 
it  is  given  the  bottle  more  frequently.  I  have  seen  not  a  few  over-fed  infants 
who  on  account  of  their  fretfulness  were  applied  to  the  breast  at  intervals  of 
a  few  minutes,  so  that  the  health  of  their  mothers  was  impaired  by  the  lack 
of  sleep  and  the  drain  upon  their  systems ;  and  the  infants,  on  account  of 
too  frequent  nursing,  had  indigestion,  and  occasionally  gastro-intestinal 
catarrh.  Moreover,  milk  drawn  too  frequently  from  the  breast  usually 
contains  an  excess  of  the  solids,  so  that  it  is  digested  with  more  difficulty 
than  when  it  is  drawn  at  the  proper  intervals,  as  I  have  elsewhere  stated. 
For  this  reason  also  too  frequent  application  of  infants  to  the  breast  is  likely  • 
to  cause  indigestion  and  gastro-intestinal  derangements. 

Cases  might  be  related  to  substantiate  these  statements.  Thus  in  Decem- 
ber last  I  attended  an  infant  of  four  months  that  had  been  very  fretful  and 
with  insufficient  sleep  for  weeks.  The  wet-nurse  who  had  charge  of  it  had 
apparently  the  proper  requisites,  such  as  health,  youth,  robustness,  and  well- 
developed  breasts,  which  seemed  to  furnish  sufficient  milk  and  of  good  qual- 
ity. But  the  infant,  though  fairly  nourished,  had  so  little  sleep  and  was  so 
fretful,  crying  so  much  during  the  night  as  well  as  day,  that  the  whole  house- 
hold was  deprived  of  the  needed  rest.  The  nature  of  the  baby's  ailment 
was  soon  detected,  for  its  stools  presented  appearances  indicative  of  indiges- 
tion and  intestinal  catarrh.  They  contained  numerous  rounded,  whitish 
masses,  apparently  of  casein  mixed  with  mucus  and  thin  fecal  matter. 
Pepsin  preparations  with  bismuth  were  at  first  employed,  without  any 
marked  result,  but  improvement  began  at  once  when  the  infant,  instead  of 
being  frequently  applied  to  the  breast,  as  had  been  the  practice,  was  allowed 
to  take  it  only  every  third  hour,  and  was  fed  nothing  in  the  interval.  It  had 
been  over-fed,  and  the  remedy  more  effectual  than  the  medicines  employed 
was  the  simple  one  of  its  less  frequent  application  to  the  breast.  Over-feed- 
ing is,  I  think,  more  common  with  bottle-fed  infants  than  with  those  nour- 
ished at  the  breast. 

InsufB.cient  Nutriment. — We  have  alluded  in  a  preceding  page  to 
insufficient  feeding  of  the  newly-born,  but  older  infants,  both  wet-nursed 
and  bottle-fed.  frequently  do  not  obtain  sufficient  nutriment.  In  families  of 
the  city  poor  nursing  mothers  often  have  scanty  diet  and  are  over-worked,  and 
the  milk  which  they  furnish  to  their  nurslings  under  such  circumstances  is 
liable  to  be  watery  and  insufficient.  Sometimes  infants,  when  they  have 
reached  an  age  at  which  the  breast-milk  is  inadequate  and  additional  food 
is  urgently  needed,  are  nevertheless  denied  this  by  their  mothers.  Even 
mothers  who  are  apparently  robust,  and  give  the  breast  at  proper  intervals, 
often  have  insufficient  milk,  so  that  their  infants  do  not  thrive,  and  they  are 
ignorant  of  the  cause.  MM.  Yernois  and  Becquerel,  on  careful  examination 
of  89  infants  wet-nursed  by  women  apparently  in  good  health,  ascertained 
that  15  were  insufficiently  nourished.  An  infant  that  obtains  sufficient  breast- 
milk  draws  the  breast  quietly  and  continuously  twelve  or  fifteen  minutes, 
when  it  releases  its  hold  of  the  nipple  and  probabl}^  falls  into  a  quiet  sleep, 
having  a  satisfied  aspect.  If  the  breast-milk  is  scanty  and  insufficient,  the 
baby  is  fretful  when  it  nurses,  frequently  lets  go  of  the  nipple,  and  does  not 
have  the  quiet  sleep  of  the  satisfied  infant.  If  its  mouth  be  inspected  when 
it  is  nursing,  it  will  be  found  to  contain  but  little  milk.  But  if  the  supply 
of  breast-milk  be  abundant,  it  will  appear  in  quantity  between  the  lips  and 
in  the  mouth  of  the  infant  during  the  nursing. 

Again,  many  bottle-fed  infants  are  allowed  sufficient  food,  but  it  is  not 
adapted  to  their  age,  and  is  digested  with  difficulty,  so  that  the  nutriment 
which  they  derive  from  it  is  insufficient.  Much  has  been  said  and  written 
upon  the  practice  common  in  tenement-houses  of  giving  farinaceous  food  to 


Q UANTITY  OF  FOOD  REQ  UIBED  IN  INFANCY  AND  CHILDHOOD.     49 

infants  under  the  age  of  three  months,  when  the  saliva,  which  is  the  chief 
agent  that  digests  starch,  is  scanty  and  insuificient  for  its  digestion.  In  the 
feeding  of  older  children  in  families  of  the  laboring  class  we  know  how  fre- 
quently food  is  employed  that  is  unsuitable  to  the  age — that  acts  as  an  irri- 
tant to  the  stomach  and  intestines,  producing  attacks  of  vomiting  and  diar- 
rhoea. The  portion  of  such  food  that  is  digested  and  which  serves  for 
nutrition  is  insufficient,  while  the  undigested  part  acts  as  an  irritant.  Infants 
that  receive  such  unsuitable  diet  really  suflFer  from  lack  of  food,  although  its 
bulk  may  be  sufficient.  They  are  hungry  from  the  lack  of  pi'oper  nutri- 
ment, and  are  consequently  fretful.  They  digest  and  assimilate  so  small  a 
part  of  this  unsuitable  diet  that  they  lose  flesh  and  have  the  usual  symptoms 
of  innutrition. 

It  is  evident  from  this  survey  of  what  actually  occurs  in  the  feeding  of 
infants  that,  while  it  is  of  the  utmost  importance  that  food  should  be  of  the 
proper  kind  according  to  the  age  and  properly  prepared,  it  is  also  equally 
necessary  for  their  successful  alimentation  that  they  be  fed  at  proper  inter- 
vals and  with  the  proper  amount  of  food. 

A  few  years  since  Drs.  Chadbourne,  Parker,  and  myself  made  observa- 
tions in  the  New  York  Infant  Asylum  and  Xew  York  Foundling  Asylum  in 
order  to  determine  how  much  food  children  require  at  different  ages.  Those 
selected  for  observation  were  well  nourished,  and  they  were  accurately  weighed 
before  and  after  each  nursing  or  feeding.  Eleven  infants  under  the  age  of 
three  weeks,  who  took  the  breast,  with  three  exceptions,  twelve  times  in  the 
twenty-four  hours,  were  found  to  take  in  the  average  12.55  ounces  of  the 
breast-milk  in  the  day  and  night,  as  is  seen  by  the  following  table  : 


Table  I.- 

—Neioly- 

horn  Infants  (those  xmder  the  Age  of  Three 

Weeks). 

! 

Milk  nursec 

in  24  hours. 

No. 

Name. 

.              i    Number  of 
^^^-             nursings. 

Quantity  in 
weight. 

Quantity  in 
fluidounces. 

1                        i 

oz.     dr. 

1 

J.  F 

17  days.     |         11 

10       * 

9.75 

2 

H.  C. 

• 

16     '■'                   9 

13     5 

13.24 

3 

H.  J. 

.  !    19     "                  9 

10     3 

10.07 

4 

R.  .    . 

.  '      5     "        1         12 

22     7 

22.22 

5 

H.  B. 

.  i       6      "         ;          12 

15     5* 

15.25 

6 

W.  F. 

•  1      5     " 

12 

10     1* 

9.88 

7 

N.  H. 

.  j    14     " 

12 

17     3 

16.85 

8 

C.  F. 

5     " 

12 

5     4 

5.37 

9 

F.  D. 

7     " 

12 

14    4 

14.8 

10 

E.  S. 

6     " 

12 

8     1 

7.74 

11 

E.  B. 

3  weeks.  |         12 

14     1 

13.68 

The  observations  in  the  second  table  relate  to  infants  between  the  ages 
of  one  month  and  ten  months,  and,  with  one  exception,  between  the  ages  of 
two  months  and  ten  months.  It  was  found  that  they  received  on  the  average 
23.79  fluidounces  of  breast-milk  in  twenty-four  hours.  The  number  of 
nursings  in  the  day  and  night  varied  from  seven  to  ten.  Therefore  those 
infants  between  the  ages  of  one — or,  more  accurately,  two — months  and  ten 
months,  if  they  took  the  breast  eight  times  in  the  twenty-four  hours,  required 
three  ounces  at  each  nursing ;  if  twelve  times,  they  required  two  ounces 
each  time. 

According  to  these  statistics,  infants  under  the  age  of  three  weeks  uour- 


60 


INFANCY  AND  CHILDHOOD. 


ished  at  the  breast  and  suckled  twelve  times  in  the  twenty-four  hours  require 
only  one  ounce,  or  not  more  than  one  ounce  and  a  drachm,  at  each  nursing ; 
and  the  very  small  size  of  the  stomach  at  this  age  shows,  I  think,  that  it 
cannot  receive  much  more  than  this  without  distention.  After  the  third 
week  the  amount  required  for  healthy  nutrition  gradually  increases. 


Table 

II. 

-Ages  from  One  Month  to  Ten  Months. 

Milk  nursed 

in  24  hours. 

No. 

Name. 

Age. 

Number  of 
nursings. 

Quantity  in 
weight. 

Quantity  in 
iiuidounces. 

oz.     dr. 

1 

A.  S 

6  months. 

8 

26  n 

25.3 

2 

J.  B. 

4       " 

9 

38       J 

36.8 

3 

W.  G. 

Zl     " 

8 

24     2 

23.5 

4 

L.  B. 

7       " 

10 

27     3J 

26.6 

5 

W.  L. 

1  5J     " 

11 

28     7 

28 

6 

J.  C. 

5       " 

10 

29     7 

29 

7- 

A.  W. 

3J     " 

8 

19     2 

18.6 

8 

F.  Van 

B 

2  m.  10  d. 

7 

24     4 

23.7 

9 

E.  W. 

6  months. 

10 

12  ^ 

12.2 

10 

F.  S. 

H    " 

8 

26    7 

26.1 

11 

s.  w. 

4       " 

8 

23     5 

22.9 

12 

J.  G. 

9       " 

8 

24     IJ 

23.4 

13 

B.  J. 

7       " 

8 

27     4 

26.6 

14 

T.  C. 

6       " 

10 

26     6^ 

26 

15 

A.  R. 

6       " 

10 

21     6 

21.1 

16 

C.  H. 

1  m.  5  d. 

8 

11     IJ 

10.84 

According  to  my  observations,  infants  in  good  health  and  well  nourished 
do  not  all  require  or  take  the  same  amount  of  food.  Some  infants,  like 
adults,  need  more  food  than  others,  but  the  following  table  indicates,  I  think, 
nearly  the  quantity  required  during  the  first  twelve  months  of  infancy,  either 
of  breast-milk,  or  of  cow's  milk  prepared  so  as  to  resemble  as  closely  as  pos- 
sible breast-milk  in  consistence  and  nutritive  properties.  It  will  be  observed 
that  this  table  resembles  closely  that  prepared  by  Professor  Rotch  of  Har- 
vard University,  and  published  in  his  instructive  paper  on  infant  feeding  in 
the    Cyclopstdia  of  the  Diseases  of  Children : 


Table  III.- 

-Deductions 

from 

the  above  Statistics. 

At  each  feeding. 

Number  of 
daily  feedings. 

Total 
daily  quantity. 

During  the  first  week  1  oz 

10 
10 

8 
8 
7 
6 
5 

10  oz. 

At  the  tliird  week  1^  oz    .        

15  " 

At  the  sixth  week  2  oz      

16  " 

At  the  third  month  3  oz 

24  " 

At  the  fourth  month  4  oz 

28  " 

At  the  sixth  month  6  oz 

36  " 

At  the  tenth  to  twelfth  months  S  nz 

40  " 

q  UANTITY  OF  FO  OD  REQ  UIBED  IN  INFANCY  AND  CHILDHO  OD.     51 


Table  TV. —  Observations  relating  to  the  Diet  during  Twenty-four  Hours  of 
Ticenty-eight  Healthy  Children  heticeen  the  Ages  of  Two  and  Three  Years, 
with  an  Average  Age  of  Two  Years  and  Eight  Months. 


Breakfast. 


Bread 
Butter 
Milk 


Meat  . 
Potatoes 
Milk     . 


Milk 

Bread 

Butter 


DlNNEE. 


Supper. 


Total  amount. 


6  lbs.    4  oz.  1  dr. 

13  oz.  5  dr. 

22  lbs.  14  oz.  2  dr. 


8  lbs.    0  oz.  5  dr. 

6  lbs.  13  oz.  7  dr. 

17  lbs.    9  oz.  7  di'. 


19  lbs.  12oz.  1  dr. 

7  lbs.    1  oz.  2  dr. 

14  oz.  7  dr. 


Average  for  each. 


3. 5    oz. 
0.45  oz. 
12.7    fl.  oz. 


4.6 
3.9 
9.4 


oz. 
oz. 


10.5  fl. 
4.0  oz. 
0.53  oz. 


DATLY  AVERAGE  FOR  EACH  CHILD. 

Bread 7.5    oz. 

Butter 0.98  oz. 

Meat  (beef) 4.6    oz. 

Potatoes 3.9    oz. 

]VIilk 32.6    fl. 


Table  V. —  Observations  upon  Twelve  Children  between  the  Ages  of  Three  and 
Six  Years :   Average  Age,  Four  Years  and  Ten  Months, 


Total  amount. 

Average  for  each. 

Bread    .    . 
Butter  .    . 
Milk 

Breakfast. 

4  lbs.    6  oz.  3J  dr. 
5  oz.  2    dr. 
280  fl.  oz. 

9  lbs.    1  oz.  3    dr. 

1  lb.      0  oz.  1    dr. 
9  lbs.  12  oz.  7    dr. 
112  fl.  oz. 

2  oz.  2J  dr. 

2  lbs.    4  oz.  n  dr. 

5  oz.  5i  dr. 
192  fl.  oz. 

5.86    oz. 

0.427  oz. 

23.3  fl.  oz. 

Beef.    .    . 
Bread    .    . 
Kice 

Dinner. 

12.1  oz. 

1.6  oz. 

13.0  oz. 

Milk                 

9.3  fl.  oz. 

Butter 

Supper. 

3.0  oz. 

Butter . 

Milk 

16.0  fl.  oz. 

DAILY  AVERAGE  FOR  EACH  CHILD. 

Milk - 48.6    fl.  oz. 

Beef 12.1    oz.  avoir. 

Eice  . •    •  13.0    oz.     " 

Bread - l<^-3    oz.      " 

Butter 1.08  oz.     " 


52 


INFANCY  AND  CHILDHOOD. 


Table  VI. —  Observations  relating  to  the  Diet  of  Twenty-four  Children — 
Twelve  Boys,  Twelve  Girls — between  the  Ages  of  Four  Years  and  Ten 
Years :  Average,  Six   Years  and   Ten  Months. 


Breakfast. 


Bread 

Butter 
Milk 


Dinner. 


Koast  beef 
Potatoes  . 
Bread  .  . 
Milk  .  . 
Butter  .    . 


Supper. 


Bread 

Milk 

Butter 


Total  amount. 


7  lbs.  13  oz.  3    dr. 
12  oz.  3^  dr. 
348  fl.  oz. 


18  lbs.  11  oz.  0    dr. 
15  lbs.    8  oz.  3    dr. 
1  lb.      6  oz.    J  dr. 
192  fl.  oz. 

4idr. 


6  lbs.    2  oz.  U  dr. 
384  fl.  oz. 

11  oz.  5j  dr. 


Average  for  each. 


5.21    oz. 

0.51    oz. 

14.5      fl.  oz. 


12.46    oz. 
10.30    oz. 

0.92    oz. 

8.0      fl.  oz. 

0.012  oz. 


4.1      oz. 
16.0      fl.  oz. 
0.16    oz. 


DAILY   AVERAGE  FOR   EACH   CHILD. 

Koast  beef 12.46  oz. 

Bread •.    .    .    .  10.23  oz. 

Potatoes •  10.3    oz. 

Butter 0.99  oz. 

Milk 38.5    fl.  oz. 

Compare  the  above  observations  witb  those  of  Professor  Dalton.  who 
estimates  that  a  healthy  adult  taking  active  exercise  requires,  each  day, 

Meat 16    oz. 

Bread 19    oz. 

Butter 3^  oz. 

Water 52    oz., 

while  one  leading  a  sedentary  life  needs  considerably  less. 

It  will  be  seen  by  the  above  tables  that  even  more  food  appears  to  be 
needed  during  the  period  of  childhood  than  in  adult  life.  We  would  suppose 
this  to  be  so  without  statistical  evidence,  for  the  active  exercise  and  rapid  and 
progressive  growth  of  this  period  necessarily  require  a  large  amount  of  nutri- 
ment. Moreover,  while  adults  do  well  with  solid  food  and  water,  statistics 
show  that  the  best  diet  for  children  who  have  passed  beyond  infancy  is  one 
of  milk,  with  solid  food. 

Although  we  are  able,  by  observations,  to  determine  the  average  amount 
of  food  required  in  twenty-four  hours  by  children  of  various  ages,  we  repeat 
that  it  would  be  wrong  to  prescribe  a  fixed  amount  for  all  children  of  a  given 
age,  for  some  need  more  than  others.  A  child  should  never  go  hungry  after 
a  meal.  In  some  of  the  best-conducted  institutions  of  New  York  the  chil- 
dren eat  of  plain  food  all  that  they  desire  at  each  meal,  while  in  other  insti- 
tutions the  food  at  supper  is  limited,  but  is  abundant  at  the  other  meals.  As 
children  go  to  bed  so  soon  after  supper,  it  is  proper  to  have  this  meal  light 
and  of  such  food  as  is  easily  digested. 

The  time  required  in  the  digestion  of  different  foods  has  been  investigated 
by  Beaumont  and  Bichat,  but  their  investigations  relate  to  adults.     The  time 


ARTIFICIAL  FEEDING.  53 

occupied  in  the  gastric  digestion  of  various  foods  has  been  determined  in 
adult  cases  by  inspecting  the  interior  of  the  stomach  through  a  gastric  fistula. 
No  such  opportunity  has  ever  occurred,  so  far  as  I  am  aware,  of  inspecting 
the  process  of  digestion  in  the  interior  of  the  stomach  either  in  infancy  or 
childhood.  But  recently  experiments  have  been  made  for  the  purpose  of 
determining  the  time  occupied  in  gastric  digestion  in  infancy.  The  import- 
ance of  such  experiments  is  apparent,  for  if  we  know  how  soon  after  feeding 
gastric  digestion  is  completed  and  the  stomach  emptied,  we  will  know  how  fre- 
quent the  feeding  should  be.  According  to  H.  Leo,  in  an  infant  a  few  weeks 
old  one  hour  sufiices  for  the  stomach  digestion  of  the  milk  which  it  receives, 
so  that  this  organ  is  already  empty  one  hour  after  the  nursing,  and  in  a  con- 
dition to  receive  more  milk.  In  older  infants,  who  receive  more  milk,  the 
milk  is  retained  longer  in  this  organ,  one  and  a  half  hours  being  required  for 
the  stomach  digestion  of  human  milk,  and  two  hours  for  the  digestion  of 
cow's  milk  (Berlin,  klin.  WochenscJir.,  No.  49,  1888).  Recently  (1889),  Dr. 
Max  Einhorn  of  New  York  has  investigated  the  stomach  digestion  of  infants, 
using  a  Nelaton  catheter  No.  14  A,  with  which  he  withdrew  the  contents  or 
determined  the  emptiness  of  the  stomach.  He  ascertained  that  in  the  infant 
receiving  human  milk  the  stomach  was  empty  two  hours  after  the  nursing, 
and  probably  in  one  and  a  half  hours.  After  feeding  with  equal  parts  of 
cow's  milk  and  barley-water,  the  stomach  was  practically  empty  at  a  little 
before  the  close  of  the  second  hour.  After  feeding  with  milk  and  water, 
equal  parts,  the  stomach  was  empty  in  about  one  and  a  half  hours.  The 
digestibility  of  several  of  the  proprietary  foods  which  are  most  in  use  was 
also  ascertained  in  a  similar  manner.  A  considerable  amount  of  these  foods 
was  still  in  the  stomach  undergoing  digestion  two  hours  after  they  were 
administered.  These  interesting  and  instructive  observations  of  Dr.  Einhorn 
indicate  the  intervals  required  in  feeding  with  milk  and  with  other  foods. 

It  is  seen  that  there  is  a  general  agreement  in  the  result  obtained  by  dif- 
ferent observers  in  regard  to  the  amount  of  food  required  at  each  feeding, 
and  the  proper  intervals  between  the  feedings,  during  infancy  as  well  as 
childhood. 


CHAPTER    VIII. 

AKTIFICAL  FEEDING. 

Occasionally  the  mother  is  unable  to  suckle  her  infant,  and  a  hired  wet- 
nurse  cannot  be  or  is  not  obtained.  Artificial  feeding  is  then  necessary.  In 
the  large  cities  this  mode  of  alimentation  for  young  infants  should  be  dis- 
couraged, if  human  milk  abundant  and  of  good  quality  can  be  obtained,  for 
it  frequently  ends  in  death,  preceded  by  evidences  of  faulty  nutrition.  A 
considerable  proportion  of  those  nourished  in  this  manner  thrive  during  the 
cold  months,  but  on  the  approach  of  the  warm  season  they  are  the  first  to  be 
affected  with  diarrhoea  and  other  symptoms  indicating  derangement  of  the 
digestive  function.  In  New  York  City  a  large  proportion  of  the  artificially- 
fed  infants   who   enter  the   summer  months   die   before  the   return  of  cool 


54 


INFANCY  AND  CHILDHOOD. 


weather,  unless  saved  by  removal  to  the  country ;  but  the  mortality  of  these 
infants  has  been  in  a  measure  reduced  of  late  years  by  improvement  in  the 
mode  of  feeding  and  in  the  sanitary  condition  of  the  nursery.  In  the  country 
and  in  small  inland  cities  the  results  of  artificial  feeding  are  much  more  favor- 
able. In  elevated  farming  sections,  on  account  of  the  salubrity  of  the  air 
and  the  facility  with  which  milk,  fresh  and  of  the  best  quality,  is  obtained, 
artificial  feeding  is  attended  by  much  less  risk  than  in  the  cities. 

Young  infants,  fed  by  the  hand,  obviously  require  food  prepared  so  as  to 
resemble  as  closely  as  possible  human  milk  in  its  composition.  Woman's 
milk  in  health  is  always  alkaline.  It  has  a  specific  gravity  of  1031.7  ;  cow's 
milk  has  a  specific  gravity  of  1029.  That  of  cows  stabled  and  fed  upon  other 
fodder  than  hay  or  grass  is  decidedly  acid.  That  from  cows  in  the  country 
with  good  pasturage  is  also  slightly  acid.  In  two  dairies  in  Central  New 
York  a  hundred  miles  apart,  in  midsummer,  with  an  abundant  pasturage,  two 
competent  persons  whom  I  requested  to  make  the  examinations  found  the 
milk  moderately  acid  immediately  after  the  milking  in  all  the  cows. 

How  to  feed  infants  deprived  of  breast-milk  is  a  very  important  problem. 
The  following  results  of  a  large  number  of  analyses  of  woman's  and  cow's 
milk,  made  by  Konig  and  quoted  by  Leeds,  and  of  several  of  the  best-known 
and  most-used  preparations  designed  by  their  inventors  to  be  substitutes  for 
human  milk,  show  how  far  these  substitutes  resemble  the  natural  aliment  in 
their  chemical  characters : 


Woman's  milk. 

Cow's  milk. 

Mean. 

Minimum. 

Maximum. 

Mean. 

Minimum. 

Maximum. 

Water 

87.09 

83.6 

90.90 

87.41 

80.32 

91.50 

Total  solids  . 

12.91 

9.10 

16  31  • 

12.59 

8.50 

19.68 

Fat    .    . 

3.90 

1.71 

7.60 

3.66 

1.15 

7.09 

Milk-sugar  . 

6.04 

4.11 

7.80 

4.92 

3.20 

5.67 

Casein  .    .    . 

0.63 

0.18 

1.90 

3.01 

1.17 

7.40 

Albumen  .    . 

1.31 

0.39 

2.35 

0.75 

0.21 

5.04 

Albuminoids 

1.94 

0.57 

4.25 

3.76 

1.38 

12.44 

Ash   .... 

0.49 

0.14 

0.70 

0.50 

0.87 

The  following  analyses  of  the  foods  for  infants  found  in  the  shops,  and 
which  are  in  common  use,  were  made  by  Leeds  of  the  Stevens  Institute : 

Farinaceous  Foods. 


Water 

Fat 

Grape-sugar 

Cane-sugar 

Starch     

Soluble  carbohydrates 
Albuminoids     .    .    .    . 
Gum,  cellulose,  etc. 
Ash 


1. 
Blair's 
wheat 
food. 


9.85 
1.56 
1.75 
1.71 
64.80 
13.69 
7.16 
2.94 
1.06 


Hubbell's 
wheat 
food. 


7  78 

0.41 

7.56 

4.87 

67.60 

14.29 

10.13 

Undet'm'd 

1.00 


3. 

Imperial 
granum. 


5.49 
1.01 

Trace. 

Trace. 

78.93 
3.56 

10.51 
0.50 
1.16 


Ridge's 
food. 


9.23 
0.63 
2.40 
2.20 
77.96 
5.19 
9.24 

'0.60' 


5. 

"ABC 

Cereal 

milk. 


9.33 

1.01 

4.60 

15.40 

58.42 

20.00 

11.08 

1.16 


6. 

Robinson's 

patent 

barley. 


10.10 
0.97 
3.08 
0.90 

77.76 
4.11 
5.13 
1.93 
1.93 


ARTIFICIAL  FEEDING. 

Leihig^s  Foods. 


55 


Water 

Fat 

Grape-sugar    .... 

Cane-sugar 

Starch 

Soluble  carbohydrates 
Albuminoids  .... 
Gum,  cellulose,  etc.  ■ 
Ash 


KeaslDey 

Savory 

Mellin's. 

Hawley's 

Horlick's 

and 
Matti- 
son's. 

and 
Moore's 

5.00 

6.60 

3.39 

27.95 

8.34 

0.15 

0.61 

0.08 

None. 

0.40 

44.69 

40.57 

34.99 

36.75 

20.41 

3.51 

3.44 

12.45 

7.58 

9.08 

None. 

10.97 

None. 

None. 

36.36 

85.44 

76.54 

87.20 

71.50 

44.83 

5.95 

5.38 

6.71 

None. 

9.63 
0.44 

1.89 

1.50 

1.28 

0.93 

0.89 

Baby  sup 
No.l. 


5.54 

1.28 

2.20 

11.70 

61.99 

14.35 

9.75 

7.09 

Undeterm' 


Baby 

sup 

No.  2. 


11.48 

0.62 

2.44 

2.48 

51.95 

22.79 

i    7.92 

!    5.24 

d     1.59 


Milk  Foods. 


Water 

Fat 

Grape-sugar  and  milk-sugar, 

Cane-sugar 

Starch 

Soluble  carbohydrates    .    . 

Albuminoids 

Ash 


Nestle's. 


4.72 

1.91 

6.92 

32.93 

40.10 

44.88 

8.23 

1.59 


Anglo-Swiss. 


6.54 
2.72 
23.29 
21.40 
34.55 
46.43 
10.26 
1.20 


Gerber's. 


6.78 

2.21 

6.06 

30.50 

38.48 

44.76 

9.56 

1.21 


American-Swiss. 


0.68 

6.81 

5.78 

36.43 

30.85 

45.35 

10.54 

1.21 


It  is  seen  by  examination  of  the  analyses  of  the  above  foods  that  all, 
except  such  as  consist  largely  or  wholly  of  cow's  milk,  differ  widely  from 
human  milk  in  their  composition,  and  although  some  of  them — as  the  Liebig 
preparations,  in  which  starch  is  converted  into  grape-sugar  by  the  action  of 
the  diastase  of  malt— may  aid  in  the  nutrition  and  be  useful  as  adjuncts  to 
milk,  physicians  of  experience  and  close  observation  agree  that  when  breast- 
milk  fails  or  is  insufficient  our  main  reliance  for  the  successful  nutrition  of 
the  infant  must  be  on  animal  milk. 

Cow's  milk,  being  readily  obtained,  is  commonly  used  as  a  substitute  for 
human  milk,  compared  with  which  it  contains  less  sugar,  but  more  casein  and 
salts.  Its  composition,  however,  varies  considerably  according  to  the  food 
of  the  cow.  The  variations  in  the  milk  of  the  cow  according  to  the  nature 
of  its  food  and  other  circumstances  have  been  considered  in  a  preceding 
chapter. 

It  is  obvious  from  the  above  facts  that  the  analyses  of  different  specimens 
of  cow's  milk  must  differ  greatly,  and  the  same  is  true  of  the  milk  of  the  goat 
and  ass,  and  probably  of  the  ewe.  In  fact,  different  samples  of  the  milk  of 
the  same  animal  may  differ  more  from  each  other  in  their  chemical  character 
than  the  average  milk  of  one  animal  from  that  of  another. 

The  milk  of  the  goat  and  that  of  the  ass  have  been  recommended  as  food 
for  infants  in  preference  to  cow's  milk,  on  the  ground  that  they  more  nearly 
resemble  human  milk.  But  the  milk  of  neither  the  ass  nor  the  goat,  so  far  as  its 
chemical  character  is  concerned,  would  seem  to  possess  any  marked  advantage 
over  cow's  milk.  The  ass's  milk  is  procured  with  difficulty,  and  is  seldom 
used.  An  objection  to  goat's  milk  is  the  unpleasant  odor  which  it  often  pos- 
sesses, due  to  the  presence  of  hircic  acid.  It  is  stated,  however,  by  Parmen- 
tier,  that  this  odor  is  only  noticed  in  the  milk  of  goats  that  have  horns.     An 


56  INFANCY  AND  CHILDHOOD. 

important  advantage  in  the  city  in  the  use  of  goat's  milk  is  that  the  animal 
can  be  kept  at  little  expense,  so  that  even  poor  families  who  are  not  able  to 
purchase  and  feed  a  cow  can  generally  possess  a  goat,  from  which  fresh  milk 
can  be  obtained  at  any  time.  Preference  is  to  be  given  to  goat's  milk  when 
fresh  over  cow's  milk  brought  from  the  country,  perhaps  watered  on  the  way, 
several  hours  old  when  received,  and  in  commencing  fermentation.  But  cow's 
milk  of  good  quality  and  free  from  fermentative  changes  is  probably  not  inferior 
to  goat's  milk  as  a  food  for  infants,  and  from  its  abundance  it  must  continue 
to  be  in  common  use  for  this  purpose. 

In  order  to  solve  the  problem  of  the  feeding  of  infants  deprived  of  the 
breast-milk,  it  will  be  well  to  recall  to  mind  the  part  performed  in  the  diges- 
tive function  by  the  different  secretions  which  digest  food. 

1st.  The  saliva  is  alkaline  in  health.  It  converts  starch  into  grape-sugar. 
It  has  no  effect  upon  fat  or  the  protein  group.  It  is  the  secretion  of  the 
parotid,  submaxillary,  and  sublingual  glands,  which  in  infants  under  the  age 
of  three  months  are  very  small,  almost  rudimentary.  The  power  to  convert 
starch  into  sugar  possessed  by  saliva  is  due  to  a  ferment  which  it  contains 
called  ptyalin. 

2d.  The  gastric  juice  is  a  thin,  nearly  transparent,  and  colorless  fluid,  acid 
from  the  presence  of  a  little  hydrochloric  acid.  It  produces  no  change  in 
starch,  grape-sugar,  or  the  fats,  except  that  it  dissolves  the  covering  of  the 
fat-cells.  Its  function  is  to  convert  the  proteids  into  peptone,  which  is 
effected  by  its  active  principle,  termed  pepsin. 

3d.  The  bile  is  alkaline,  and  it  neutralizes  the  acid  product  of  gastric 
digestion.  It  has  no  effect  on  the  proteids.  It  forms  soaps  with  the  fatty 
acids,  and  has  a  slight  emulsifying  action  on  fat.  The  soaps  are  said  to  pro- 
mote the  emulsion  of  fat.  Their  emulsifying  power  is  believed  to  be  increased 
by  admixture  with  the  pancreatic  secretion.  Moreover,  the  absorption  of  oil 
is  facilitated  by  the  presence  of  bile  upon  the  surface  through  which  it  passes. 

4th.  The  pancreatic  juice  appears  to  have  the  function  of  digesting  what- 
ever alimentary  substance  has  escaped  digestion  by  the  saliva,  gastric  juice, 
and  bile.  It  is  a  clear,  viscid  liquid  of  alkaline  reaction.  It  rapidly  changes 
starch  into  grape-sugar.  It  converts  proteids  into  peptones  and  emulsifies 
fats.  While  the  gastric  juice  requires  an  acid  medium  for  the  performance 
of  its  digestive  function,  the  pancreatic  juice  requires  one  that  is  alkaline. 
These  important  facts  should  be  borne  in  mind,  that  such  a  mistake  as  pre- 
scribing pepsin  with  chalk  mixture  or  the  extractum  pancreatis  with  dilute 
muriatic  acid  may  be  avoided. 

5th.  The  intestinal  secretions  are  mainly  from  the  crypts  of  Lieberkiihn, 
and  their  action  in  the  digestive  process  is  probably  comparatively  unimport- 
ant, but  in  some  animals  they  have  been  found  to  digest  starch.  It  will  be 
observed  that  of  all  these  secretions  that  which  digests  the  largest  number 
of  nutritive  principles  is  the  pancreatic.  It  digests  all  those  which  are 
essential  to  the  maintenance  of  life  except  fat,  and  it  aids  the  bile  in  emul- 
sifying fat. 

It  is  seen  from  this  brief  review  of  the  action  of  the  digestive  ferments 
that  starch  is  digested  in  only  a  very  small  quantity  by  infants  under  the 
age  of  three  months,  and  therefore  that  those  foods  which  consist  largely  of 
starch  afford  but  little  nutriment  at  this  age.  The  impropriety  also  of  admin- 
istering for  days  large  quantities  of  an  alkali,  as  is  frequently  done,  is  appar- 
ent from  the  above  statement  in  regard  to  the  action  of  pepsin,  since  it  may 
retard  or  prevent  gastric  digestion. 

It  is  very  important  for  the  welfare  of  the  infant  that  the  suckling  mother 
or  wet-nurse  lead  a  quiet  and  regular  life.  I  was  much  impressed  by  the  ex- 
perience of  a  family  that  allowed  their  wet-nurse  to  go  out  of  an  evening. 


ARTIFICIAL  FEEDING.  57 

She  spent  the  night  in  debauchery,  and  returned  home  in  the  morning  ex- 
hausted and  totally  unfit  for  her  duties  as  wet-nurse.  Unfortunately,  she  was 
allowed  to  give  the  breast  to  the  baby,  which  was  immediately  after  seized 
with  convulsions,  ending  in  death.  Occasionally  the  mother,  though  appar- 
ently in  good  general  health,  does  not  furnish  milk  that  is  suitable  for  the 
baby.  The  milk  may  seem  abundant  and  may  present  the  usual  appearance, 
but  it  does  not  satisfy  the  nursling.  It  frets  when  applied  to  the  breast,  and 
afterward  its  sleep  is  insufficient  and  it  does  not  thrive,  so  that  it  is  necessary 
to  employ  a  wet-nurse  or  wean  the  baby.  The  cause  of  this  anomalous  state 
of  the  mother's  milk  is  probably  an  irregular  and  excited  mode  of  life.  I 
have  observed  it  in  mothers  fond  of  society  and  late  hours. 

An  important  fact,  which  we  have  stated  in  a  foregoing  page,  and  one 
that  I  find  the  laity  are  generally  ignorant  of,  is  that  frequent  suckling 
increases  the  quantity  of  the  milk  and  its  richness,  so  that  if  the  interval  be 
two  hours  between  the  drawing  of  the  milk,  it  will  be  richer  than  if  four 
hours  intervene.  If  the  mother  says  that  she  suckles  her  baby  every  six 
hours,  and  makes  use  of  artificial  food  between — unfortunately,  a  not  uncom- 
mon practice  among  the  poor — we  will  find  that  the  little  milk  obtained  from 
her  breast  is  thin  like  dish-water,  and  the  infant  obtains  very  little  nutriment 
from  it.  If  the  mother  be  healthy  and  the  flow  of  milk  be  normal,  she  can, 
I  think,  ordinarily  nourish  the  infant  entirely  at  the  breast  until  it  reaches 
the  age  of  six  months,  after  which  some  artificial  food  is  usually  required. 
Weaning  should,  as  a  rule,  be  at  the  age  of  ten  or  twelve  months,  but  wean- 
ing in  a  city  like  New  York,  in  which  the  summer  diarrhcea  is  so  prevalent 
and  fatal,  should  never  take  place  in  the  summer  months. 

How  to  feed  a  baby  deprived  of  the  breast-milk  during  its  first  year  is  one 
of  the  most  important  problems  which  the  physician  is  required  to  solve.  It 
is  evident  that  under  such  circumstances  a  food  which  most  closely  resembles 
human  milk  should  be  selected,  and  this  is  animal  milk — in  this  country  neces- 
sarily cow's  milk.  This,  therefore,  is  properly  selected  as  the  most  important 
dietetic  article  after  weaning  during  the  remainder  of  infancy  and  childhood. 
Indeed,  cow's  milk  constitutes  an  important  part  of  the  food  during  the  entire 
period  of  growth  and  development,  but,  unfortunately,  it  is  a  culture-medium 
for  bacteria,  and  numerous  epidemics  of  the  communicable  diseases  have  re- 
sulted from  its  use.  It  is  evident  that  milk  designed  for  the  nursery  should 
be  as  free  as  possible  from  microbes,  prepared  so  as  to  be  easily  digested  like 
human  milk,  and  be  sufficiently  nutritious. 

As  the  result  of  many  analyses  Prof.  Leeds,  in  addition  to  similar  facts 
tabulated  above,  has  arranged  the  following  tables,  showing  the  comparative 
•composition  of  human  and  bovine  milk.  These  tables  indicate  the  changes 
which  must  be  made  in  cow's  milk  so  that  it  corresponds  with  mother's  milk : 

Human  Milk.  Bovine  Milk. 

ALKALIJTE.  FEEBLY   ACID. 

Sp.  gravity 1.0313   .    .  1.0297 

Bacteria  absent.  Always  present. 

Fats  2  to  7 Average  4.13  3  to  6           .    .  Average  3.75 

Lactose  5.4  to  7.9 "        7.0  3.5  to  5.5    .    .         "        4.42 

Albuminoids  0.85  to  4.86  .    .         "        2.0  3  to  6    .    :    .    -         "        3.76 

Ash  .    .    .    .0.13  to  0.37    .    .         "        0.2  0.6  to  0.9    .    .         "        0.68 

Diseases  communicated  by  Cow's  Milk. 

In  the  healthy  state  the  mammary  gland  in  woman  and  the  udder  of  the 
cow  contain  no  microbes,  but,  as  a  rule,  cow's  milk  by  the  various  manipu- 


58  INFANCY  AND  CHILDHOOD. 

lations  which  it  undergoes  before  it  reaches  the  nursery  becomes  infected  by 
bacteria,  as  is  seen  by  the  above  table  prepared  by  Prof.  Leeds,  and  not  infre- 
quently by  such  as  are  pathogenic.  The  diseases  of  chief  interest,  on  account 
of  their  severe  and  fatal  nature,  which  are  known  to  be  communicated  by 
infected  cow's  milk  are  tuberculosis,  scarlet  fever,  diphtheria,  and  typhoid 
fever.  Henry  E.  Armstrong,  Medical  Officer  of  Health  at  Newcastle-on- 
Tyne,  states  (^Practitioner,  March,  1892)  that  "  ten  years  ago  the  editor  of 
the  British  Medical  Journal  showed  that  up  to  date  71  epidemics  in  England 
had  been  traced  to  milk — namely,  50  of  enteric  fever,  15  of  scarlet  fever,  and 
6  of  diphtheria,  the  total  number  of  sufferers  being  4800."  He  does  not 
enumerate  the  cases  of  tuberculosis  caused  by  infected  milk,  and  yet  recent 
observations  justify  the  belief  that  such  cases  are  not  uncommon. 

Dr.  H.  C.  Ernst  (^Boston  Med.  and  Surg.  Journ.,  Sept.  26,  1889)  read  a 
paper  before  the  Association  of  American  Physicians,  in  which  he  reviewed 
Koch's  assertion  that  the  milk  of  tubercular  cows  contains  the  tubercular 
bacillus,  and  is  infectious  only  when  tubercles  are  present  in  the  udder  or 
lacteal  tract.  In  a  large  proportion  of  the  tubercular  cows  examined  by  him 
the  specific  bacilli  were  present  and  active  in  the  milk  when  the  udders  and 
teats  were  entirely  healthy.  Klein  also  believes  that  observations  confirm 
the  opinion  (^Glasgoiv  Herald.,  May  27,  1889)  that  the  milk  of  the  tubercular 
cow  may  contain  the  tubercular  bacillus  in  whatever  part  of  the  animal  the 
tubercles  are  located.  This  theory,  that  the  milk  from  a  tuberculous  cow, 
even  when  the  lacteal  tract  is  healthy,  sometimes  contains  the  tuberculous 
bacillus,  and  may  therefore  communicate  phthisis,  has  been  confirmed  by 
others  (Prudden). 

The  following  brief  resume  of  cases  reported  by  well-known  clinical 
teachers  shows  the  need  of  frequent  and  careful  inspection  as  regards  the 
presence  of  tuberculosis  in  the  dairy  which  furnishes  milk  for  the  nursery : 
Ollivier  {La  Semaine  medicale,  Feb.  25,  1891)  states  that  within  three 
months,  in  a  school  for  girls,  there  occurred  eleven  cases  of  tuberculosis,  of 
which  five  were  fatal,  and  with  several  of  these  patients  the  disease  seemed 
to  originate  along  the  gastro-intestinal  tract.  Two  other  pupils  of  this  school 
died  of  tuberculosis.  Their  previous  excellent  health  and  that  of  their 
parents  justified  the  belief  that  they  also  contracted  tuberculosis  from  the 
milk.  On  searching  for  the  cause  of  this  disease,  it  was  believed  to  be  the 
milk-supply,  and  on  killing  the  cow  that  furnished  the  milk  its  lungs  were 
found  to  be  in  an  advanced  stage  of  tuberculosis. 

Prof.  Demme  states  that  an  infant  of  four  months  died  from  tuberculosi& 
of  the  mesenteric  glands.  The  microscopic  examination  revealed  tubercle 
bacilli  in  glands  partly  cheesy.  No  anatomical  changes  indicative  of  disease 
were  discovered  elsewhere  in  the  body,  and  the  parents  were  healthy.  The 
child  had  been  fed  from  birth  with  uncooked  milk  from  a  cow  that  the  physi- 
cian ordered  killed.  The  left  lung  of  the  cow  was  found  to  be  diseased,  and 
it  contained  tubercle  bacilli.  A  microscopic  examination  of  the  milk  pressed 
out  from  its  udder  showed  the  presence  of  the  pathogenic  bacilli.  Recently 
another  similar  case  has  been  reported.  A  boy  of  four  years,  previously 
healthy  and  of  healthy  parentage,  died  of  meningitis,  diagnosticated  tuber- 
cular, and  it  was  believed  by  the  attending  physicians  to  have  been  produced 
by  the  use  of  milk  from  cows  which  were  afterward  killed  and  found  to  be 
tubercular.  Mr.  Law,  in  an  able  paper  published  in  the  65th  Bulletin  of  the 
Cornell  University  Experiment  Station,  remarks  that  "  Hischberger  inocu- 
lated rabbits  in  the  abdominal  cavity  with  the  milk  of  twenty-nine  tuber- 
culous cows,  of  which  the  udders  were  or  appeared  sound,  and  produced 
tuberculosis  fourteen  times." 


ARTIFICIAL  FEEDING.  59 

Steigenberger  relates  the  case  of  an  infant  of  five  months  of  healthy 
parentage.  It  had  caseous  glands  and  abscesses  of  the  neck,  apparently 
tubercular  and  attributed  to  the  milk-supply. 

Dr.  I.  L.  Porteus,  F.  E,.  C.  S.  E.,  has  published  the  following  interesting 
statistics  relating  to  the  subject  under  consideration :  In  countries,  like  Fin- 
land, Sweden,  Northern  Norway,  and  Lapland  in  the  far  north,  in  which  cows 
are  scarce  and  the  reindeer  furnishes  the  principal  food,  tuberculosis  is  rare, 
as  it  is  also  in  Algeria,  where  milch  cows  are  few  and  away  from  the  cities. 
On  the  other  hand,  Porteus  states  that  in  Hannover,  a  dairying  country, 
where  cows  are  abundant,  60  to  70  per  cent,  of  the  cattle  are  tubercular,  and 
in  Edinburgh  26  per  cent,  are  similarly  affected.  Mr.  Law  says :  "  In  infected 
breeding -and  dairy  herds  in  New  York,  consisting  largely  of  mature  cows, 
I  have  found  a  maximum  of  98  per  cent,  and  a  minimum  of  5  per  cent, 
tubercular." 

Scarlet  Fever,  Diphtheria,  Typhoid  Fever. — Armstrong,  the  Health 
OfBcer,  states  that  in  Newcastle  12  cases  of  scarlet  fever  occurred  in  28 
families  that  were  supplied  with  milk  by  a  dairyman  whose  family  were 
affected  with  this  disease.  W.  A.  McLachlin  of  Dumbarton  says  that  in 
one  instance  in  his  rural  practice  diphtheria  was  traced  to  water  obtained 
from  two  sunken  wells  which  received  the  drainage  of  adjacent  houses  and  a 
graveyard.  After  the  health  of  the  community  had  been  restored  by  closing 
the  wells  and  obtaining  water  from  a  fresh  source,  a  return  of  the  diphtheria 
was  traced  to  the  washing  of  milk  utensils  with  water  from  one  of  the  wells. 
Dr.  R.  R.  Francis,  Health  Inspector  of  Montclair,  N.  J.,  reports  an  epidemic 
of  typhoid  fever,  numbering  45  cases,  which  was  produced  by  the  typhoid 
bacilli  in  milk.  These  cases  were  traceable  to  the  milk  supplied  by  a  dairy- 
man in  whose  family  typhoid  fever  had  recently  occurred  (N.  Y.  daily  papers, 
April  12,  1894).  Many  similar  cases  have  been  reported  showing  the  causal 
relation  of  infected  milk  to  diphtheria,  scarlet  and  typhoid  fevex's,  so  that 
physicians,  and  to  a  certain  extent  the  laity,  are  aware  of  this  fact,  and  it 
would  be  superfluous  to  cite  more  instances. 

Not  only  do  scrofula  and  malnutrition,  in  addition  to  the  diseases  men- 
tioned above,  result  from  the  use  of  impure  milk,  but  in  certain  parts  of  the 
United  States  another  malady  not  sufficiently  investigated  results  from  the 
same  cause. 

Milk  Sickness. — At  the  Tenth  International  Medical  Congress,  held  in 
Berlin,  a  paper  was  read  on  the  milk  sickness  occurring  in  central  and  west- 
ern portions  of  the  United  States.  It  appears  to  prevail  in  newly-opened 
settlements,  disappearing  when  the  soil  is  fully  cultivated.  Animals  contract 
the  disease  when  they  pasture  late  at  night  or  early  in  the  morning.  When 
sick  they  travel  but  little  and  hold  their  heads  to  the  ground,  and  have  as  a 
rule  constipation  and  poor  appetite.  Some  recover,  but  those  that  die  have 
tremors  which  continue  three  or  four  days  before  the  fatal  event.  The  use 
of  milk  from  an  infected  herd  communicates  the  disease  to  man.  In  man  the 
symptoms  are  languor,  anorexia,  nausea,  vomiting,  pyrosis,  constipation,  and 
excessive  thirst,  dry  skin,  moist  and  coated  tongue,  difficult  and  sighing  res- 
piration, retracted  but  not  tender  abdomen,  no  elevation  of  temperature,  and 
no  change  of  pulse.  The  symptoms  of  this  unknown  disease  are  like  those 
of  some  vegetable  poison.  Its  communication  to  children  through  the  milk 
must  be  disastrous. 

Since  cow's  milk  must  be  the  substitute  for  human  milk  when  the  latter 
is  wanting,  and  in  all  cases  after  weaning  is  the  most  important  dietetic 
article  during  infancy  and  childhood,  its  exact  composition  and  the  nature 
of  its  ingredients  should  be  understood.  Human  milk  contains,  on  the  aver- 
age, a  little  more  fat  or  cream  than  cow's  milk,  and  2^-  per  cent,  more  sugar, 


60  INFANCY  AND   CHILDHOOD. 

while  of  the  albuminoids,  mainly  casein,  the  quantity  in  cow's  milk  is  nearly 
twice  that  in  human  milk. 

Lactose  or  milk-sugar^  deprived  of  spores  and  proteids,  forms  a  white, 
translucent,  and  hard  crystalline  substance.  It  is  regarded  by  chemists  as 
intermediate  between  cane-sugar  and  starch,  having  little  sweetness,  but 
being  soluble  in  water.  By  its  oxidation  in  the  system  it  produces  animal 
heat.  It  is  therefore  an  important  ingredient  in  milk,  being  about  one-half 
of  its  solid  constituents.  Its  heat-producing  property  is  especially  needed  in 
the  young  infant,  whose  normal  temperature  is  98.5°  F.,  and  whose  feeble 
muscular  movements  have  little  eifect  in  producing  heat.  Several  microbes 
have  the  power  to  change  lactose  into  lactic  acid,  according  to  the  following 
formula  :  milk-sugar,  Ci2H.,aOu  -|~  HjO  ■=  -t(C3H603)  (Fownes).  The  change 
of  milk-sugar  into  lactic  acid  occurs  in  normal  digestion.  Pasteur  held  that 
the  change  was  produced  by  a  fungus,  the  Peiiicillium  glaucum,  but  late 
chemists  attribute  it  to  bacteria,  as  stated  above.  The  formation  of  lactic 
acid  is  attended  by  curdling  of  the  casein.  By  the  presence  of  abnormal 
ferments  the  lactic  acid  sometimes  undergoes  a  further  change,  producing 
alcohol  and  carbonic  acid,  according  to  the  following  formula :  CsHgOs 
=  CjHgO  +  CO,.  This  abnormal  digestion  causes  flatulence,  which  is  common 
in  the  bottle-fed  infant,  and  is  a  frequent  cause  of  fretfulness  and  disturbed 
sleep.  Another  abnormal  fermentation,  designated  the  butyric,  sometimes 
occurs.  It  is  really  a  putrefactive  change,  the  lactic  acid  being  converted 
into  butyric  and  carbonic  acids  and  water.  This  fermentation  is  represented 
by  the  following  formula  :  2C3H6O3  (lactic  acid)  ^  C^HgO^  +  2CO2  (carbonic 
acid)  2H2O  (water). 

Fat  or  Cream. — The  oil-globules  in  human  and  animal  milk  are  not  sur- 
rounded by  an  envelope,  as  was  formerly  believed,  but  albuminous  particles 
are  attracted  to,  and  become  adherent  to.  the  globules,  so  as  to  serve  the 
purpose  of  an  envelope  and  prevent  the  globules  from  uniting  with  each 
other. 

Alhuminoids. — These  are  chiefly  casein  and  lactalbumin.  and  a  small 
amount  of  peptones,  perhaps  produced  by  the  action  of  microbes.  Casein 
occurs  in  milk  principally  in  combination  with  the  alkaline  base  potassium, 
as  a  caseinate  of  potassium.  By  the  action  of  an  acid  not  too  concentrated 
bovine  casein  forms  large  coagula,  and  human  casein  forms  particles  like  a 
coarse  powder,  and  is  therefore  more  readily  digested.  The  lactalbumin 
separates  from  the  casein  and  remains  in  the  whey,  but  by  the  application 
of  heat  it  coagulates  like  other  forms  of  albumen.  Not  only  is  there  the 
diff'erence.  as  stated  above,  in  the  coagulation  by  the  gastric  juice  of  the 
casein  in  human  and  in  bovine  milk,  but  the  proportionate  quantity  of  casein 
in  cow's  milk  is  considerably  greater  than  in  human  milk,  as  is  seen  by  the 
table  previously  published.  The  excess  of  albuminoids  in  cow's  milk  is 
mainly  an  excess  of  casein.  To  this  difl'erence  in  the  nature  and  quantity 
of  casein  in  the  two  kinds  of  milk  the  fact  is  largely  attributable  that,  while 
the  infant  digests  easily  and  fully  human  milk,  its  digestion  of  cow's  milk  is 
difficult,  frequently  attended  by  gastro-intestinal  pain  and  vomiting  of  caseous 
coagula  or  their  appearance  in  the  stools. 

Inorganic  Matter. — This  is  between  three  and  four  times  greater  in  bovine 
than  in  human  milk.  The  excess  is  largely  due  to  the  potash  and  calcium 
pho.sphate  existing  for  the  most  part  in  combination  with  the  casein.  In 
the  ash  of  both  human  and  bovine  milk  the  following  substances  have  been 
isolated :  potash,  soda,  lime,  oxide  of  iron,  phosphoric  and  sulphuric  acids, 
and  chlorine. 

How  to  Obtain  Good  Cores  Milk. — If  the  milk  employed  in  the  nursery 
be  of  good  quality  and  be  given  in  proper  quantity  and  at  proper  intervals, 


ARTIFICIAL  FEEDING.  61 

and  the  digestive  function  of  the  child  be  in  its  normal  state,  we  can  con- 
fidently expect  healthy  digestion  and  the  required  nutrition  and  growth  of 
the  tissues.  But  slight  disturbing  agencies  produce  fermentative  changes 
in  the  milk  which  are  abnormal,  and  are  manifested  by  vomiting,  flatulence, 
gastro-intestinal  pains  and  diarrhoea,  with  unhealthy  and  partially-digested 
stools.  The  frequency  of  this  unhealthy  digestion  or  fermentation  of  cow's 
milk  when  administered  to  young  children,  and  consequent  loss  of  flesh  and 
strength,  with  dangerous  even  fatal  prostration,  are  now  fully  recognized. 

It  is  evident  that  milk  designed  for  the  nursery  should  contain  the  proper 
proportion  of  nutritive  constituents,  and  be  free  from  pathogenic  microbes 
and  other  impurities.  No  more  important  duty  devolves  upon  parents  than 
to  procure  milk  which  approaches  as  nearly  as  possible  to  this  standard  of 
purity  and  excellence. 

Dr.  E.  F.  Brush  of  Mount  Vernon,  who  has  made  a  lifelong  study  of  the 
habits  of  the  cow,  has  directed  attention  to  the  fact  that  this  animal,  running 
at  large  in  the  pasture,  is  as  likely  to  drink  muddy  and  foul  water,  even  that 
containing  filthy  and  putrefying  matter,  as  it  is  pure  water,  and  to  browse 
upon  weeds  which  are  noxious,  even  poisonous,  so  that  such  water  and  such 
weeds  should  be  removed  or  excluded  from  the  pasturage.  Dr.  Brush  also 
calls  attention  to  the  fact  that  the  cow  during  the  oestrus  or  rutting  period, 
during  abortion,  which  he  says  is  common,  and  after  parturition,  furnishes 
milk  deleterious  and  dangerous  for  nursery  use.  He  has  observed  cases  in 
which  such  milk  has  caused  severe  gastro-enteritis. 

Fortunately,  the  laity  as  well  as  the  medical  profession  are  at  last  fully 
aware  of  the  importance  of  obtaining  milk  from  cows  that  are  not  only 
healthy,  but  are  properly  fed  and  cared  for.  It  is  a  matter  of  the  greatest 
importance  that  the  presence  of  tuberculosis  in  the  cow,  which  is  known  to 
be  a  common  disease  in  the  United  States,  can  be  readily  detected  by  inject- 
ing tuberculin  under  the  skin  of  the  animal,  since,  thus  employed,  it  causes 
fever  in  the  tubercular  cow,  but  not  in  one  that  is  healthy.  With  this  test 
many  cows  with  tuberculosis  in  dairies  supplying  the  New  York  market  have 
been  killed  or  excluded.  Meal,  grass,  or  hay  of  good  quality  without  weeds 
constitute  the  proper  food  of  the  cow.  Brewers'  grains  and  swill  in  any 
form  must  be  forbidden.  The  cows  should  be  provided  with  airy  stables, 
kept  clean,  and  with  abundant  straw  to  lie  upon.  They  should  be  supplied 
with  pure  and  fresh  water,  and  must  not  be  stabled  with  other  animals. 
Those  upon  whom  devolves  the  task  of  milking  and  the  subsequent  care  of 
the  milk  should  have  finger-nails,  hands,  and  person  scrupulously  clean. 
The  teats  and  udder  of  the  cow  should  also  be  clean,  free  from  cracks,  sores, 
and  indurations.  They  should  be  cleaned  with  a  moistened  sponge  or  other- 
wise immediately  befoi*e  the  milking,  so  as  to  prevent  hairs  and  foreign  sub- 
stances from  falling  into  the  milk,  and  any  milk  rendered  impure  by  the 
cows  stepping  into  the  pail  or  otherwise  must  be  rejected.  The  milk,  imme- 
diately after  the  milking,  must  be  cooled  to  50°  F.  or  lower  by  being  placed 
in  running  water  or  surrounded  by  ice,  and  the  vessels  containing  it  should 
be  open  half  an  hour  to  one  hour  to  allow  the  gases  to  escape.  The  dairy 
supplying  the  milk  should  be  frequently  and  fully  inspected  by  a  competent 
veterinarian,  and  all  feverish  and  sick  cows  be  excluded  from  the  herd.  Dr. 
Woodhead  very  properly  proposes  (Brit.  Med.  Journ.,  Se^pt.  19,  1891)  that 
a  regular  staff  of  veterinary  inspectors,  educated  and  competent  for  such 
work,  be  appointed,  who  shall  examine  every  two  weeks  the  cows  furnishing 
the  milk-supply,  and  that  they  shall  have  the  power  to  exclude  from  the 
herd  cows  having  or  suspected  of  having  tuberculosis  or  other  severe  disease, 
and  that  it  be  penal  for  a  milkman  to  offer  in  market  the  milk  from  a  con-. 
demned  or  suspected  cow.     No  phthisical  person  or  person  recently  exposed 


62  INFANCY  AND  CHILDHOOD. 

to  any  communicable  disease  should  be  employed  in  any  branch  of  the  dairy. 
In  preparing  milk  for  the  market  it  should  be  strained  through  fine  gauze, 
and  must  not  be  exposed  in  any  room  in  which  there  is  dust  or  has  recently 
been  severe  sickness.  The  bottles  or  cans  sent  to  customers  must  in  the 
transit  be  kept  cool  by  ice  around  them,  except  in  midwinter,  and  must  be 
full,  so  as  to  prevent  churning. 

in  the  cities  at  a  distance  from  the  dairies  pure  and  wholesome  milk  for 
nursery  use  can  be  obtained  in  no  other  way  than  by  strict  compliance  by 
dairymen  and  middlemen  with  the  directions  given  above.  No  more  import- 
ant duty  devolves  upon  parents  than  to  see  that  these  directions  are  rigidly 
enforced.  From  the  fact  that  this  subject  is  engaging  the  attention  of  medi- 
cal societies  it  is  probable  that  in  the  near  future  more  rigid  rules  will  be  for- 
mulated for  the  control  of  the  milk-supply  of  general  applicability,  which 
milk  companies  under  written  agreement  will  accept  or  lose  their  customers. 
Sterilization  at  a  Low  Heat — Pasteurization. — Since  cow's  milk  is  not  only 
a  vehicle,  but  a  culture-bed  of  bacteria,  and,  though  prepared  for  market 
with  the  utmost  care,  ordinarily  contains  more  or  fewer  of  them,  some  of 
which,  as  we  have  seen,  are  pathogenic,  its  sterilization  before  its  use  in  the 
nursery  becomes  a  paramount  duty. 

The  experiments  of  Pasteur  and  others  have  demonstrated  the  important 
fact  that  a  temperature  of  160°  to  170°  F.,  continued  from  fifteen  to  twenty 
minutes,  destroys  the  germs  of  tuberculosis,  typhoid  fever,  scarlet  fever, 
pneumonia,  and  bacteria,  as  well  as  developed  germs  of  almost  any  kind. 
The  New  Jersey  State  Dairy  Commission  reports  that  sterilization  at  the 
high  temperature  frequently  employed  diminishes  the  germicidal  action  pres- 
ent in  raw  milk.  If  cholera-germs  be  placed  in  fresh  raw  milk  and  in  milk 
sterilized  by  heat,  after  three  hours  a  smaller  number  of  germs  will  be  found 
in  the  former  than  in  the  latter.  The  lactalbumin,  which  is  allied  to  serum- 
albumin,  is  coagulated  by  heat,  rendering  the  milk  more  viscous,  and  pro- 
ducing the  unpleasant  flavor  characteristic  of  boiled  milk.  By  the  action  of 
heat  the  albumen  is  rendered  less  soluble  and  is  apparently  digested  with 
more  difficulty,  A  heat  above  165°  F.  destroys  the  starch-fermenting  in- 
gredient of  milk,  the  galactozyme,  which  is  an  important  loss  to  the  young 
infant,  whose  saliva  has  not  yet  acquired  that  power.  The  milk-sugar  is 
changed  or  destroyed.  The  fat  or  cream  occurs  in  drops  or  pellicles  upon  the 
sterilized  milk,  and  it  is  necessary  that  the  digestive  function  should  restore 
it  to  an  emulsion  before  it  can  be  absorbed.  The  casein  is  also  changed  by 
sterilization  so  as  to  be  less  readily  and  fully  precipitated  by  rennet.  Bagin- 
sky  states  that  it  requires  more  rennet  and  a  higher  temperature  to  effect  the 
digestion  of  the  casein  of  sterilized  than  of  raw  milk.  Since  sterilization 
produces  the  bad  results  noticed  above,  it  is  evident  that  sterilization  at  a  low 
heat — (160°  to  167°) — designated  Pasteurization — since  it  is  sufficient  to  de- 
stroy the  pathogenic  microbes,  should  always  be  recommended,  and  never  a 
higher  temperature.  If  by  greater  care  in  the  management  of  the  dairy  and 
of  the  milk-supply  the  time  ever  arrives  when  the  milk  is  free  from  microbes, 
its  sterilization  by  heat  or  otherwise  will  not  be  required. 

Predigestion — Dilution. — Since  human  milk  contains  more  fat  and  less 
casein  than  cow's  milk,  and  since  in  the  vessel  holding  milk  the  cream  rises 
and  casein  sinks,  the  upper  third  may  be  advantageously  employed  for  infants 
under  the  age  of  three  months,  and  the  upper  half  for  those  over  the  age  of 
three  months.  By  employing  the  upper  part  of  the  milk  we  are  enabled  to 
prepare  a  food  which  more  closely  resembles  human  milk,  the  aliment  which 
Nature  provides. 

When  human  milk  cannot  be  obtained  for  the  infant  under  the  age  of  one 
year,  the  best  substitute  for  it  can  be  prepared  from  cow's  milk  mixed  with 


ARTIFICIAL  FEEDING.  63 

dextrinized  barley  or  wheat  gruel.  My  preference  is  for  barley  flour  pre- 
pared as  follows :  Barley  flour  is  placed  dry  in  a  double  boiler  and  subjected 
to  the  heat  of  boiling  water  from  five  to  seven  days,  the  fire  abating  at  night. 
All  the  nutritive  properties  are  preserved  by  this  method  of  employing  heat, 
whereas  by  the  old  method  of  boiling  the  flower-ball  in  water  some  of  the 
fat,  soluble  albuminoids,  and  mineral  matters  escape  into  the  water  and  are 
lost.  By  the  action  of  the  heat  the  starch-granules  swell  and  burst,  and  the 
starch  consequently  is  more  readily  acted  on  by  the  diastase  subsequently 
added. 

How  to  Prepare  Dextrinized  Barley  Gruel  and  Cows  Milk  for  Nursery 
Use. — A  heaped  tablespoonful  of  the  flour  which  has  been  subjected  to  the 
prolonged  action  of  heat  in  the  manner  mentioned  above  should  be  added  to 
thirty  tablespoonfuls  of  boiled  water  for  an  infant  of  three  months,  or  to 
twenty-five  tablespoonfuls  for  one  of  six  months,  and  boiled  from  three  to  six 
minutes  to  facilitate  admixture.  When  it  has  cooled  to  blood-heat  half  a 
drachm  or  perhaps  one  drachm  of  diastase  (Forbes's  or  other  of  good  qualit}^) 
should  be  added  to  it.  This  in  a  few  minutes  changes  the  starch  into  dextrin 
and  maltose.  This  predigestion  renders  it  thinner  and  a  useful  and  conve- 
nient diluent  for  the  milk. 

The  most  indigestible  constituent  of  cow's  milk  is  the  casein.  While  the 
relative  proportion  of  it  is  diminished  by  employing  the  upper  third  or  half 
in  the  bottle  or  can,  the  addition  to  it  of  the  dextrinized  gruel  mechanically 
separates  the  particles  of  casein,  and  tends  to  prevent  the  formation  of  thick 
curds  and  promote  a  loose  and  friable  coagulation,  so  that  it  is  more  readily 
digested  than  the  casein  of  milk  not  treated  in  this  manner. 

But  the  feeble  digestive  power  of  the  young  infant  can  be  greatly  assisted 
by  adding  to  the  milk  the  so-called  "  Peptogenic  Milk  Powder,"  consisting  of 
pancreatin,  lactose,  and  the  alkaline  milk  salts,  a  digestive  mixture  devised  by 
Fairchild  Brothers  &  Co.  This  supplies  a  desideratum  long  needed.  This 
peptogenic  milk  powder  is  prepared  for  use  both  in  tubes  and  in  cans,  the 
latter  containing  the  measure  of  the  quantity  to  be  employed  for  a  certain 
amount  of  milk. 

Difierent  pediatrists  have  published  formulae  showing  the  frequency  of 
feeding  and  quantity  of  food  proper  for  infants  of  different  ages,  the  food 
being  prepared  so  as  to  resemble  as  nearly  as  possible  human  milk  in  bulk 
and  nutritive  properties.  But  if  dextrinized  gruel,  which  is  readily  absorbed 
and  assimilated,  be  employed  as  a  diluent  of  the  milk,  the  quantity  or  bulk 
would  probably  be  greater  than  that  stated  in  most  of  the  dietary  tables. 
Infants,  especially  those  under  the  age  of  three  months,  sometimes  do  well 
with  the  dextrinized  barley  gruel  in  excess  of  the  predigested  milk,  and 
infants  with  feeble  digestion  are  sometimes  benefited  by  taking  a  few  drops 
of  pepsin  or  other  digestive  ferment  before  each  feeding.  Thus  at  the  pres- 
ent time,  at  midsummer,  when  so  many  of  the  bottle-fed  are  attacked  by 
the  summer  diarrhoea,  a  bottle-fed  infant  of  five  months  remains  in  the  best 
of  health,  being  fed  every  two  hours  during  the  day  with  dextrinized  barley 
gruel  three  and  a  half  ounces  and  Pasteurized  and  peptonized  upper  half 
of  milk  two  and  a  half  ounces.  Each  feeding  is  preceded  or  accompanied 
by  a  dose  of  a  few  drops  of  one  of  the  digestive  ferments.  The  number  of 
feedings  is  about  nine  or  ten  in  twenty-four  hours.  I  have  in  a  number  of 
instances  seen  infants  under  the  age  of  three  months  thrive  and  escape  the 
dreaded  summer  diari'hoea  when  fed  with  two  parts  of  the  dextrinized  gruel 
mixed  with  one  part  of  the  Pasteurized  and  peptonized  upper  half  of  the 
milk.  Some  infants  do  better  if  the  amount  of  water  at  each  feeding  be 
half  an  ounce  or  one  ounce  greater. 

A  word  should  be  said  in  reference  to  the  use  of  condensed  milk,  of  which 


64  INFANCY  AND   CHILDHOOD. 

there  are  four  or  five  kinds  in  market.  If  sufficiently  fresh  and  diluted  with 
dextrinized  barley  gruel,  it  answers  very  well,  according  to  my  observation, 
in  an  emergency.  It  is  sterilized  by  the  heat  required  for  condensation,  and 
the  barley  flour  properly  prepared  in  a  double  boiler,  and  when  made  into  a 
gruel  treated  with  diastase,  supplies  fat,  dextrin,  and  maltose,  which  the  infant 
can  readily  digest.  I  therefore  frequently  recommend  it  when  there  is  diffi- 
culty or  delay  in  obtaining  good  milk.  In  recommending  fresh  condensed 
milk  I  should  state  that  my  question  to  the  company.  How  much  water  is 
expelled  from  the  milk  by  the  heat  of  condensation  ?  was  never  answered ; 
but  in  practice  I  have  recommended  to  add  two  heaped  teaspoonfuls  of  the 
milk  to  fifteen  of  water,  boiled,  as  the  equivalent  of  seventeen  teaspoonfuls 
of  ordinary  milk. 

In  no  institution  in  America  are  there  so  many  young  foundlings  nourished 
by  the  bottle  as  in  the  New  York  Foundling  Asylum.  At  the  present  time 
in  one  ward  are  thirteen  bottle-fed  infants  under  the  age  of  two  months,  and 
they  receive  every  two  hours,  preceded  by  six  or  eight  drops  of  the  essence 
of  pepsin  or  the  elixir  of  digestive  ferments,  one  ounce  each  of  the  dextrin- 
ized barley  gruel  and  the  Pasteurized  upper  part  of  milk.  Never  before 
have  these  waifs  escaped  to  such  an  extent  the  summer  diarrhoea  and  vomit- 
ing which  have  heretofore  been  very  fatal. 

My  purpose  is  to  recommend  a  mode  of  alimentation  which  can  be  easily 
employed  by  the  poor  in  tenement-houses  as  well  as  by  those  in  better  circum- 
stances, and  which  I  think  will  be  more  successful  in  saving  life  than  the 
modes  of  alimentation  which  are  in  common  use. 

After  the  first  year  the  food  may  be  made  of  such  consistence  as  to  be 
given  with  the  spoon.  In  the  second  year  and  subsequently  a  pap  may  be 
made  of  stale  bread  boiled  in  water  sufficient  to  cover  it,  and  mixed  with 
fresh  milk,  care  being  taken  that  all  lumps  are  reduced  to  a  pulp.  Beef  tea 
is  a  laxative  on  account  of  the  salts  which  it  contains,  as  is  also  chicken  tea, 
but  a  small  or  moderate  amount  of  it  may  be  given  once  or  twice  a  day, 
preferably  made  into  a  light  pap  with  a  soda  cracker  or  stale  bread.  Few 
vegetables  are  proper  for  infants  under  the  age  of  one  year,  but  the  potato, 
baked  and  mashed  so  as  to  be  like  flour,  may  be  given  at  the  tenth  or  twelfth 
month.  It  contains  a  large  amount  of  starch,  but  appears  to  be  readily 
digested  by  infants  of  the  age  mentioned  if  given  once  a  day  in  moderate 
quantity,  with  a  little  butter  and  salt  added.  In  the  second  year  a  greater 
variety  of  food  may  be  allowed,  but  the  full  diet  of  the  table  must  not  be 
given  till  after  infancy,  or  at  the  age  of  three  years.  In  the  beginning  of 
the  second  year  the  infant  is  weaned.  He  has  twelve  teeth,  eight  incisors, 
and  four  molars,  which,  with  their  broad  surfaces,  are  designed  for  chewing. 
Let  him  have  now,  once  or  twice  each  day,  in  addition  to  the  food  which  has 
previously  been  employed,  a  small  piece  of  roast  beef,  rare  done  and  cut  very 
fine.  Other  meat,  as  mutton,  may  sometimes  be  given  instead.  After  the 
age  of  eighteen  months  light  puddings  of  farinaceous  substances,  properly 
prepared,  as  of  rice  and  corn  meal,  may  be  added  to  the  dietary. 

All  the  teeth  of  the  first  set  have  appeared  at  the  age  of  two  years  and 
five  months,  and  the  time  has  now  arrived  when  a  more  marked  transition 
may  be  made  from  liquid  to  solid  food.  Certain  fruits  may  be  allowed  even 
before  this  period,  as  also  the  jellies  of  most  berries  and  of  fruits,  which 
being  deprived  of  seeds  and  parenchyma  are  for  the  most  part  i-eadily 
digested,  while  they  give  a  relish  to  the  farinaceous  food  with  which  they 
are  eaten.  Pastries  as  ordinarily  made,  whatever  fruits  they  may  contain, 
are  too  rich  and  indigestible  for  young  children. 


BATHING,   CLOTHING,  SLEEP,  EXERCISE.  65 

CHAPTER   IX. 

BATHING,    CLOTHIXG,    SLEEP,    EXEKCISE. 

Bathing  is  now  recognized  in  all  civilized  countries  as  one  of  the  chief 
promoters  of  bodily  comfort  and  health.  The  first  bathing  of  the  infant, 
which  is  immediately  after  birth,  should  be  in  water  at  a  temperature  a  little 
below  that  of  the  blood — namely,  at  about  96° — after  which  the  general 
bath  is  inadmissible  until  the  navel-string  is  detached.  In  the  infant  reaction 
of  the  surface  when  chilled  is  tardy  and  uncertain,  and  therefore  there  is 
great  danger  of  catching  cold  when  the  surface  is  cooled  by  water  and  does 
not  quickly  react.  It  is  a  matter  of  daily  observation  that  infants  become 
chilly  and  their  extremities  remain  cool  in  a  medium,  whether  air  or  water, 
in  which  older  children  and  adults  would  have  comfortable  warmth.  There- 
fore they  are  liable  to  contract  bronchitis,  sore  throat,  intestinal  catarrh,  or 
other  inflammation  from  very  slight  exposures.  This  fact  must  be  borne  in 
mind  in  considering  the  subject  of  bathing. 

During  the  first  year  after  the  detachment  of  the  navel-string  the  bath 
should  be  employed  daily,  but  not  longer  than  three  minutes,  during  which 
time  thorough  ablution  can  be  performed.  Different  authorities  disagree  in 
regard  to  the  proper  temperature  of  the  bath  during  the  first  months  of 
infancy.  Steiner  of  Prague,  a  high  authority  in  children's  diseases,  says : 
"  During  the  first  nine  months  the  infant  should  have  a  daily  bath  a  little 
above  blood  heat,"  but  most  authors  recommend  a  temperature  a  little  below 
blood  heat.  In  my  opinion  it  should  be  at  92°,  which  is  considerably  below 
blood  heat,  but  which  communicates  a  moderately  warm  sensation  to  the  hand. 
After  the  age  of  ten  months,  or  even  of  eight  months  for  vigorous  children, 
the  temperature  of  the  bath  may  be  reduced  to  90°,  and  it  should  not  be 
lower  than  this  during  the  remainder  of  infancy,  or  if  it  be  used  a  little 
lower  care  should  be  taken  to  produce  reaction  by  brisk  rubbing  and  exercise 
after  a  short  bath.  At  the  close  of  infancy,  or  at  two  and  a  half  years,  the 
temperature  may  be  still  further  reduced,  but  it  should  not,  even  for  the  most 
robust  children  of  eight  or  ten  years,  be  below  78°,  which  is  recorded  on  our 
thermometers  as  the  temperature  of  summer  heat,  and  is  about  that  of  our 
northern  lakes  during  midsummer. 

The  rules  given  in  the  books,  not  to  bathe  or  direct  a  child  to  be  bathed 
immediately  after  eating  or  after  much  exercise,  when  the  pores  of  the  skin 
are  perspiring,  should  be  heeded.  The  head  should  first  be  wet  with  the 
water,  and  castile  soap  should  be  applied  over  the  surface  to  ensure  cleanli- 
ness. The  strongly-scented  toilet  soaps  sometimes  contain  rancid  fats  or 
other  deleterious  substances,  and  should  be  regarded  with  suspicion.  In  hot 
weather  a  daily  bath  is  advisable,  but  in  the  cooler  months  it  is  sufficient  if 
the  child  bathe  twice  or  three  times  in  the  week.  If,  from  lack  of  conveni- 
ences or  for  other  reasons,  general  bathing  be  dispensed  with  and  the  surface 
be  washed  from  a  basin  or  bowl,  cooler  water  may  be  used  than  would  be 
proper  for  the  general  bath,  and  a  longer  time  to  complete  bathing  would 
evidently  be  required.  The  bath-room  should  be  comfortably  warm,  and 
after  the  bath  the  surface  should  be  briskly  rubbed  with  flannel  or,  in  case 
of  older  children,  with  a  suitable  coarse  towel,  and  exercise  afterward  encour- 
aged to  ensure  full  reaction.  In  New  York,  in  one  of  the  largest  and  best 
managed  asylums,  both  boys  and  girls  are  allowed  to  bathe  in  bath-houses  in 
the  Hudson  when  the  water  and  weather  are  not  too  cool. 


66  INFANCY  AND   CHILDHOOD. 

It  may  be  well  to  add  to  these  general  remarks  on  bathing  the  recent 
statement  of  a  high  authority  on  thermometric  observations  and  temperature, 
that  during  hot  days  a  bath  in  hot  water,  employed  in  the  hours  of  greatest 
atmospheric  heat,  tends  to  reduce  the  heat  of  body  and  to  preserve  its  normal 
temperature  during  the  remainder  of  the  day.  Wunderlich  says  :  "  In  tropical 
countries  and  in  very  hot  seasons  no  means  of  cooling  is  so  lasting  as  a  bath 
or  douche  of  very  warm  water." 

Clothing. 

One  of  the  most  important  duties  of  the  mother  or  nurse  is  the  selection 
of  clothing  for  children  which  will  be  suitable  for  their  age  and  the  season. 
In  the  matter  of  dress,  as  in  that  of  diet,  many  errors  are  unconsciously 
committed.  In  a  room  of  proper  temperature,  which  during  the  cool  months 
should  be  70°  for  infants  and  68°  for  children  old  enough  to  run  about,  the 
head  should  never  be  covered  unless  in  case  of  young  infants  ;  but  the  sides 
of  the  head,  as  well  as  the  neck  and  shoulders,  may  be  lightly  covered  in 
sleep.  It  is  the  common  practice  to  leave  off  the  "  bellyband,"  which  is 
applied  after  birth,  when  the  infant  has  reached  the  age  of  three  or  four 
months  ;  but  from  the  fact  that  infants  so  often  take  cold,  especially  at  night 
by  throwing  off  bedclothes,  both  in  cool  weather,  when  the  temperature  of 
the  apartment  may  fall  below  70°,  and  in  summer,  when  there  are  currents 
of  air  through  open  windows,  I  advise  the  continuance  of  the  band  during 
the  first  year  or  eighteen  months.  In  the  summer  it  should  be  made  of  light 
merino  and  in  the  winter  of  flannel.  It  should  never  be  so  thick  and  heavy 
as  to  be~  uncomfortable,  or  so  snug  as  to  interfere  in  the  least  with  the  free 
movements  of  the  chest  and  abdomen  in  respiration.  It  should  extend  to 
and  not  over  the  ribs,  and  should  be  secured  either  with  safety-pins  or  a  few 
stitches.  If  excoriations  or  prickly  heat  appear  on  the  skin  under  the  band 
in  hot  weather — a  very  common  eruption  in  infancy — the  surface  should  be 
dusted  with  equal  parts  of  subnitrate  of  bismuth  and  stearate  of  zinc,  or  a 
mixture  in  equal  parts  of  lycopodium  and  oxide  of  zinc,  and  a  single  layer 
of  linen  should  be  applied  over  it  and  under  the  band.  If  the  eruption  be 
severe,  it  might  be  best  to  substitute  a  linen  or  soft  muslin  band  for  a  time 
in  place  of  the  merino. 

A  cardinal  principle  in  the  clothing  of  children  is  that  the  garments  should 
always  be  so  loose  as  not  to  interfere  in  the  least  with  the  functional  activity 
of  organs.  The  fitting  and  putting  on  of  the  dress  is  left  too  much  to  the 
discretion  of  the  nurse,  who  is  usually  ignorant  of  the  important  facts  in 
physiology,  and  unwittingly  and  with  the  best  intentions  injures  her  charge. 
I  have  often  interposed  to  loosen  the  dress  of  young  infants,  which  was  so 
tight  as  sensibly  to  embarrass  respiration ;  and  the  case  of  a  new-born  infant 
has  been  reported  to  me  in  which  it  seemed  probable  that  death  resulted  from 
this  cause.  Infants  especially,  who  are  so  liable  to  pulmonary  collapse  and 
intestinal  hernia,  should  have  loose  covering  of  both  chest  and  abdomen. 
Pressure  over  the  stomach  always  feels  uncomfortable,  and  this  organ,  almost 
as  much  as  the  lungs,  needs  full  expansion  and  free  movement  in  order  to 
perform  its  function  of  digestion  properly.  The  same  is  true  also  of  the 
intestines,  but  they  tolerate  compression  better,  and  their  movements  are  less 
impeded  than  those  of  the  stomach  by  too  tight  dressing.  Another  part 
where  too  snug  an  application  of  the  dress  does  very  great  harm  is  the  neck, 
since  moderate  pressure  in  this  region  may  retard  the  circulation  of  blood 
through  very  important  vessels — to  wit,  those  which  supply  the  brain  or  return 
blood  from  this  organ.  The  dress  about  the  neck  should  always  be  so  loose 
that  the  four  fingers  of  the  nurse  can  be  readily  introduced  underneath  it. 


BATHING,   CLOTHING,  SLEEP,  EXERCISE.  67 

Skirts  upon  girls  are  sometimes  supported  by  being  tied  tigbtly  around  the 
waist  and  over  the  stomach.  This  should  never  be  allowed,  but  they  should 
always  be  supported  by  shoulder-straps  and  be  loose  around  the  waist. 

Clothing  protects  the  body  according  to  its  thickness  and  the  feebleness 
of  its  conducting  power  of  heat.  Woollen,  fur,  and  feather  garments  have 
very  low  conducting  power,  and  wool,  from  its  plentiful  supply  and  cheap- 
ness, must  always  be  the  material  which  is  chiefly  worn  in  the  winter  season ; 
while  cotton,  and  in  still  greater  degree  linen,  are  active  conductors  of  heat, 
allowing  its  quick  escape  from  any  part  of  the  body  which  it  covers,  and 
they  are  therefore  the  proper  material  for  summer  clothing. 

The  color  of  the  garment  matters  little  as  regards  the  escape  of  heat  from 
the  body,  for  whatever  its  color  its  surface  next  the  body  is  necessarily  dark 
from  the  exclusion  of  light ;  but  the  color  is  important  as  regards  the 
absorption  of  heat  from  the  atmosphere  and  the  solar  rays.  Black  has  the 
highest  absorptive  power,  while  white  has  the  least,  and  the  mixed  colors 
have  absorptive  powers  which  are  intermediate.  In  experiments  made  with 
shirtings  of  different  colors,  while  white  received  100°  F.,  black  received 
208°  F.  A  light  color  is  therefore  the  best  to  dress  children  in  during  the 
hottest  weather. 

The  covering  which  is  proper  for  the  head  of  a  child  when  outdoor  must 
evidently  vary  considerably  in  different  seasons  and  in  different  states  of 
weather.  Many  a  young  child  with  scanty  growth  of  hair  has  contracted 
that  painful  disease,  inflammation  of  the  ear,  followed  perhaps  by  a  protracted 
discharge  and  more  or  less  impairment  of  hearing,  in  consequence  of  taking 
cold  from  insufiicient  covering  of  head  and  ears  in  inclement  and  changeable 
weather  ;  even  leaving  off  accidentally  a  band  or  tie  which  a  child  is  accus- 
tomed to  will  sometimes  give  it  a  cold. 

In  this  connection  I  wish  to  call  attention  to  the  common  and  dangerous 
practice  among  the  poor  of  allowing  children  to  go  bareheaded  in  the  sun 
during  the  season  when  the  atmospheric  heat  is  highest.  Xot  a  summer 
passes  in  which  I  do  not  meet  cases  of  inflammation  of  the  brain  which  I 
believe  to  be  largely  due  to  exposure  to  the  sun's  rays.  There  is  no  better 
and  safer  covering  for  the  head  of  a  child  who  is  allowed  to  go  in  the  open 
air  during  the  hot  weather  than  the  light,  cool,  and  inexpensive  straw  hat. 

The  feet  should  always  be  warm  and  dry,  the  shoes  worn  in  wet  weather 
being  waterproof,  and  special  care  should  be  taken  in  the  selection  of  shoes 
that  they  be  pliable  and  loose,  so  as  to  allow  freedom  of  growth  without  com- 
pression of  any  part.  If  during  the  period  of  growth  proper  precautions  are 
taken  in  this  respect,  the  chiropodist  would  have  little  to  do  in  subsequent 
years.  Corns,  bunions,  and  ingrowing  toe-nails  orginate  from  hard  and  un- 
yielding or  too  tightly-fitting  shoes. 

Sleep. 

The  newly-born  infant  until  about  the  age  of  six  or  eight  weeks  requires 
not  less  than  twenty-one  hours'  sleep  each  day.  It  sleeps,  therefore,  most  of 
the  time  when  not  awake  for  the  purpose  of  nursing,  bathing,  and  change  of 
clothing.  If  it  do  not  have  this  amount  of  sleep  and  be  wakeful,  it  is  prob- 
ably not  well.  After  the  eighth  week  it  requires  less  and  less  sleep  with 
advancing  age,  and  at  the  end  of  the  first  year  fourteen  hours  of  sleep  each 
day  sufl&ces.  At  the  age  of  eighteen  months  about  twelve  hours  of  sleep  are 
needed,  a  part  of  which  should  be  in  the  middle  of  the  day.  At  the  age  of 
two  and  a  half  or  three  years,  and  subsequently  during  childhood,  about  ten 
hours  are  required  at  night,  and  if  the  child  be  tired  or  sleepy  in  the  day- 
time it  should  be  allowed  to  sleep.     Sufiicient  sleep  is  essential  for  the  nor- 


68  INFANCY  AND  CHILDHOOD. 

mal  development  of  the  body  and  the  normal  functional  activity  of  the 
organs  in  infancy  and  childhood. 

During  sound  sleep  the  senses  no  longer  receive  and  communicate  impres- 
sions. They  enter  into  the  state  of  sleep  in  the  following  order :  Sight  is 
first  lost,  and  then  touch,  taste,  smell,  and  lastly  hearing.  In  sound  sleep 
also  the  frequency  of  the  respiration  and  pulse  is  slightly  diminished.  Exci- 
tation of  any  of  the  senses  has  a  tendency  to  prevent  sleep.  A  bright  light, 
rough  handling,  and  loud  noises  render  young  children  wakeful,  and,  if  they 
be  deprived  of  the  needed  sleep,  fretful.  Slight  excitation  of  certain  of  the 
senses,  as  by  a  low  humming  voice  or  gentle  rocking,  on  the  other  hand,  tend 
to  procure  sleep.  The  time  of  soundest  sleep  is  about  one  hour  after  its 
commencement,  after  which  it  becomes  gradually  less  profound  until  the 
child  awakens.  The  child  should  be  habituated  to  taking  its  sleep  at  a  cer- 
tain hour,  and  if  it  be  well  and  not  subjected  to  any  unusual  excitement,  it 
will  be  drowsy  and  will  sleep  readily  when  that  hour  arrives.  In  the  asylums 
of  New  York,  where  from  long  and  abundant  experience  the  management  of 
children  is  systematized,  infants  and  the  younger  children  are  usually  put  to 
bed  between  six  and  seven,  and  the  older  children  between  seven  and  eight, 
o'clock,  the  last  meal  being  light  and  readily  digested. 

Various  causes  produce  wakefulness  in  children.  We  have  already  alluded 
to  strong  impressions  upon  the  senses.  A  swollen  and  tender  gum,  indiges- 
tion with  flatulence  and  colic,  eczema  with  tenderness  and  itching,  as  well  as 
the  more  serious  forms  of  sickness,  produce  wakefulness.  Unpleasant  and 
exciting  sensations  of  whatever  kind,  reaching  the  brain,  keep  up  a  state  of 
excitement  and  prevent  its  repose.  The  fretful  and  sleepless  baby  in  the  hot 
and  stifling  air  of  the  tenement-house  in  the  heat  of  summer  soon  falls  asleep 
when  taken  to  cooler  air  outside. 

It  is  scarcely  necessary  to  call  attention  to  some  accepted  and  important 
facts  regarding  the  dormitory  of  children.  Free  ventilation  is  required  either 
through  ventilators  or  through  the  windows,  slightly  raised  in  winter  and 
more  widely  open  in  summer".^^^' A  Somali  room  should  not  contain  more  than 
two  children,  and  the  temperature  of  the  sleeping  apartment  should  be  at 
about  68°  F.     A  temperature  too  cool  causes  wakefulness. 

The  amount  of  blood  circulating  in  the  brain  in  sleep  is  less  than  when 
awake,  and  too  active  a  circulation,  as  from  fever  or  much  excitement,  causes 
wakefulness.  If  the  head  be  unduly  hot,  and  in  the  infant  the  anterior  fon- 
tanel pulsate  forcibly,  a  cloth  wrung  out  of  cold  water  should  be  applied  over 
it,  and  a  general  bath  or  hot  foot-bath  should  be  used  in  order  to  diminish  the 
cerebral  circulation.  On  the  other  hand,  if  the  brain  be  not  properly  nour- 
ished in  consequence  of  poverty  of  the  blood,  as  is  sometimes  the  case  with 
pallid  and  scrofulous  children,  the  diet  should  be  more  nutritious  and  iron 
may  be  needed. 

If  the  sleeplessness  continue  when  all  causes  so  far  as  possible  have  been 
removed,  medicinal  treatment  will  be  necessary.  Frequently  in  families 
before  the  physician  is  summoned  the  so-called  soothing  syrups  have  been 
used,  which  contain  an  opiate,  and  the  use  of  which  should  be  forbidden.  The 
safest  remedy  is  one  of  the  bromides,  which  may  be  given  dissolved  in  water 
in  three-grain  doses  to  an  infant  between  the  ages  of  six  and  twelve  mouths, 
and  one  grain  additional  should  be  added  for  each  year,  or  the  aniseed  cordial 
of  the  National  Formulary  may  be  prescribed.  The  dose  if  required  may  be 
repeated  after  two  hours. 

Exercise. 

Exercise  is  an  important  hygienic  requirement.  Harm  often  results  from 
modes  of  exercise  which  are  not  adapted  to  the  age.     Occasionally  I  meet 


BATHING,   CLOTHING,  SLEEP,   EXERCISE.  69 

<3ases  of  permanent  bow-leg  which  have  manifestly  resulted  from  attempts  to 
make  infants  stand  at  the  age  of  four  or  five  months.  They  should  never  be 
encouraged  to  walk  or  stand  till  about  the  age  of  one  year,  and  if  they  do  at 
the  age  of  nine  or  ten  months,  let  it  be  voluntary  and  not  taught  by  stand- 
ing them  upon  their  feet.  In  case  of  infants  with  rachitis — which  disease  is 
common  in  cities,  and  is  characterized  by  a  lack  of  lime-salts  in  the  bones, 
and  can  be  detected  by  great  backwardness  in  teething — attempts  to  stand 
or  walk  for  any  length  of  time  should  be  discouraged  till  by  the  use  of  phos- 
phorus, cod-liver  oil  and  improvement  of  the  general  health  the  rachitis  is 
cured.  Much  of  the  permanent  deformity  which  mars  the  beauty  and  sym- 
metry of  adult  life  orginates  in  rachitis  and  might  have  been  prevented. 

The  infant  before  he  is  old  enough  to  stand  takes  sufficient  exercise  in  a 
way  that  is  natural  and  harmless.  Let  him  lie  upon  his  back  in  the  crib  or 
on  the  floor,  with  a  blanket  under  his  body  and  pillow  under  his  head,  with 
all  his  clothes  loose,  so  as  not  to  restrain  the  free  movement  of  his  limbs.  A 
healthy  infant  seems  to  enjoy  this  attitude,  moving  all  his  limbs  sufficiently 
to  give  them  the  required  exercise,  and  evincing  his  delight  and  exuberance 
of  life  by  utterances  which  ai'e  as  expressive  as  words. 

In  the  cool  months  of  our  latitude  infants  should  not  be  taken  outdoor 
until  the  age  of  three  months,  and  then  only  for  a  brief  time  in  the  warmest 
part  of  the  day  ;  but  in  the  summer  they  should  begin  to  receive  outdoor  air 
and  exercise  at  the  age  of  one  month.  In  warm  weather  the  face  should 
never  be  covered  by  a  veil  or  otherwise,  and  air  and  light  should  have  free 
access  to  it.  The  rays  of  the  sun,  however,  from  a  clear  sky  should  be 
excluded,  either  by  a  parasol  or  the  shade  of  trees  or  houses  or  by  the  carriage 
in  which  the  infant  is  conveyed.  In  cold  weather  or  when  there  is  a  strong 
wind  the  protection  of  a  veil  is  needed.  Rude  tossing  of  infants,  which  is 
common  in  families,  should  always  be  forbidden.  Its  effect  on  the  cerebral 
circulation  is  likely  to  be  bad,  and  it  involves  risk  of  serious  accident.  In 
one  instance  to  my  knowledge  death  resulted  from  injury  received  in  this 
way. 

Walking,  as  it  is  the  natural,  so  it  is  the  best,  exercise  for  the  older  infants 
and  during  the  period  of  childhood.  It  promotes  digestion  when  not  carried 
to  the  extent  of  fatigue,  and  gives  gentle  exercise  to  all  the  muscles.  The 
baby-carriage  answers  a  useful  purpose  when  combined  with  walking.  With 
the  ordinary  hired  nurse  it  is  safer  for  the  infant  to  be  taken  out  in  this 
vehicle  than  in  the  arms,  for  if  the  nurse  in  careless  walking  should  trip  great 
harm  might  result.  In  one  instance  which  came  under  my  notice  convulsions 
and  idiocy  were  plainly  referable  to  the  fall  of  an  infant  from  its  nurse's 
arms  upon  its  head. 

The  ordinary  lawn  sports  of  childhood,  as  croquet  for  both  sexes,  play- 
ing ball  or  quoits  for  boys,  which  are  rendered  more  exciting  by  the  spirit  of 
rivalry,  are  also  useful  for  muscular  exercise  and  development,  while  they 
involve  little  danger.  The  swing  affords  a  pleasant  exercise,  and  with  the 
propulsion  required  it  gives  gentle  but  efficient  activity  to  most  of  the 
muscles. 

Many  of  the  gymnastic  exercises  are  too  severe,  involve  too  much  risk 
of  ruptured  tendons,  sprained  joints,  and  even  of  dislocated  or  broken 
limbs. 

Among  all  the  ingenious  inventions  to  provide  sports  and  pastimes  for 
children  there  are  none  better  than  gardening  and  farming  where  facilities 
will  allow  them,  conjoined  with  the  ordinary  household  duties.  The  healthy 
and  robust  development  of  the  farming  population,  their  almost  complete 
immunity  from  rachitic  and  scrofulous  ailments,  are  attributable  to  their  out- 
door mode  of  life  and  the  many  kinds  of  healthful  work  which  farm-life 


70  INFANCY  AND   CHILDHOOD. 

requires.  Such  work  is  always  in  the  highest  degree  beneficial  for  children 
old  enough  to  participate  in  it,  while  it  develops  the  habit  of  productive 
industry. 


CHAPTER    X. 

DIAGNOSIS  OF  INFANTILE  DISEASES. 

General  Observations. 

Diseases  in  early  life  differ  in  important  particulars  from  those  occurring 
in  maturity.  Some  which  are  common  in  the  former  age  are  unknown  or  are 
rare  in  the  latter,  and  those  which  occur  equally  at  all  ages  often  present 
peculiar  symptoms  and  a  peculiar  clinical  history  in  the  young.  Therefore 
physicians  who  are  skilful  in  treating  adults  may  be  unskilful  in  treating 
children.  Excellence  as  a  physician  of  children  can  only  be  achieved  by 
special  and  continued  study  of  their  ailments. 

Again,  as  regards  the  diseases  of  infancy,  in  which  period  there  are  a  great 
amount  of  sickness  and  a  large  mortality,  diagnosis  must  evidently  be  made 
from  the  objective  symptoms — from  examining  the  features,  attitude,  utter- 
ances, the  pulse,  respiration,  etc.,  and  inspecting  the  surfaces,  so  far  as  they 
are  accessible  to  view,  and  the  eliminated  products.  We  lack  for  this  age  the 
important  information  which  speech  affords.  Some  general  remarks,  there- 
fore, in  reference  to  the  appearances  and  functions  of  the  system  in  early  life, 
and  the  changes  which  they  undergo  in  various  pathological  states,  seem 
requisite  in  order  to  a  clearer  appreciation  of  the  symptoms  and  more  ready 
diagnosis  of  individual  diseases. 

Features— External  Appearance  of  the  Head,  Trunk,  and  Limbs 

in  Disease. 

In  the  new-born,  as  soon  as  respiration  and  the  new  circulation  are  estab- 
lished, the  cutaneous  capillaries  become  distended  with  blood  and  the  skin 
presents  a  congested  appearance.  By  the  close  of  the  first  week  this  external 
hyperaemia  begins  to  abate,  and  is  soon  replaced  by  the  normal  capillary 
circulation. 

The  surface  or  portions  of  the  surface  of  the  new-born  often  present  for  a 
few  hours  a  livid  color,  due  to  the  mode  of  delivery.  Protracted  lividity 
occurs  from  atelectasis  or  malformation  of  the  heart  or  great  vessels ;  lividity 
induced  by  exertion  or  excitement,  while  the  respiration  is  normal,  indicates 
malformation  of  the  heart  or  vessels ;  temporary  lividity  sometimes  occurs  in 
severe  acute  diseases,  especially  those  of  the  respiratory  organs :  lividity, 
whether  temporary  or  permanent,  is  a  sign  of  imperfect  decarbonization  of 
the  blood. 

The  cheeks  of  children  are  congested  in  febrile  and  inflammatory  diseases, 
except  in  a  cachectic  or  prostrated  state  of  the  system.  Transient  circum- 
scribed congestion  of  the  face,  ears,  or  forehead  constitutes  a  reliable  sign  of 
cerebral  disease.  Strabismus  occurring  in  connection  with  febrile  reaction, 
oscillation  of  iris,  inequality  of  pupils,  and  drooping  of  upper  eyelids,  also 
denote  cerebral  disease.  The  pupils  are  contracted  during  sleep,  evenly 
dilated  in  death. 


DIAGNOSIS  OF  INFANTILE  DISEASES.  71 

Dilatation  of  the  alae  nasi  during  inspiration,  with  contraction  of  the  eye- 
brows and  a  countenance  indicative  of  suffering,  attends  severe  inflammation 
of  the  respiratory  organs.  Absence  of  tears  during  the  act  of  crying  shows 
a  severe  and  probably  fatal  form  of  disease  in  infants  over  the  age  of  four 
months. 

Rapid  wasting  of  the  features,  causing  deep  suborbital  depressions,  prom- 
inence and  pointedness  of  the  cheek-bones  and  chin,  and  hollowness  of  the 
cheeks,  are  signs  of  severe  diarrhoeal  malady ;  the  most  striking  examples  of 
this  sudden  collapse  of  features  are  afforded  by  patients  affected  with  cholera 
infantum.  In  severe  cases  of  this  disease  the  physiognomy,  from  a  state  of 
fulness  and  health,  presents  in  a  few  hours  such  a  wasted  and  senile  appear- 
ance that  the  friends  with  difficulty  recognize  the  features  with  which  they 
are  familiar.  Muscular  tonicity  is  also  greatly  impaired  in  this  disease — that 
of  the  orbicular  muscles  of  the  lips  and  eyelids  to  such  an  extent  that  the 
mouth  is  open  and  the  eyeballs  exposed  during  sleep.  Great  emaciation 
occurring  gradually  is  a  symptom  of  subacute  or  chronic  disease  of  a  grave 
character,  often  of  tuberculosis  or  chronic  entero-colitis. 

Strabismus  sometimes  occurs  in  children  who  have  no  serious  disease.  It 
is  then  due  to  simple  paralysis  of  one  or  more  of  the  motor  muscles  of  the 
eye.  But  when  supervening  upon  other  symptoms  of  a  neuropathic  charac- 
ter it  is  a  grave  symptom,  indicating  organic  disease  of  the  encephalon,  as 
effusion,  meningitis,  etc.  A  permanently  downward  direction  of  the  axes  of 
the  eyes,  with  smallness  of  the  face  and  great  expansion  of  the  cranium,  is  a 
sign  of  chronic  hydrocephalus.  The  scalp  in  this  disease  is  tense,  bald,  or 
sparingly  covered  with  hair,  the  fontanelles  and  sutures  open  and  enlarged, 
and  the  cranial  bones  yield  to  pressure.  Great  expansion  of  the  cranium 
above  the  ears,  while  the  frontal  portion  is  not  enlarged  or  but  slightly, 
denotes  hypertrophy  of  the  brain. 

The  appearance  of  the  general  cutaneous  surface  possesses  much  greater 
diagnostic  value  in  the  diseases  of  infancy  and  childhood  than  in  those  of 
adult  life.  The  eruptive  fevers,  so  common  in  the  young  and  comparatively 
rare  in  the  adult,  reveal  themselves  to  us  in  great  part  by  the  changes  which 
they  cause  in  the  appearance  of  the  integument.  The  peculiar  color  of  the 
skin  in  constitutional  syphilis,  hereafter  to  be  described,  and  which  is  more 
marked  in  infancy  and  early  childhood  than  at  any  other  age,  is  a  diagnostic 
sign  of  great  value  in  obscure  cases.  In  the  infant  the  cold  stage  of  inter- 
mittent fever  is  manifested,  not  by  muscular  tremors,  but  by  lividity,  pallor, 
and  the  goose-skin  appearance  of  the  surface. 

Bulbous  enlargement  of  the  fingers  and  incurvation  of  the  nails  are  signs 
of  cyanosis,  and  therefore  of  malformation  at  the  centre  of  the  circulatory 
apparatus,  or  of  tuberculosis  or  chronic  pulmonary  disease  attended  by  mal- 
nutrition. Enlargement  of  the  spongy  portions  of  bones,  causing  prom- 
inences, softness,  and  bending  of  the  bones,  and  consequent  deformity  of  the 
limbs,  patency  of  the  fontanelles,  a  large  and  square  shape  of  the  head  from 
calcareous  deposit  external  to  the  cranium,  and  delayed  dentition,  are  among 
the  signs  of  rachitis. 

In  early  infancy  the  glands  of  the  skin  and  mucous  surfaces,  or  which 
connect  by  their  orifices  with  these  surfaces,  are  slightly  developed.  There- 
fore, sensible  perspiration  and  lachrymation  are  rare  under  the  age  of  three 
months.  A  thick  Meibomian  secretion  of  a  puriform  appearance  collecting 
between  the  eyelids  in  a  state  of  great  depression  is  an  unfavorable  prognos- 
tic sign ;  it  is  observed  most  frequently  in  cerebral  and  intestinal  maladies 
shortly  before  death.  Passive  congestion  of  the  vessels  of  the  conjunctiva 
sometimes  occurs  under  the  same  circumstances,  due  to  feebleness  of  the 


72  INFANCY  AND  CHILDHOOD. 

heart's   action    and  imperfect   capillary   circulation.      It   indicates   the   near 
approach  of  death. 

Attitude— Movements— The  Voice. 

A  sharp,  piercing  cry,  head  firmly  retracted,  flexure  of  the  limbs  with  a 
degree  of  rigidity,  abduction  of  the  great  toe,  clonic  or  tonic  spasm  of  the 
muscles,  irregular  movements  of  one  or  more  limbs,  with  consciousness  im- 
paired or  with  mental  hallucinations,  are  symptoms  of  grave  disease  of  the 
cerebro-spinal  system.  Irregular  muscular  movements,  partly  controlled  by 
the  will  and  occurring  during  full  consciousness,  are  symptoms  of  chorea,  a  ' 
disease  nearly  always  ending  favorably  in  children,  though  incurable  in  the 
adult.  Contraction  of  the  eyebrows,  turning  of  the  eyes  and  face  from  light, 
avoidance  of  noises  as  if  painful,  are  signs  of  headache.  Frequent  carrying 
of  the  hand  to  the  ear  and  pressing  with  the  ear  against  the  breast  of  the 
mother  or  nurse  are  symptoms  of  otalgia.  Frequent  carrying  of  the  fingers 
to  the  mouth  in  connection  with  fretfulness  or  other  symptoms  of  suifering 
indicates  stomatitis,  gingivitis  whether  from  difiicult  dentition  or  other  causes, 
painful  pharyngitis,  or  some  obstructive  disease  of  the  larynx.  Frequent  rub- 
bing or  pi'essing  the  nose  may  be  due  to  intestinal  worms  or  intestinal  irrita- 
tion from  other  causes.  It  may  be  due  to  coryza  or  headache.  Frequent 
forcible  rubbing  or  striking  the  nose  should  lead  to  a  careful  examination  and 
perhaps  guarded  prognosis.  It  often  indicates  grave  cerebral  disease,  and  may 
be  a  precursor  of  convulsions. 

In  severe  obstructive  disease  of  the  larynx  the  child  is  restless,  moving 
from  side  to  side.  In  most  inflammations  of  the  respiratory  organs  a  semi- 
erect  position  gives  most  relief.  The  voice  in  severe  laryngitis  is  often  hoarse 
or  indistinct,  and  is  usually  so  in  the  pseudo-membranous  form  ;  in  pleuritis 
or  pneumonitis  it  is  restrained  or  abrupt,  since  the  movements  of  the  walls 
of  the  chest  give  pain. 

The  voice  in  severe  diseases  of  the  abdominal  organs  is  feeble  and  plain- 
tive. It  is  sometimes  short  and  restrained  in  acute  dyspepsia,  in  peritonitis, 
and  in  cases  of  great  abdominal  distention.  The  horizontal  position  gives 
most  relief  in  abdominal  diseases.  In  case  of  abdominal  pain  the  patient 
often  presses  his  hand  upon  the  abdomen  and  flexes  his  thigh  over  it.  Per- 
fect quietude,  with  features  sunken  and  unchanged  by  smile  or  crying,  is  a 
symptom  of  severe  and  exhausting  diarrhoeal  afi'ections. 

Respiratory  System. 

The  respiration  of  the  infant  under  the  age  of  six  months  is  very  irregular, 
and  it  is  more  irregular  the  nearer  the  time  to  birth.  If  the  new-born  infant 
be  closely  observed,  it  will  be  seen  to  sigh  often  ;  it  breathes  pretty  uniformly 
and  regularly  for  a  moment,  and  then,  without  appreciable  cause,  the  respira- 
tion is  intermitted ;  it  holds  its  breath  when  it  smiles  or  moves  its  head  or 
even  its  limbs ;  it  is  very  subject  to  hiccup  ;  this  is  more  common  the  first 
week  of  life  than  at  any  other  age.  So  much  is  the  breathing  of  the  young 
infant  disturbed  by  these  causes  that  the  number  of  respirations  ordinarily 
varies  in  consecutive  minutes.  In  order,  therefore,  to  determine  with  accuracy 
the  frequency  of  the  normal  respiration  for  this  time  of  life  it  is  necessary  to 
take  the  average  of  several  observations. 

At  birth,  while  the  function  of  the  heart  has  for  months  been  regularly 
performed,  the  lungs  are  still  quiescent.  The  one  organ  has  been  active  dur- 
ing the  greater  part  of  foetal  development,  the  other  is  yet  untried.  Here- 
after, in  the  new  order  of  things,  so  intimate  is  the  relation  between  the  heart 
and  lungs  that  the  proper  performance  of  the  function  of  the  one  is  essential 


DIAGNOSIS  OF  INFANTILE  DISEASES.  73 

to  that  of  the  other.  Therefore,  the  commencement  of  respiration  and  the  re- 
turn of  circulation,  which  latter  is  modified  and  temporarily  arrested  at  birth, 
are  nearly  simultaneous.  Respiration  begins  in  the  first  half  minute  of  inde- 
pendent existence ;  often,  indeed,  attempts  to  inspire  occur  before  delivery  is 
completed.  The  exceptions  to  this  early  establishment  of  respiration  are  after 
tedious  or  unnatural  births.  The  establishment  of  the  new  circulation  is  a 
moment  later. 

Respiration  in  Health.- — -As  the  air-cells  at  birth  are  closed,  the  establish- 
ment of  respiration  is  difficult.  The  air  at  first  penetrates  a  few  pulmonary 
cells,  but  gradually  more  and  more  are  inflated  through  the  forcible  inspira- 
tions which  the  crying  of  the  infant  produces,  till  after  a  variable  time  respi- 
ration becomes  easy  and  complete.  If  the  cry  be  feeble,  and  especially  if  with 
this  feebleness  there  be  considerable  congestion  of  the  brain,  the  result  of 
tedious  birth,  the  full  establishment  of  respiration  is  in  a  corresponding  degree 
gradual  and  slow. 

The  freqviency  of  respiration  in  healthy  infants  has  been  stated  in  a  pre- 
ceding chapter. 

As  the  child  advances  from  the  age  of  one  year  the  number  of  respira- 
tions per  minute  gradually  diminishes,  but  through  the  whole  period  of  child- 
hood it  remains  greater  than  in  the  adult.  At  the  age  of  five  years,  when  the 
child  is  quiet  but  awake,  it  is  about  27  ;  at  the  age  of  ten  years,  about  22. 

Respiration  in  Disease. — In  cerebral  diseases  the  respiration  becomes  slow, 
-and,  if  somnolence  occur,  intermittent  and  accompanied  by  sighing.  In  young 
infants,  in  the  drowsiness  which  supervenes  when  the  blood  is  imperfectly 
-decarbonized  during  severe  attacks  of  capillary  bronchitis  or  broncho-pneu- 
monia, respiration  is  likely  to  be  intermittent. 

In  inflammatory  diseases  of  the  larynx  and  trachea  respiration  is  but 
slightly  accelerated,  and,  if  there  be  no  obstruction,  its  rhythm  is  normal ; 
if  there  be  obstructive  disease,  its  rhythm  is  altered ;  the  inspiratory  act  is 
lengthened.  In  bronchitis  respiration  is  accelerated  in  proportion  to  the 
degree  of  extension  downward  of  the  inflammation.  It  is  in  no  disease  more 
accelerated  than  in  severe  capillary  bronchitis. 

In  pleuritis  and  pneumonitis  the  respiration  is  accelerated  in  proportion 
to  the  extent  and  acuteness  of  the  inflammation.  Inspiration  ending  abruptly 
and  succeeded  by  an  expiratory  moan  is  a  symptom  of  both  pleuritis  and 
pneumonitis  in  their  acute  stages.  In  certain  cases  of  irritative  or  inflam- 
matory disease  of  the  abdominal  organs  respiration  presents  a  similar  charac- 
ter ;  it  is  modified  in  this  manner  in  consequence  of  the  pain  experienced  in 
movements  of  the  diaphragm.  Ordinarily,  however,  in  abdominal  diseases, 
respiration  is  nearly  natural. 

The  cough  is  an  important  diagnostic  symptom.  It  is  loud  and  sonorous 
in  spasmodic  croup,  hoarse  or  harsh  in  true  croup,  clear  and  distinct  in  bron- 
chitis, suppressed  and  painful  in  the  early  stages  of  pneumonitis  and  pleuritis, 
convulsive  and  with  more  inspirations  than  expirations  in  pertussis.  A  cough 
■due  to  coexisting  bronchitis  is  one  of  the  first  and  most  constant  symptoms  of 
measles.  Typhoid  and  remittent  fevers,  difficult  dentition,  intestinal  worms, 
irritating  ingesta,  and  severe  burns  sometimes  give  rise  to  a  cough  which  is 
nearly  dry  and  painless.  Occurring  in  such  diseases,  it  is  sometimes  depend- 
ent on  more  or  less  bronchitis,  to  which  the  primary  disease  has  given  rise. 

A  .strongly-marked  nasal  or  palatal  cry  is  present  in  syphilitic  ozfena, 
hypertrophied  tonsils,  and  paralysis  of  the  soft  palate.  If  these  can  be 
excluded,  it  indicates  retropharyngeal  abscess.  On  one  occasion  Politzer 
heard  this  cry  in  a  baby  that  the  mother  said  was  well  ;  but  he  introduced 
his  finger  in  the  fauces,  felt  the  expected  swelling,  and  by  an  incision  evac- 
iuated  a  considerable  amount  of  pus. 


74  INFANCY  AND  CHILDHOOD. 

An  excessively  prolonged,  loud-toned  expiration,  with  normal  inspiration 
and  without  dyspnoea,  is,  according  to  Politzer,  an  early  symptom  of  chorea, 
sometimes  preceding  all  other  symptoms.  He  was  once  called  to  a  child^ 
apparently  well  and  asleep,  in  whom  this  symptom  had  continued  two  hours, 
and  was  supposed  by  the  mother  to  indicate  croup.  Later  the  ordinary 
symptoms  of  chorea  appeared.  The  same  author  regards  a  high  thoracic, 
continued  sighing  inspiration  as  almost  pathognomonic  of  weak  heart  and 
of  certain  cases  of  acute  fatty  heart.  Unlike  the  condition  in  laryngeal 
stenosis,  while  the  diaphragm  is  nearly  inactive  the  accessory  muscles  of 
inspiration  act  strongly.  This  symptom  occurs  early,  antedating  the  lividity, 
pallor,  weak  pulse,  and  cold  extremities. 

A  distinct  pause  after  each  expiration,  ascertained  in  a  quiet  room  by 
placing  the  ear  close  to  the  mouth,  distinguishes  laryngeal  catarrh  from  croup 
(Politzer).  Stridulous  inspiration  usually  indicates  acute  laryngeal  catarrh, 
but  I  have,  in  a  considerable  number  of  instances,  been  asked  to  prescribe  for 
infants  with  stridulous  respiration  which  commenced  early,  perhaps  in  the 
first  or  second  month,  and  continued  night  and  day  till  about  the  close  of 
the  first  year,  when,  in  the  development  of  the  child,  it  ceased.  It  is  attended 
by  no  dyspnoea  or  suffering,  does  not  interfere  with  the  nutrition  or  growth, 
is  not  benefited  by  any  known  treatment,  and  it  seems  that  it  may  exist 
within  physiological  limits. 

A  shrill,  loud  cry,  night  after  night,  in  sleep,  while  the  child  is  well  in  the 
day-time,  is  probably  due  to  dreams,  and  it  may  be  treated  by  a  large  dose 
of  quinine  at  bed-time,  but  a  full  dose  of  the  bromide  of  potassium  or  sodium 
is  perhaps  more  likely  to  give  relief.  A  cry  lasting  five  or  ten  minutes  and 
occurring  several  times  in  the  day  indicates  spasm  of  the  bladder,  especially 
if  dysuria  be  present.  It  is  best  treated  by  belladonna,  provided  that  there 
be  no  calculus.  A  cry  during  defecation  indicates  fissure  of  the  anus,  and 
is  to  be  treated  by  an  ointment  of  zinc  and  belladonna.  A  violent  and  pro- 
tracted cry,  with  restlessness,  pressing  the  head  on  the  pillows  or  breast  of 
the  nurse,  and  frequent  carrying  of  the  finger  to  the  ear,  indicate  otalgia. 

Circulatory  System. 

In  all  ages  and  countries  the  pulse  has  been  considered  an  important 
symptom,  both  in  diagnosis  and  prognosis.  It  aids  the  practitioner  in  deter- 
mining, approximately,  not  only  the  character,  but  the  gravity,  of  diseases.  It 
is  somewhat  remarkable,  from  the  importance  which  is  attached  to  the  pulse 
in  medical  practice,  that  its  natural  frequency  and  its  character  in  infancy  are 
not  more  accurately  known.  It  is  true  that  eminent  observers,  as  Trousseau 
and  Valleix,  have  published  statistics  relating  to  the  infantile  pulse  in  health, 
but  these  statistics  disagree,  and  therefore  do  not  aff'ord  a  reliable  standard 
with  which  to  compare  the  pulse  in  disease.  Moreover,  some  published 
statistics  of  the  pulse  possess  but  little  value  from  the  small  number  of 
observations ;  some  from  the  fact  that  records  of  the  infantile  pulse  are 
grouped  with  those  of  older  children ;  and  others  because  the  state  of  the 
infant  as  regards  its  activity  or  emotions  is  not  mentioned. 

Pulse  in  Health. — It  is  not  easy  to  collect  statistics  of  the  pulse  during 
the  period  of  infancy  which  are  entirely  free  from  error,  since  slight  derange- 
ments of  the  system  in  the  infant  frequently  occur  which  are  not  manifested 
by  any  marked  symptoms,  but  which  produce  acceleration  of  pulse.  In 
collecting  the  following  statistics  sources  of  error,  so  far  as  possible,  were 
avoided. 

The  movements  of  the  heart  commonly  begin  about  one-eighth  of  a  min- 
ute  after  birth.     They  are   at  first  slow,  the  ventricular   contractions   not 


DIAGNOSIS  OF  INFANTILE  DISEASES. 


75 


numbering  more  than  eight  or  ten  by  the  close  of  the  first  quarter  minute. 
In  the  second  quarter  the  cries  are  vigorous,  and  the  pulse  now  is  rapidly 
accelerated,  rising  commonly  above  120,  and  sometimes  above  160,  beats  per 
minute.  In  fifty-seven  observations  of  the  pulse  in  healthy  infants  during 
the  first  half  hour  of  life,  after  the  first  quarter  of  a  minute  I  found  that  the 
extremes,  with  one  exception,  were  104  and  164— average,  139.  The  statis- 
tics of  the  normal  pulse  in  infancy  have  been  stated  in  a  preceding  chapter. 


Pulse  dm 

•iiiff  or  after 

Active  Movements  or  Great  Mental  Excitement. 

Age. 

First  week. 

Close  of  first 
week   to   close 
of  first  month. 

Close  of  first  to 

close   of  third 

month. 

Close  of  third 

to  close  of  sixth 

month. 

Close  of  sixth 

month  to  close 

of  first  year. 

140 
160 
140 
152 

■ 

162 
156 
140 
152 

176 
152 
158 
144 
152 
180 

132 
148 
148 
144 
156 
156 

132 
144 

152 
182 
198 
160 

Extremes  .  . 
Mean  .... 

140-160 
148 

146-162 
152 

144-180 
160 

132-156 
147 

132-198 
156 

It  is  seen  by  the  above  table  that  by  active  exercise  or  great  mental  excite- 
ment the  pulse  may  become  as  rapid  as  in  grave  diseases.  Thei'e  is  greater 
acceleration  of  pulse  from  the  emotions  and  from  exercise  in  feeble  than  in 
robust  children.  Obviously,  in  order  to  determine  to  what  extent  the  pulse 
is  accelerated  in  disease  it  is  necessary  that  it  should  be  counted  during  a 
state  of  quietude.  As  the  age  increases  it  is  less  and  less  influenced  by  the 
emotions  and  physical  exertion  ;  still,  during  the  whole  period  of  childhood 
such  influences  do  have  more  or  less  e9"ect  on  its  fi-equency. 

Pulse  in  Disease.— Febrile  and  inflammatory  diseases  produce  greater 
acceleration  of  pulse  in  early  life  than  in  maturity.  Diseases  or  derangements 
of  system,  particularly  those  of  the  digestive  organs,  which  do  not  materially 
affect  the  pulse  in  the  adult,  often  cause  acceleration  of  it  in  children.  The 
febrile  pulse  of  early  life  usually  has  exacerbations  in  its  frequency.  These 
commonly  occur  in  the  latter  part  of  the  day.  Distinct  and  more  or  less  reg- 
ular febrile  exacerbations  and  remissions  are  common  in  several  diseases  of 
early  life,  some  of  which  are  serious,  while  others  involve  little  danger. 
Among  these  diseases  may  be  mentioned  diflScult  dentition,  intestinal  worms, 
incipient  meningitis,  and  constipation.  An  intermittent  and  irregular  pulse 
is  common  in  fully-developed  meningitis  and  certain  other  severe  organic 
diseases  of  the  encephalon.  It  may  be  due  also  to  disease  of  the  heart,  and 
it  also  occurs  in  some  children  from  temporary  disturbance  of  the  digestive 
function.  The  pulse  is  slow  in  compression  of  the  brain  and  in  sclerema  of 
the  new-born. 

Animal  Heat. 

The  importance  of  thermometric  observations  as  an  aid  to  the  diagnosis 
of  children's  diseases  is  within  a  few  years  more  fully  recognized.  Two 
diseases  may  at  their  commencement  have  very  similar  symptoms,  except  in 
the  temperature,  which  may  vary  greatly.     In  such  cases  the  thermometer  is 


76 


INFANCY  AND   CHILDHOOD. 


of  great  value  as  an  aid  in  differential  diagnosis.  In  a  preceding  chapter  we 
have  given  the  statistics  relating  to  the  temperature  of  infants  in  health. 
We  may  add  that  in  33  infants  under  the  age  of  seven  days  A.  Roger  found 
the  average  temperature  to  be  98.6°  F. 

Elevation  of  temperature  above  the  normal  is  regarded  by  physicians  as 
an  important  evidence  of  disease.  But  a  rise  in  temperature  of  three  or  four 
degrees  frequently  occurs  in  young  children  from  slight  causes,  as  indigestion, 
constipation,  and  mental  excitement.  Those  physicians  who  have  given  little 
attention  to  this  subject  will  probably  be  surprised  by  the  history  of  the  fol- 
lowing case : 

Case. — A  female  child  in  its  second  year,  wet-nursed  by  its  mother  in  the  New 
York  Infant  Asylum,  during  my  attendance  in  1894,  and  carefully  attended  by  the 
resident  physicians,  Drs.  A.  and  E.  Parry,  had  a  mild  intestinal  catarrh,  but  not  so 
as  to  appreciably  affect  the  temperature.  But  the  infant  was  extremely  emotional. 
The  sudden  entrance  of  a  stranger,  slamming  the  door,  the  attempt  of  a  stranger 
to  hold  it,  caused  the  high  and  transient  elevations  shown  in  the  following  chart : 

Fig.  3. 


Days    1     2  1  3     4     5     0     7  1  8     9  1 10    11   12    ISl  14  15    16  17    18  10  20   21   22  23  24   25  26  2"   23  29  30   31   32    33  34  35   36  37    38  39 

Hour   MEMEMEMEMEMEMEMeMEMEMEMEMEMEMEMEMEMEMlEMEMEMEMEMEMEMEMEMEMEHEMEMEMEMEMEMEMEMiEME 

o"-                              -           - _         L           _           .                    .               ..                ....__-                    .                                 "                    J 

10^::::;:^:::: 1 :::":::::::::::::+:::::::::::::: 

103° i.i          I   r         [                   &r , 

'._-._  __.../\ ji'""""  "  ".  — -iv-t A— _.,—,. 

of \-—,X ^i{    I        \^  ^— .^ ^ /J— - -L._  _ 

Z' -.._.] ,    \    \  _J       l\ u-.-/— -i-v K-\ 

M^--,-         ,                 L                            ^             \    /              %\                   ]       /     /                1           ^           .    X     S 

-^^..=  _..sL__^-L-::::  :::::::::::::  ===___A^__./v._...L.__J_. 

A  physician  examining  this  case  would  probably  make  a  serious  error  in 
diagnosis  and  prognosis  if  he  did  not  remain  long  enough  to  witness  the 
decline  of  the  fever. 

It  is  very  important  that  the  normal  temperature  be  preserved  during 
infancy.  In  bottle-fed  infants  a  continued  temperature  at  or  below  97° 
indicates  a  fatal  termination.  In  the  large  number  of  foundlings  in  the  New 
York  Foundling  Asylum,  most  of  whom  are  necessarily  deprived  of  breast- 
milk,  I  have  not  yet  seen  one  live  more  than  a  few  weeks  whose  temper- 
ature remained  below  97°.  Young  children,  therefore,  whose  temperature 
continues  subnormal  notwithstanding  the  use  of  abundant  well-selected  food, 
alcoholic  stimulation,  and  warm  external  appliances  should  be  placed  in  an 
incubator.  On  the  other  hand,  I  have  seen  an  infant  with  a  temperature  of 
90°  in  the  New  York  Infant  Asylum,  placed  in  the  incubator  and  wet-nursed, 
survive.  It  is  true  that  the  wet-nursing  was  a  very  important  part  of  the 
treatment. 

An  incubator  designed  by  Dr.  S.  Marx  of  New  York  possesses  the  merits 
of  simplicity  of  construction,  ease  of  management,  and  moderate  cost.  The 
apparatus  consists  of  a  wooden  box  30  inches  long,  16  inches  wide,  and  24 
inches  in  height,  with  a  lining  of  non-conducting  hair-felt  |  inch  thick,  over 
which  is  a  layer  of  sheet  zinc,  the  top  of  the  box  being  supplied  with  a  slid- 
ing cover  of  glass.  Within  the  box  is  suspended  a  wire  cradle  designed  to 
hold  the  infant,  hanging  about  2  inches  from  the  top  of  the  box  and  being  9 
inches  in  depth.  The  heat  is  generated  by  means  of  a  copper  boiler  situated 
on  a  platform  which  projects  out  from  the  bottom  of  the  box  at  one  end. 
The  boiler  is  connected  with  the  box  by  means  of  a  coil  of  lead  pipe  passing 
through  the  bottom  of  the  bos  and  imbedded  in  sterilized  gravel.     The  water 


DIAGNOSIS  OF  INFANTILE  DISEASES. 
Fig.  4. 


77 


Fig.  5. 


in  the  boiler  is  heated  by  a  Bunsen  burner,  and  the  steam  passing  through 
the  pipe  heats  the  gravel,  above  which  are  valves  for  the  ingress  of  cold  air, 


78  INFANCY  AND  CHILDHOOD. 

which,  becoming  heated,  rises  and  circulates  in  and  around  the  cradle,  and 
finds  a  vent  in  the  valves  at  the  top  of  the  box. 

The  heat  is  measured  by  a  long,  delicate  thermometer  fastened  to  the 
upper  and  inner  side  of  the  cradle,  and  is  regulated  by  an  electrical  thermo- 
stat of  exceeding  delicacy  fastened  to  the  outer  end.  At  the  approach  of 
the  maximum  or  minimum  heat-limit  the  thermostat  causes  the  ringing  of  a 
bell,  which  ceases  only  upon  the  attendance  of  the  person  in  charge,  ensuring 
the  watchfulness  which  is  of  so  much  importance. 

The  thermostat  receives  its  power  from  two  dry-cell  batteries  placed  on 
the  boiler  platform  and  protected  by  a  brass  box  lined  with  felt. 

Digestive  System. 

Inspection  of  the  buccal  and  faucial  surfaces  discloses  some  of  the  most 
frequent  local  diseases  of  infancy,  as  the  various  forms  of  stomatitis,  and 
others  which,  though  not  frequent,  involve  great  danger,  as  gangrene  of  the 
mouth,  diphtheria,  and  retro-pharyngeal  abscess.  Inspection  of  the  tongue 
aids  in  determining  in  many  cases  whether  the  disease  be  pursuing  a  favor- 
able course  or  has  become  asthenic  and  is  exhausting  the  vital  powers. 

Febrile  movements,  even  when  slight,  give  rise  to  coating  of  the  tongue 
and  intumescence  and  distinctness  of  its  follicles.  The  eruptive  fevers  are 
attended  by  changes  upon  the  buccal  and  faucial  surfaces  which  possess 
diagnostic  and  prognostic  value.  Hyperfemia  of  these  surfaces  appears  early 
in  rubeola  and  scarlatina  prior  to  those  phenomena  which  are  justly  regarded 
as  pathognomonic.  It  is  therefore  often  an  important  sign  in  the  initial  period 
of  these  diseases  when  the  diagnosis  is  obscure.  The  appearance  of  the 
fauces  in  diphtheria  and  croup,  indicating  not  only  the  nature  of  the  disease, 
but  its  gravity,  need  only  be  referred  to  in  this   connection. 

Inspection  of  the  buccal  and  faucial  surfaces  sometimes  enables  us  to 
form  a  probable  opinion  in  reference  to  the  nature  of  diseases  which  are 
seated  in  other  parts.  In  the  infant  protracted  stomatitis  is  a  common 
accompaniment  of  chronic  diarrhoea,  and  it  indicates  its  inflammatory 
nature. 

Vomiting  is  more  frequent  in  infancy  than  in  childhood,  and  in  either 
period  than  in  adult  life.  It  is  common  in  cerebral  affections,  and  is  one  of 
the  first  symptoms  of  scarlet  fever,  and  is  not  uncommon,  though  less  fre- 
quent, in  the  commencement  of  other  essential  fevers  and  of  acute  inflam- 
mations. It  is  a  symptom  of  indigestion,  entero-colitis,  cholera  infantum, 
and  intussusception  ;  it  is  common  also  after  the  paroxysmal  cough  of  per- 
tussis, and  not  infrequent  in  the  bronchial  inflammations  of  young  infants. 

Intestinal  gas  is  in  part  secreted  or  exhaled  from  the  mucous  membrane, 
as  the  experiments  of  Hunter  and  others  have  shown,  and  is  in  part  the 
product  of  chemical  changes  in  the  food.  A  certain  amount  of  gas  in  the 
intestines  is  normal ;  it  subserves  a  useful  purpose.  An  abnormal  amount 
of  it  is  common  in  various  diseases,  as  indigestion,  chronic  entero-colitis,  peri- 
tonitis, typhoid  fever.  It  is  a  frequent  cause  of  gastralgia  and  enteralgia  in 
the  infant.  In  scrofulous  or  feeble  infants  with  impaired  muscular  tonicity 
and  faulty  digestion  the  abdomen  is  often  habitually  more  or  less  distended 
with  gas,  which  does  not,  under  such  circumstances,  give  rise  to  pain  or  other 
local  symptoms ;  it  has  significance  as  showing  the  general  condition  of  the 
child. 

In  the  rachitic,  whose  thorax  is  compressed  and  liver  often  enlarged, 
while  the  vertebral  column  is  shortened,  the  abdomen  is  commonly  pro- 
tuberant. In  feeble  children,  usually  more  or  less  rachitic,  whose  lungs 
are  seldom  fully  inflated  and  whose  chests  are  consequently  depressed,  the 


BIAONOSrS  OF  INFANTILE  DISEASES. 


79 


Fig.  6. 


abdomen  is  also  prominent.  The  accompanying  woodcut  represents  one  of 
these  cases  presented  for  treatment  at  the  Out-door  Department  at  Bellevue. 

In  feeble  children  who  have  suffered  from 
repeated  and  protracted  attacks  of  bronchitis, 
and  whose  chest-walls  are  consequently  de- 
pressed, a  similar  abdominal  prominence  occurs. 

Retraction  of  the  abdominal  walls  is  common 
in  meningitis  and  in  many  exhausting  diseases. 
Tenesmus  is  a  symptom  of  intussusception  in 
the  infant  and  of  colitis  in  children. 

Much  light  is  thrown  on  the  character  of 
intestinal  diseases  by  the  appearance  of  the 
stools.  Muco-sanguineous  stools  accompanied 
by  fever  are  a  sign  of  colitis.  Stools  contain- 
ing unmixed  blood  and  not  accompanied  by 
fever  may  result  from  a  rectal  polypus  and  from 
purpura  haemorrhagica.  Scanty  evacuations  of 
blood,  with  obstinate  constipation,  are  a  symp- 
tom of  intussusception  in  infants. 

The  alvine  discharges  of  infants  often  present 
a  green  color  ;  sometimes  they  have  the  normal 
yellow  hue  when  passed  from  the  bowels,  but 
become  green  on  exposure  to  the  air  or  from 
reaction  of  the  urine.  By  the  microscope  the 
green  coloring  matter  is  seen  to  occur  in  small, 
irregular  masses.    This  green  substance  has  been 

supposed  to  be  bile.  I  am  convinced  that  as  it  occurs  in  the  stools  of  the 
infant  it  is  commonly  produced  by  the  action  of  the  intestinal  secretions  on 
the  contents  of  the  intestines ;  for  I  have  often  noticed  that  the  contents  in 
and  above  the  jejunum  were  yellow,  while  in  and  below  the  ileum  their  color 
was  green.  Probably  the  green  color  is  due  to  the  formation  of  biliverdin 
from  the  bile  which  is  mixed  with  the  fecal  matter. 

The  green  hue  may  occur  from  very  different  causes.  It  may  be  due  to 
overfeeding,  to  the  action  of  cold,  to  irritating  ingesta,  to  inflammation,  etc. ; 
it  may  be  transient,  subsiding  within  a  day  or  two,  or  it  may  continue  several 
days.  All  infants  at  times  have  green  evacuations,  even  when  they  appear 
in  good  health. 

In  the  commencement  of  a  large  proportion  of  diarrhoeal  maladies  in 
infancy  the  stools  give  an  acid  reaction  to  litmus-paper.  This  acid,  if  in 
considerable  quantity,  is  irritating,  increasing  the  peristaltic  movements  of 
the  intestines  and  the  functional  activity  of  the  intestinal  follicles,  causing 
erythema  of  the  skin  around  the  anus,  and  reacting  upon  and  intensifying 
the  intestinal  disease. 

The  presence  of  intestinal  worms  and  the  species  may  be  ascertained  by 
microscopic  examination  of  the  stools  of  a  child  which  is  affected  with  these 
entozoa.  The  stools  contain  ova,  which  differ  in  size  and  shape  according  to 
the  species  of  worm. 


Nervous  System. 

Pain. — This  symptom  affords  important  aid  to  the  physician  in  determin- 
ing the  seat  and  nature  of  the  diseases  of  children.  Pain  in  the  head  may 
occur  in  them  from  coryza  involving  the  frontal  sinuses,  or  from  febrile 
movement  in  the  commencement  of  an  essential  fever,  or  from  inflammation 
of  one  of  the  organs  of  the  trunk.     Produced  by  such  a  cause,  it  abates  in 


80  INFANCY  AND  CHILDHOOD. 

two  or  three  days.  If  it  be  protracted,  whether  constant  or  intermittent,  it 
is  in  many  cases  not  neuralgic,  as  it  so  often  is  in  the  adult,  but  is  due  to 
oro-anic  disease  of  the  brain  or  meninges.  Complaint,  therefore,  of  headache 
in  a  child,  without  any  apparent  general  cause  or  local  cause  external  to  the 
cranium,  should  awaken  solicitude" and  if  it  be  protracted  the  physician  should 
examine  carefully  in  reference  to  the  presence  of  a  cerebral  or  meningeal  dis- 
ease. Mild  frontal  headache  continuing  for  weeks  or  months  is  neuralgic 
and  due  to  aneemia.  It  is  increased  by  pressure  over  the  occiput  and  upper 
cervical  vertebrae. 

Grave  thoracic  or  abdominal  inflammations  in  the  adult  are  almost  always 
attended  by  a  corresponding  amount  of  pain  and  tenderness,  but  in  children 
these  symptoms  are  often  absent,  or  when  present  are  frequently  not  commen- 
surate with  the  amount  of  disease.  Thus,  entero-colitis  of  nursing  infants  is, 
in  a  large  proportion  of  instances,  almost  free  from  these  symptoms. 

Pain  in  the  chest  or  abdomen,  occasional  or  constant,  continuing  for  weeks 
or  months,  with  fever,  and  unattended  by  thoracic  or  abdominal  disease,  indi- 
cates caries  of  the  vertebrae.  Its  most  common  seat  is  the  epigastric,  umbili- 
cal, or  hypochondriac  region.  It  is  a  neuralgia  due  to  irritation  of  the 
sensitive  root  of  one  or  more  of  the  spinal  nerves.  It  is  a  very  important 
symptom  to  the  diagnostician,  showing  the  nature  of  the  disease,  which  in  its 
incipiency  is  so  obscure.  Pain  in  the  leg,  especially  the  inside  of  the  knee, 
is  of  a  similar  character,  indicating  disease  of  the  hip-joint. 

Children  with  certain  acute  febrile  and  inflammatory  diseases  sometimes 
have  hypersesthesia  of  portions  of  the  surface ;  it  is  especially  marked  upon 
the  anterior  aspect  of  the  trunk.  The  physician  might  be  misled  into  the 
belief  that  the  tenderness  occurred  over  the  seat  of  the  disease  and  indicated 
an  inflammation ;  but  the  pain  of  hypersesthesia  can  be  diagnosticated  from 
that  of  inflammation  by  the  fact  that  it  is  so  extensive,  is  less  on  firm  than 
light  pressure,  and  is  especially  observed  upon  the  inner  surface  of  the  thighs. 
The  symptoms  pertaining  to  the  nervous  system  occurring  in  the  various  dis- 
eases treated  of  in  this  book  will  be  fully  described  in  connection  with  those 
diseases,  and  therefore  need  not  detain  us  in  this  connection. 


CHAPTER    XI. 

THEEAPEUTICS. 

The  young  practitioner  is  often  perplexed  in  deciding  exactly  what  dose 
of  the  stronger  and  more  dangerous  medicinal  agents  to  prescribe  for  a  child. 
A  practical  rule,  which  holds  good  for  many  medicines,  has  been  proposed  by 
Dr.  Cowling,  as  follows :  "  The  proportional  dose  for  any  age  under  adult  life 
is  represented  by  the  number  of  the  following  birthday  divided  by  twenty- 
four."  This  rule  is  inadmissible  for  infants  under  the  age  of  six  months,  but 
will  apply  for  those  that  are  older  for  the  use  of  a  large  number  of  medicines. 
Another  rule,  proposed  by  another  British  physician,  Professor  Clarke,  is  based 
on  difi"erenees  in  weight  of  children  and  adults  :  The  adult  dose  is  represented 
by  150.  The  dose  of  a  child  is  determined  by  dividing  its  weight  in  pounds 
by  150.  But  it  is  an  interesting  fact,  and  one  of  practical  importance,  that 
children  bear  and  often  require,  in  order  to  obtain  the  desired  eifect,  a  much 
larger  proportionate  dose  of  certain  agents  than  adults.  This  is  partly  attrib- 
utable to  the  active  elimination  in  childhood.     Belladonna  is  notably  one  of 


THERAPEUTICS.  81 

the  agents  which  children  tolerate,  and  it  may  be  added  that  some  children 
can  take  a  much  larger  dose  of  it  than  others  without  producing  the  physio- 
logical effects.  Thus,  recently  I  increased  gradually  the  tincture  of  bella- 
donna to  twelve  drops  for  a  child  of  four  years  without  producing  the  usual 
efflorescence ;  and  Farquharson  says,  "  The  dose  ....  I  have  pushed  in  a 
child  of  ten  suffering  from  incontinence  of  urine  to  f^ij  (British  Pharmacop.) 
with  good  effect  and  the  development  of  mild  forms  of  physiological  disturb- 
ance." Arsenic  is  also  better  tolerated  by  children  than  adults.  An  infant 
of  six  months  can  take  two-drop  doses  of  Fowler's  solution  three  times  daily 
without  ill  effect.  Prussic  acid,  strychina,  iron,  ipecacuanha,  and  alcohol  are 
also  required  in  larger  proportionate  doses  in  childhood  than  is  indicated  by 
the  rule  either  of  Dr.  Cowling  or  Professor  Clarke. 

When  practicable,  medicines  should  be  given  in  the  liquid  form.  Those 
not  soluble  may  often  be  given  in  suspension  in  some  vehicle  which  in  great 
part  disguises  the  taste.  A  good  vehicle  for  the  bitter  vegetables,  as  the  salts 
of  quinia,  is  the  elixir  adjuvans  of  Caswell  and  Hazard. 

The  elixir  adjuvans  may  also  be  advantageously  employed  in  the  adminis- 
tration of  many  other  medicines  apart  from  those  which  are  repulsive  on 
account  of  their  bitterness.  It  holds  them  in  suspension,  so  that  if  they  have 
a  greater  specific  gravity  than  the  elixir,  it  is  necessary  to  shake  the  bottle 
thoroughly  before  using  it.  The  elixir  taraxaci  comp.  is  another  good  vehi- 
cle for  the  bitter  vegetables,  but  perhaps  their  bitterness,  especially  that  of 
quinine,  is  more  effectually  disguised  by  the  syr.  yerbae  santae  comp.  than 
by  any  other  vehicle.  1  am  sure,  from  many  observations,  that  unpleasant 
doses  are  liable  to  be  wasted  to  a  greater  or  less  extent,  and  the  repug- 
nance of  children  to  medicines  employed  has  induced  many  a  parent  to  seek 
other  and  less  disagreeable  modes  of  treatment.  Chemistry  has  greatly  aided 
the  therapeutics  of  childhood,  in  that  it  has  enabled  us  in  so  many  instances 
to  prescribe  the  active  principles  in  place  of  the  large,  nauseous  doses  formerly 
employed. 


PART    II 


DISEASES  OF  THE  NEWLY-BORK 


CHAPTER    I. 


MALFORMATIONS. 

The  malformations,  both  of  internal  and  external  organs,  are  numerous, 
and  they  require  attention  according  to  their  seat  and  gravity. 

Acrania. 

In  this  malformation  the  bones  and  integuments  forming  the  cranial  arch 
are  absent.  In  extreme  cases  the  cranial  arch,  part  of  the  neck,  the  brain, 
and  the  medulla  oblongata  are  lacking.  A 
vascular  mass  lies  on  the  exposed  base  of 
the  skull,  often  resembling  the  placenta  in 
appearance.  It  consists  of  connective  tis- 
sue in  addition  to  the  vessels.  It  is  the 
representative  of  the  cerebral  meninges, 
and  is  continuous  below  with  the  spinal 
meninges.  Its  smooth  surface  is  the  ana- 
logue  of  the  arachnoid. 

The  sensation  which  is  imparted  to  the 
finger  of  the  accoucheur  pressed  upon  it  is  very 
similar  to  that  produced  by  a  placenta.  In 
some  specimens  small  portions  of  cerebral  mat- 
ter are  found  among  the  vessels  of  this  tumor, 
but  they  are  so  disconnected  and  isolated  that 
they  do  not  perform  in  any  way  the  functions 
of  a  brain.  Occasionally  the  vascular  tumor  is  absent  and  the  medulla — or,  if  this 
be  absent,  the  upper  extremity  of  the  spine — is  exposed. 

The  absence  of  the  brain  and  cranial  arch  gives  a  remarkable  appearance. 
The  frontal,  parietal,  and  occipital  bones  are  absent,  except  those  portions 
which  are  near  the  base  of  the  cranium.  These  portions  are  very  thick  and 
closely  united,  as  if  there  were  the  usual  amount  of  osseous  substance,  but 
instead  of  expanding  into  the  arch  it  had  collected  in  an  irregular  mass  at 
the  base  of  the  cranium.  The  eyes  are  prominent,  the  neck  thick  and  short, 
while  the  body  and  limbs  are  ordinarily  well  developed.  The  physiognomy 
has  a  frog-like  appearance.  Those  portions  of  the  cranial  nerves  which  lie 
without  the  cranium  are  well  developed,  although  the  intracranial  portions 
are  absent.  In  this  anomaly  of  acrania  and  anencephalus  a  twin  is  often 
present  which  in  some  manner  has  interfered  with  the  normal  development 
of  the  foetus. 
82 


MALFORMATIONS.  83 

Symptoms. — If  the  medulla  be  absent,  of  course  viability  is  impossible. 
If  it  be  present,  respiration  may  occur  for  a  time,  but  is  irregular.  The 
monster  may  be  made  to  cry,  but  the  cry  is  a  reflex  phenomenon  resembling 
a  sob  or  hiccough.  It  may  nurse,  its  digestive  function  is  well  performed, 
and  regular  urinary  and  fecal  evacuations  occur.  There  is  a  tendency  in  such 
monsters  to  convulsions.  Blowing  upon  them  and  pressure  upon  the  project- 
ing medulla,  if  this  be  present,  frequently  produce  this  result. 

Prognosis. — Fortunately,  non-viability  or  speedy  death  is  the  result.  If 
the  medulla  be  present  and  respiration  and  circulation  be  established,  never- 
theless death  usually  results  within  two  or  three  days,  and  with  scarcely  an 
exception  within  ten  days.  Convulsions  sooner  or  later  supervene,  ending  in 
fatal  coma. 

Deficiencies  of  the  brain  are  of  various  grades  of  incompleteness  between 
the  normal  and  absent  brain.  Portions  of  the  brain  may  be  absent  or  rudi- 
mentary, while  the  remainder  of  the  organ  has  its  normal  development.  The 
deficiencies  are  usually  in  the  cerebral  hemispheres,  while  the  base  of  the 
brain,  which  is  important  for  the  maintenance  of  life,  is  perfect.  Both  hemi- 
spheres may  be  absent,  or  one  absent  while  the  other  is  complete  or  small  and 
rudimentary.  Incompleteness  of  the  brain  may  be  manifested  by  the  small 
size  of  the  cranium  and  the  retreating  forehead,  but  occasionally  the  cranium 
has  its  normal  shape  and  size,  on  account  of  an  increase  in  the  cerebro-spinal 
fluid  proportionate  to  the  deficiency  in  the  cerebral  development. 

Such  a  case  was  under  observation  in  the  Nursery  and  Child's  Hospital  in  1862. 
She  took  the  breast  and  received  food  when  placed  in  her  mouth,  but  without  appar- 
ent relish.  She  was  supposed  for  a  time  to  be  blind,  as  she  was  apparently  uncon- 
scious of  objects  around  her.  There  was  a  total  absence  of  intellectual  manifesta- 
tions. The  size  and  shape  of  the  head  did  not  differ  from  the  normal,  but  the  frontal 
bone  lay  a  little  lower  than  the  parietal.  She  died  of  entero-colitis  at  the  age  of  ten 
months,  and  at  the  autopsy  a  sac  containing  about  three-fourths  of  a  pint  of  neaidy 
transparent  cerebro-spinal  liquid  occupied  the  site  of  the  cerebral  hemispheres. 
Rudimentary  hemispheres  were  found  constituting  a  part  of  the  walls  of  the  sac. 
The  weight  of  the  brain  after  being  a  few  days  in  dilute  alcohol  was  6^-  ounces. 
In  this  case  the  fluid  was  nearly  sufficient  to  compensate  for  the  lack  of  brain- 
substance. 

Sy3IPT0ms. — Since  in  cases  of  imperfect  brain  in  which  life  is  preserved 
the  arrest  of  development  is  usually  in  the  cerebral  hemispheres,  the  symp- 
toms which  indicate  the  deficiency  relate  chiefly  to  the  degree  of  mental 
endowment.  If  the  hemispheres  are  partially  developed,  there  is  a  degree 
of  intelligence  proportionate  to  the  amount  of  the  cerebral  substance  present. 
If  the  arrest  of  development  be  on  one  side,  there  may  be  no  appreciable  lack 
of  intelligence  or  mental  activity,  since  one  hemisphere  may  perform  the 
functions  of  both. 

Prognosis. — Life  depends  on  the  seat  of  the  arrested  development.  If 
the  cerebral  hemispheres  be  deflcient,  the  child  may  live  and  thrive,  though 
idiotic ;  but  if  the  arrest  of  development  be  at  the  base  of  the  brain,  which 
controls  the  functions  of  animal  life  and  gives  origin  to  nerves  which  are 
essential  to  the  physical  well-being,  life  is  uncertain  and  probably  will  be 
short.  It  is  evident  that  therapeutic  measures  cannot  remedy  a  congenital 
deficiency  in  the  brain,  but  the  patient,  philanthropic  teacher  can  impart  some 
instruction  to  the  idiotic,  and  occasionally  improve  in  a  measure  their  lament- 
able condition. 

Meningocele,  Encephalocele,  Hydrencephalocele. 

An  opening  exists  at  some  point  in  the  skull,  through  which  the  meninges, 
or  meninges  with  brain-substance,  protrude.     The  deficiency  is  congenital,  and 


84 


DISEASES  OF  THE  NEWLY-BOBN. 


the  tumor  exists  at  birth  or  is  noticed  soon  after.  It  is  termed  a  meningocele 
if  only  meninges  protrude ;  an  encephalocele  if  it  contain  brain-substance  in 
addition  to  the'meninges  ;  and  a  hydrencephalocele  if.  in  addition  to  the  brain- 
substance,  the  mass  contain  liquid  in  its  interior. 

The  most  frequent  site  of  these  tumors  is  the  occiput,  where  the  protru- 
sion occurs  from  an  opening  in  or  at  the  edge  of  the  occipital  bone.  The  next 
most  frequent  location  is  the  naso-frontal  region.  Rarely  they  occur  upon 
the  temporal,  parietal,  and  basilar  portions  of  the  skull.  Ordinarily,  the  open- 
ing in  the  occipital  bone  through  which  the  protrusion  takes  place  is  at  the 
median  line,  or  near  it,  anterior  or  posterior  to  the  occipital  protuberance. 
The  opening,  if  in  the  anterior  part  of  the  occipital  bone,  may  extend  to  the 
fontanel ;  if  in  the  posterior  part,  it  may  extend  to  the  foramen  magnum.  It 
may  connect  posteriorly  through  the  foramen  magnum  with  the  cleft  of  a 
spina  bifida.     If  the  opening  of  the  occipital  bone  be  large,  the  tumor  is  also 


usually  large.  Prescott  Hewitt  cites  a  case  in  which  it  extended  to  the 
loins  ;  but  so  large  a  mass  consists  mostly  of  liquid  and  is  rare.  An  occipital 
encephalocele  contains  brain-substance  from  the  cerebellum  or  posterior  cere- 
bral lobes  or  from  both.  If  the  tumor  upon  the  occiput  be  a  hydrencephalo- 
cele, the  liquid  is  from  the  posterior  cornu  of  a  distended  lateral  ventricle  or 
from  a  distended  aad  dropsical  fourth  ventricle,  and  it  occupies  the  interior 
of  the  tumor,  the  brain-substance  surrounding  it. 

If  the  tumor  be  in  the  frontal  region,  the  protrusion  usually  occurs  between 
the  cribriform  plate  of  the  ethmoid  bone  and  the  frontal  bone,  and  it  appears 
externally  between  the  nasal  and  the  frontal  bones.  Exceptionalh",  the  point 
of  protrusion  is  between  the  lateral  halves  of  the  frontal  bone.  The  anterior 
lobe  or  lobes  of  the  cerebrum  protrude  in  an  encephalocele  in  this  location  ; 
if  the  tumor  be  a  hydrencephalocele,  the  liquid  is  derived  from  the  anterior 
cornua  of  the  lateral  ventricles.  As  a  rule  the  frontal  are  smaller  than  the 
occipital  tumors,  and  the  skin  covering  them  is  more  frequently  red  and 
vascular,  so  as  to  present  the  appearance  of  vascular  tumors. 

Exceptionally,  the  protrusion  occurs  from  a  fontanel  or  from  the  line  of 
one  of  the  sutures,  so  that  it  is  seated  upon  the  side  of  the  skull.  Cases  are 
also  on  record  in  which  the  opening  existed  between  the  ethmoid  and  sphe- 
noid bones,  through  the  sphenoid,  or  between  the  sphenoid  and  its  greater 
wing.  Tumors  in  this  location  appear  in  the  pharynx  or  mouth,  or  enter  an 
orbit,  displacing  the  eye.  or  protrude  through  the  spheno-maxillary  fissure. 


MALFORMA  TIONS.  8  5 

The  tumor  having  this  site  is  usually  an  encephalocele  or  hydrencephaloceie, 
the  meningocele  being  rare.  Its  walls  consist  of  skin,  dura  mater,  and  arach- 
noid, with  intervening  connective  tissue.  If  the  protrusion  be  at  the  base 
of  the  brain,  of  course  the  external  covering  of  skin  is  lacking.  In  other 
locations  the  skin  constitutes  the  external  coat,  and  it  may  be  tense  and  scant- 
ily covered  with  hair,  or  red  and  vascular.  The  interior  of  the  sac  is  lined 
by  the  arachnoid  and  dura  mater.  These  tumors,  whatever  the  exact  charac- 
ter of  their  interior,  can  be  more  or  less  reduced  by  compression,  with  a  return 
of  a  part  of  their  contents  into  the  cranial  cavity  ;  but  such  compression 
usually  produces  cerebral  symptoms,  as  stupor  or  fretfulness,  vomiting,  and 
strabismus. 

Diagnosis. — The  following  characteristics  of  the  three  forms  of  these 
tumors  aid  in  their  differential  diagnosis : 

Meningocele.  Encephalocele.  Hydrencephaloceie. 

Small  at  first,  and  re-  Small,    base   wide,    no  Tumor    usually   large, 

maining  either  small  or  of  fluctuation,  opaque,  or  often  pendulous,  and  its 
moderate  size,  fluctuation  sometimes  translucent  at  surface  lobulated,  peduncu- 
distinct,  pedunculated,  the  apex,  distinct  pulsa-  lated,  fluctuating ;  portions 
translucent,  no  pulsation,  tion,  enlargement  by  forced  translucent;  pulsation  ab- 
tense  on  forced  expiration,  expiration,  partly  reduci-  sent  or  rare.  It  is  seldom 
reducible.  ble,  cerebral  symptoms  oc-    aiFected   by   pressure,  and 

curring  from  compression,  the  patient  is  likely  to  be 
microcephalic  from  the  es- 
cape of  brain-substance  ex- 
ternal to  the  cranium. 

These  protrusions  have  been  mistaken  for  various  cysts,  as,  cephalhsema- 
toma,  serous  and  sebaceous  cysts,  abscesses,  vascular  growths,  and  polypi. 
The  fact  that  such  errors  in  diagnosis  have  been  made  by  various  surgeons 
shows  the  importance  of  a  thorough  and  careful  examination  before  operative 
measures  are  employed. 

Prognosis. — Most  patients  with  this  deformity  die  in  a  few  weeks  or 
months.  The  prognosis  depends  on  the  size  of  the  aperture  and  the  amount 
of  protrusion.  It  is  most  unfavorable  in  hydrencephaloceie,  which  is  usu- 
ally attended  by  deficiency  of  brain  within  the  cranium,  sometimes  to  such 
an  extent  that  the  patient  is  microcephalic  and  early  death  is  unavoidable. 
The  hydren cephalic  tumor  is  very  liable  to  grow,  and,  after  a  time,  rupture, 
causing  immediate  death  in  convulsions  or  collapse.  In  meningocele,  if  the 
aperture  be  small,  the  tumor  may  remain  small,  become  isolated  from  the 
cranial  cavity,  and  the  patient  may  live  for  years.  But  of  the  three  forms 
of  the  tumors,  encephalocele  is  regarded  as  the  most  favorable,  since  it  is 
usually  small,  and  patients  with  it  not  infrequently  live  many  years.  The 
prognosis  in  these  tumors  is  very  similar  to  that  in  spina  bifida,  which  varies 
according  to  size  of  the  aperture  and  the  amount  and  character  of  the  pro- 
trusion. 

Treatment. — Those  who  have  had  experience  with  these  tumors  concur 
for  the  most  part  in  the  opinion  that  surgical  interference  should  not  be 
resorted  to  unless  rupture  be  imminent.  The  mass  should  be  protected  from 
abrasion,  and  that  degree  of  pressure  should  be  employed  which  can  be  toler- 
ated without  producing  cerebral  symptoms.  It  is  proper  to  draw  ofi"  the 
liquid  of  a  meningocele  if  it  be  distended  and  likely  to  rupture,  and  the  tap- 
ping may  be  repeated,  with,  exceptionally,  the  result  of  a  cure  or  of  render- 
ing the  tumor  stationary.  Mr.  Holmes  has  injected  the  tumor  with  two 
drachms  of  a  mixture  consisting  of  one  part  of  tincture  of  iodine  and  two 
of  water,  allowing  it  to  remain  ;  and  Mr.  Annandale  has  ligatured  the  mass 
in  one  instance  and  effected  a  cure.     In  encephalocele  and  hydrencephaloceie 


86 


DISEASES  OF  THE  NEWLY-BORN. 


support  and  moderate  pressure  should  be  employed,  and  in  the  latter  some  of 
the  liquid  should  be  removed  by  a  small  trocar  if  rupture  be  threatening. 

Spina  bifida  is  one  of  the  most  common  of  malformations.  The  term 
"  spina  bifida "'  is  applied  to  a  hernia  of  the  spinal  meninges,  which  produces 
a  rounded  tumor  situated  posteriorly  over  the  spine  in  the  median  line.  It  is 
due  to  the  congenital  absence  or  incompleteness  of  one  or  more  of  the  arches 
of  the  vertebras.  In  exceptional  instances  the  arch  is  complete  at  birth  ;  but 
the  lateral  portions  separate  and  are  pressed  outward  during  the  first  weeks 
of  life.  The  tumor  contains  cerebro-spinal  fluid,  and  unless  it  be  small  and 
its  walls  unusually  thick  fluctuation  may  be  detected  in  it.  When  the  child 
cries  the  tumor  enlarges,  and  it  is  reduced  by  compression,  the  fluid  re-enter- 
ing the  spinal  canal.  If  the  tumor  be  large,  its  complete  subsidence  by  pressure 
sometimes  produces  dangerous  cerebral  symptoms.     It  often  coexists  with  its 

analogue,  hydrocephalus.  If  we 
compress  the  hydrocephalic  head, 
the  spinal  tumor  enlarges,  and  vice 
versa.  Club-foot  is  another  not  in- 
frequent complication. 

In  the  case  which  is  represented  in 
the  accompanying  wood-cut  (Fig.  9) 
hydrocephalus,  spina  bifida,  and  club- 
foot coexisted.  The  child  was  brought 
to  the  children's  class  in  the  Out-door 
Department  at  Bellevue,  and  after  a 
few  visits  I  lost  sight  of  it.  It  prob- 
ably died  soon  after,  since  the  tumor, 
over  which  the  cuticle  was  wanting, 
presented  a  deep-red  appearance  as 
if  inflamed,  so  that  ulceration  and 
escape  of  the  fluid  seemed  near  at 
hand. 


Fig.  9. 


•"Sis  «*^ 


sisv"'''^^  ^~;  >^  ^^.Xj>KJ.'$S^x>^"  "^'^ 


There  is  ordinarily  but  one  spina 
bifida,  the  common  seat  of  which  is 
the  lumbar  region,  but  occasionally  two  or  more  are  present.  If  the  aperture 
through  which  the  tumor  protrudes  be  small,  it  is  usually  pedunculated,  but 
if  large  it  is  sessile.  In  some  patients  it  is  covered  with  skin,  which  may  be 
normal  or  somewhat  indurated ;  in  others  the  skin  is  absent  over  the  entire 
tumor  or  its  most  prominent  part,  and  the  dura  mater  or  the  connectiA'e  tissue 
lying  directly  over  the  dura  mater  is  exposed,  and  is  liable  to  inflammation 
from  friction.  If  the  walls  of  the  tumor  be  thin,  the  liquid  may  transude  in 
drops,  and  they  are  liable  to  give  way  by  ulceration  or  rupture.  Sudden 
escape  of  the  liquid  and  collapse  of  the  spina  bifida  involve  great  danger,  for 
convulsions,  coma,  and  death  are  the  common  result. 

The  relation  of  the  spinal  cord  or  nerves,  or  of  the  cauda  equina,  to  the 
tumor  is  a  matter  of  great  importance.  In  many  patients  the  adjacent  por- 
tion of  the  cord  or  cauda  equina  is  deflected  through  the  aperture,  and  lies 
against  the  anterior  of  the  sac.  Spinal  nerves  also  not  infrequently  lie  within 
the  sac,  some  returning  into  the  spinal  canal,  and  others  passing  through  the 
walls  of  the  sac  to  their  points  of  distribution.  Those  which  are  deflected 
into  the  tumor  and  return  into  the  canal  obviously  lie  lowest.  In  cases  with 
a  small  aperture  or  small  tumor  or  a  narrow  and  long  peduncle  neither  the 
cord,  Cauda  equina,  nor  nerves  lie  within  the  sac. 

It  is  important  to  the  practitioner  to  bear  in  mind  that  in  all  probability,  unless 
under  the  favorable  anatomical  circumstances  stated  above,  the  sac  contains  nervous 
elements.     In  rare  instances  the  liquid,  instead  of  lying  externally  to  the  cord,  lies 


MALFORMATIONS.  87 

within  its  central  canal.  The  substance  of  the  cord  then  becomes  distended,  and  it 
encloses  the  liquid  like  a  delicate  sac,  just  as  the  hemispheres  of  the  brain  are  un- 
folded and  expanded  in  the  common  form  of  congenital  hydrocephalus.  As  might 
be  expected  from  the  anatomical  characters  of  the  more  serious  forms  of  spina  bifida, 
paralysis,  more  or  less  complete,  of  the  vesical  and  rectal  muscular  fibres  and  para- 
plegia sometimes  occur,  in  which  event  the  fatal  issue  is  probably  not  far  distant. 

The  DIAGNOSIS  is  easy  in  ordinary  cases.  The  congenital  nature  of  the 
tumor  and  the  bony  edge  pf  the  aperture,  appreciable  to  the  touch,  suffice  in 
ordinary  cases  to  establish  the  diagnosis.  The  diminution  of  the  tumor  by 
pressure,  and  its  enlargement  when  the  child  cries,  are  important  diagnostic 
signs. 

There  are  various  lumbo-sacral  tumors  located  in  the  median  line  from  which 
it  is  important  that  spina  bifida  should  be  diagnosticated.  Sometimes  a  cyst  occurs 
in  this  situation  which  was  originally  a  spina  bifida,  but  obliteration  of  the  canal 
in  the  pedicle  occurred,  just  as  the  canal  connecting  a  hydrocele  with  the  abdom- 
inal cavity  closes.  Solid  congenital  tumors  sometimes  also  grow  in  the  same  situa- 
tion, among  which,  as  most  common,  may  be  mentioned  fatty  tumors  and  tumors 
containing  foetal  remains.  The  most  common  seat  of  tumors  which  enclose  foetal 
remains  is  at  the  point  where  spina  bifida  ordinarily  occurs.  Physicians  have  erred 
in  mistaking  these  tumors,  as  well  as  those  which  consist  of  fat,  for  spina  bifida ; 
but  a  mistake  in  diagnosis  can  only  occur  through  haste  or  carelessness  of  exami- 
nation. 

The  PROGNOSIS  is  unfavorable  in  most  instances.  Ordinarily  the  tumor 
increases  slowly,  and  finally  the  sac  gives  way  by  ulceration  or  rupture ;  the 
liquid  escapes,  and  death  occurs  in  convulsions  and  coma ;  or,  if  the  escape 
of  the  liquid  be  prevented  by  pressure  and  the  aperture  closes,  a  second  rup- 
ture is  probable,  with  a  fatal  result.  In  other  cases  the  tiimor  may  not  rup- 
ture, but  the  cord  is  softened  or  it  is  injured  by  being  bent,  so  that  paraplegia 
results,  and  death  after  a  time  occurs  in  a  state  of  emaciation.  Rarely  the 
tumor  may  shrivel  by  absorption  of  the  liquid,  and  the  disease  is  cured,  or 
so  nearly  cured  that  it  gives  no  inconvenience  and  the  patient  lives  for  years. 
In  other  rare  instances  the  tumor  may  remain  without  any  material  change 
and  without  giving  rise  to  symptoms.  The  spina  bifida  being  small  and  cov- 
ered with  skin,  and  the  aperture  leading  from  it  into  the  spinal  canal  being 
also  small,  the  patient  lives  through  the  natural  period  of  life  with  little 
inconvenience. 

The  TREATMENT  Can  be  limited  to  no  fixed  rule.  In  the  most  favorable 
cases,  in  which  no  symptoms  occur  and  there  is  no  indication  that  the  tumor 
will  undergo  any  unfavorable  change,  surgical  treatment  is  not  required, 
except  the  application  of  a  soft  pad  to  support  the  tumor,  so  as  to  prevent  its 
injury  by  friction.  Indications  which  justify  active  surgical  interference  are 
growth  of  tumor,  absence  of  skin  from  it,  with  tension  of  the  parietes,  so 
that  an  early  rupture  is  inevitable,  and  the  occurrence  of  dangerous  nervous 
symptoms,  as  convulsions  or  paraplegia. 

From  the  nature  of  spina  bifida  it  is  evident  that  operations  upon  it  must 
be  conducted  with  caution.  The  usual  presence  of  the  spinal  cord  in  the 
pedicle  and  in  the  sac  forbids  ligation  and  excision,  and  renders  hazardous 
attempts  to  obliterate  the  sac  by  producing  inflammation  within  it.  A  safe 
mode  of  treatment,  but  not  the  most  efficient,  is  to  puncture  the  sac  and 
withdraw  a  portion  of  the  liquid  by  a  grooved  needle  or  hypodermic  syringe 
with  antiseptic  precautions.  A  soft  pad  should  then  be  applied  to  produce 
gentle  compression.  If  no  unfavorable  symptoms  occur,  the  puncture  may 
be  repeated  after  a  day  or  two.  This  operation  is  not  devoid  of  danger, 
for  the  removal  of  the  liquid,  if  carried  beyond  a  certain  point,  may  produce 
dangerous  nervous  symptoms,  especially  convulsions.  In  performing  the 
operation  the  puncture  should  never  be  made  in  the  median  line,  on  account 


88  DISEASES  OF  THE  yEWLY-BORK 

of  the  danger  of  wounding  the  cord,  which  lies  against  the  median  portion 
of  the  sac.     The  veins,  also,  should  be  avoided. 

Another  mode  of  treatment  is  by  iodine  injections.  They  are  preferable 
to  other  methods  if  the  neck  be  long  and  pedunculated,  so  as  to  be  easily 
compressed.  If  the  tumor  be  sessile  and  the  aperture  into  the  spinal  canal 
be  free,  these  injections  involve  great  danger,  and  are  not  to  be  recommended  ; 
for  more  or  less  of  the  solution  will  inevitably  enter  the  spinal  canal  and 
give  rise  to  spinal  meningitis. 

Iodine  injections  have  been  employed  with  success  by  Professor  Brainard  of 
Chicago,  who  states  that  he  "perfectly  and  permanently  cured"  three  of  seven 
cases  :  and  by  Telpeau  of  Paris,  by  whose  method  five  in  ten  operations  were  suc- 
cessful :  and  by  many  others.  Professor  Brainard  withdrew  some  of  the  liquid  con- 
tents, and  then  injected  half  an  ounce  of  water  containing  2^  grains  of  iodine  and 
7J  grains  of  iodide  of  potassium.  In  a  few  seconds  this  was  allowed  to  flow  out, 
and  the  sac  was  then  washed  out  with  tepid  water.  Then  a  portion  of  the  cerebro- 
spinal fluid,  which  had  been  kept  warm,  was  returned  into  the  sac.  When  he  had 
withdrawn  six  ounces  of  this  fluid  he  returned  two  ounces.  In  employing  the 
iodine  or  any  other  irritating  injection  it  is  necessary  to  compress  the  pedicle,  so 
that  the  liquid  does  not  enter  the  spinal  canal.  Yelpeau  employed  one  part  of 
iodine,  one  of  iodide  of  potassium,  and  ten  of  distilled  water. 

M.  Debont  recommends  the  evacuation  of  only  a  little  of  the  fluid,  and  the  injec- 
tion of  two  or  three  drops  of  the  tincture  of  iodine  diluted  with  an  equal  quantity 
of  water.  T.  Smith. ^  by  the  injection  of  one  drop  of  the  tincture,  jjroduced  an 
amount  of  inflammation  which  nearly  obliterated  the  sac.  Since  statistics  show  so 
good  a  result  of  iodine  injections,  this  mode  of  treatment  seems  preferable  to  any 
other  for  certain  cases,  and  as  one  drop  has  produced  general  inflammation  of  the 
sac  and  nearly  obliterated  it,  it  seems  safest  and  best  to  begin  with  so  small  a 
quantity. 

If  there  be  reason  to  believe,  from  the  small  size  of  the  orifice  and  other 
anatomical  characters,  that  neither  the  cord,  eauda  equina,  nor  any  of  the 
spinal  nerves  lie  within  the  sac,  it  may  be  thought  best  to  remove  the  tumor. 
It  has.  indeed,  been  proposed  to  open  the  tumor,  immersed  under  warm  water, 
sufficiently  to  observe  the  relation  of  the  nervous  elements,  and  to  press  them 
back  gently  into  the  canal  if  they  lie  within  the  sac.  If  it  be  decided  to 
remove  the  spina  bifida,  a  clamp  or  elastic  band  is  placed  around  the  pedicle 
so  snugly  as  to  cause  firm  adhesion  of  the  walls  of  the  pedicle,  and  excite 
sufficient  inflammation  in  them  to  produce  agglutination,  but  without  causing 
strangulation  or  suppuration.  After  a  time,  perhaps  two  or  three  days, 
when  it  is  evident  that  agglutination  has  occurred  from  the  fact  that  the 
liquid  cannot  be  returned  within  the  spinal  canal  by  compressing  the  sac,  the 
tumor  may  be  removed  by  the  knife  or  ecraseur. 

Statistics  do  not  show  so  favorable  a  result  of  this  operation  as  of  the  iodine 
treatment,  and  the  reason  is  obvious,  for  it  is  only  in  exceptional  cases  that  the 
tumor  can  be  removed  without  injury  to  the  nervous  tissue,  and  incision  of  a  portion 
of  the  cord  or  of  important  nerves  either  produces  death  or  a  condition  to  which 
death  would  be  a  relief. 

Spina  bifida  has  also  been  treated  by  opening  the  sac  on  its  side,  pressing 
back  the  spinal  cord  or  its  nerves  into  the  spinal  canal,  uniting  the  edges  of 
the  wound,  and  then  applying  pressure  to  prevent  protrusion,  but  the  result 
has  not  been  favorable.  Treatment  by  simple  puncture,  followed  by  com- 
pression, and  if  it  fail,  as  it  probably  will,  the  cautious  use  of  iodine  injec- 
tions, is  the  preferable  mode  of  treating  ordinary  cases  of  spina  bifida  which 
require  surgical  interference. 

^  Holmes's  Surg.  Dis.  of  Children. 


MALFORMATIONS.  89 

Cong-enital  Abnormalities  in  the  Circulatory  System. 

The  position  of  the  heart  is  rarely  abnormal,  and  the  most  common  mal- 
position is  its  location  on  the  right  side  of  the  chest  (dextro-cardia).  This 
occurs  with  or  without  misplacement  of  other  organs.  In  cases  of  dextro- 
cardia the  liver  usually,  says  Niemeyer,  occupies  the  left  hypoehondrium, 
and  the  spleen  the  right.  In  this  misplacement  of  the  heart  the  aorta  ordi- 
narily crosses  the  right  bronchus  and  passes  along  the  right  side  of  the  ver- 
tebra, but  occasionally  it  crosses  the  spine  and  lies  in  its  usual  position  on 
the  left  side  of  the  vertebrge.  The  heart  in  this  malposition  is  sometimes 
imperfect  and  sometimes  well  formed.  In  mesocardia  the  heart  is  situated 
nearer  the  median  line  than  usual,  corresponding  in  this  respect  with  the 
position  which  it  occupies  in  the  first  months  of  foetal  life.  A  rare  malposi- 
tion is  the  location  of  the  heart  outside  the  thoracic  cavity  (ectocardia  extra- 
thoracica) — -a  condition  accompanied  by,  and  perhaps  due  to,  deficiency  in 
the  sternum  or  sternum  and  ribs.  In  other  instances  equally  rare  a  part 
of  the  diaphragm  has  been  deficient,  and  the  heart  has  lain  in  the  abdomen ; 
and  in  other  instances  still  it  has  been  located  at  the  base  of  the  neck. 
Breschet  and  others  have  cited  examples  of  these  various  forms  of  ectopia 
cordis. 

Symptoms — Prognosis.— If  the  heart  be  well  formed  and  complete,  its 
abnormal  position  within  the  thorax  may  not  give  rise  to  symptoms,  and  is 
not  incompatible  with  prolonged  life.  If  it  be  located  without  the  thoracic 
cavity  or  be  within  the  cavity  and  be  defective,  early  death  is  probable. 

Malformation  of  the  heart  occurs — 1st,  from  arrested  development  early 
in  foetal  life,  so  that  the  organ  remains  rudimentary ;  2d,  from  arrested 
development  at  a  more  advanced  stage,  when  the  cavities,  septa,  and  ves- 
sels, though  incomplete,  are  partially  formed  ;  3d,  frorn  malformation  or  mal- 
position of  parts  of  the  heart  or  of  vessels  in  immediate  relation  with  the 
heart. 

The  CAUSES  of  malformations  of  the  heart  and  of  the  vessels  related  to 
it  are  obscure,  but  the  arrest  of  growth  or  abnormal  development  has  been 
attributed  to  foetal  inflammation  of  the  parts  involved.  Occasionally  the 
malformation  appears  to  be  due  to  some  vice  or  taint  in  the  system  of  one  or 
both  parents.  Causes  which  promote  the  physical  well-being,  as  pure  air  and 
outdoor  exercise,  plain  and  nutritious  diet,  freedom  from  depressing  cares 
and  anxieties  in  parents,  diminish  the  liability  to  malformation  and  imperfect 
development  of  the  foetal  organs. 

Malformations  of  the  heart  derive  their  seriousness  and  importance  from 
the  fact  that  the  heart  is  the  central  organ  of  circulation,  so  that  when  from 
malformation  it  is  inadequate  to  perform  fully  its  function,  not  only  is  the 
nutrition  seriously  interfered  with,  but  the  flow  of  blood  through  the  lungs 
is  insufficient.  The  blood  is  not  properly  oxygenated,  and  it  is  overcharged 
with  carbonic  acid,  which  imparts  to  it  the  deeply  venous  or  livid  color 
known  as  cyanosis. 

Cyanosis. 

As  stated  above,  the  cause  of  cyanosis  when  occurring  in  infants  is  at 
the  centre  of  circulation,  and  is  a  malformation  of  the  heart  with  very  few 
exceptions. 

The  blue  disease,  being  so  manifest,  attracted  attention  at  an  early  age. 
It  appears  from  the  remarks  of  Boerhaave  that  the  common  people  believed 
that  the  cyanotic  were  possessed   by  evil  spirits.^     It  was  evidently  impos- 

^  Diseases  of  the  Humors. 


90 


DISEASES  OF  THE  NEWLY-BORN. 


sible  to  understand  its  cause  and  nature  prior  to  the  discovery  of  Harvey  in 
the  seventeenth  century,  and  most  of  the  exact  or  scientific  knowledge  pos- 
sessed by  the  profession  in  reference  to  the  etiology  and  nature  of  cyanosis 
has  been  achieved  since  the  present  century  commenced.  Boerhaave  and 
Vieussens  had  observed  cases  and  propounded  theories  in  reference  to  it.  but 
the  knowledge  of  physicians  concerning  it  remained  vague  and  indefinite. 
No  better  idea  can  be  given  of  the  prevailing  ignorance  in  reference  to  cya- 
nosis, even  after  the  present  century  commenced,  than  by  quoting  from  a  case 
related  by  Eibes  in  1814.^  The  patient  had  some  time  previously  received 
an  injury  of  the  finger.  '•  Many  physicians  of  Amsterdam,"  says  he,  "  were 
at  different  times  consulted  on  the  subject  of  this  affection,  no  one  of  whom 
understood  its  true  cause,  its  essential  character.  One  considered  it  as  par- 
taking of  the  nature  of  epilepsy,  and  caused  by  the  irritation  in  the  nervous 
system  which  the  wound  in  the  finger  had  produced.  Others  attributed  it  to 
the  presence  of  intestinal  worms.  Some  physicians  pronounced  it  an  injury 
to  the  liver  or  spleen.  Many  held  it  to  be  a  scorbutic  affection.  One  only 
believed  it  to  be  the  result  of  an  unknown  organic  disease."  In  the  present 
century  numerous  carefully  observed  cases  of  cyanosis  published  in  the 
medical  journals,  and  the  writings  of  Seller,  Louis,  Bouillaud,  Farre,  Chev- 
ers,  Peacock,  Marston,  Stille,  and  others,  have  contributed  to  a  better  under- 
standing of  the  nature  and  anatomical  characters  of  cyanosis. 

Whatever  may  be  the  explanation,  male  infants  affected  with  cyanosis  are 
in  excess  of  females  : 

180  cases  collated  bv  Aberle    ....  two-thirds  males. 

44     "  "        ''  Gintrac  .    .    .    .  28  males,  16  females. 

41     "  "        "  Stills 21       "      10 

134     "  "        "  J.  Lewis  Smith .  78      "      56        " 

The  deaths  from  cyanosis  illustrate  the  same  fact : 


In  London,  England,  in  two  years  . 
In  New  York  City,  in  five  vears  .    . 


Males. 

Females 

.418 

273 

117 

90 

Cyanosis,  though  dependent  on  a  malformation,  does  not  always  com- 
mence at  birth,  or  at  least  does  not  exist  in  degree  sufficient  to  produce  the 
cyanotic  hue  till  some  time  has  elapsed  after  birth. 

In  138  of  the  cases  of  cyanosis  which  I  have  collected  the  time  at  which  lividity 
was  first  observed  is  stated  as  follows :  In  97  it  was  within  the  first  week,  and  gen- 
erally within  a  few  hours  of  birth.  In  the  remaining  41  cases  it  commenced  as 
follows : 


In  3  at  2  weeks. 
"  1  "  3      " 
"  2  "  1  month. 
"  7  from  1  to  2  months. 
"5     "     2  "    4        " 
"  5     "     6  "  12        " 
"3     "     1  year  to  2  years. 


In  6  from  2  years  to  5  years. 
"1     "5      "     "  10      " 
"  6     "  10      "     "20      " 
"  1     "  20      "     "40     " 
"  1  over  40  years. 

41,  total. 


In  these  41  cases,  in  which  blueness  did  not  occur  till  after  the  age  of  one  week,  if 
the  patient  were  less  than  two  years  old  when  it  commenced  there  was  frequently 
no  obvious  exciting  cause,  but  above  this  age,  with  three  exceptions,  such  a  cause  is 
known  to  have  been  present. 

It  is  interesting  to  observe  how  trivial  the  exciting  cause  frequently  is, 
^  Bull,  de  la  Fac.  de  Med.,  1815. 


MALFORMATIONS.  91 

and  equally  interesting  to  note  liow  long  patients  have  enjoyed  good  health, 
not  having  the  least  lividity,  although  the  anatomical  vice  to  which  the  final 
development  of  cyanosis  was  due  had  existed  from  birth. 

Dr.  Theophilus  Thompson  relates  ^  the  history  of  a  lady,  thirty-eio;ht  years  old, 
who  was  well  till  an  attack  of  Asiatic  cholera,  after  which  her  health  was  perma- 
nently impaired.  Two  years  before  her  death  she  passed  through  a  course  of  fever, 
and  from  this  time  was  cyanotic.  In  the  Philadelphia  Medical  Examiner,  June, 
1850,  Dr.  Waters  relates  a  case  in  which  cyanosis  began  at  the  age  of  sis  years  in 
an  attack  of  measles.  In  a  case  published  by  Mr.  Napper  in  the  London  Medical 
Gazette,  1841,  the  child  fell  at  the  age  of  six  months,  and  from  this  time  had  cya- 
nosis. A  female  whose  history  is  given  by  Prof.  Tommasini  of  Bologna,  and  quoted 
by  Bouillaud,  became  cyanotic  at  the  age  of  twenty-five  in  consequence  of  difficult 
parturition.  In  the  London  Lancet,  1842,  Mr.  Stedman  relates  a  case  in  which 
cyanosis  began  at  the  age  of  ten  weeks  in  an  attack  of  convulsions.  In  the  Amer- 
ican Journal  of  Medical  Sciences,  in  1847,  Dr.  John  P.  Harrison  published  the  his- 
tory of  a  baker,  twenty  years  old,  in  whom  cyanosis  began  five  years  previously 
after  great  effort  in  carrying  wood.  Louis  and  Bouillaud  quote  from  M.  Caillot  the 
case  of  a  child  who  became  cyanotic  at  the  age  of  two  months  in  an  attack  of 
whooping  cough.  Louis  also  narrates  a  case  in  which  whooping  cough  had  the 
same  eff"ect  at  the  age  of  twelve  years.  Ribes  treated  a  child  in  whom  the  blue 
disease  began  at  the  age  of  three  years  from  a  severe  contusion  of  the  fingers.  In 
a  case  by  Marx  it  commenced  at  the  age  of  ten  months  from  a  blow  on  the  back 
inflicted  by  the  mother.  In  the  Medical  Times  and  Gazette,  for  1855,  Mr.  Speer 
gives  the  history  of  a  female  who  at  the  age  of  thirteen  years  was  put  in  a  place 
requiring  considerable  exertion,  and  from  this  time  was  cyanotic.  A  patient  whose 
case  was  related  by  Cherrier  fell  into  a  deep  ditch  in  the  winter  season,  and  imme- 
diately after  had  a  low  fever,  from  which  the  blue  disease  commenced.  In  a  case 
published  by  Tacconus  the  exciting  cause  was  believed  to  be  fright  in  consequence 
of  a  fall  from  a  great  height,  and  in  another,  related  by  Bouillaud,  it  was  a  blow 
received  on  the  epigastrium  after  the  patient  had  passed  the  age  of  fifty  years. 

It  will  be  seen  that  the  exciting  cause  of  cyanosis  is  usually  such  as  pro- 
duces a  profound  impression  on  the  system  and  affects  the  action  of  the  heart. 
Precisely  in  what  way  it  operates  to  develop  the  disease  has  not  been  satis- 
factorily explained. 

Mr.  Mayo  conjectures  that  in  the  case  related  by  him  there  was  previously  some 
compensation  which  ceased  or  became  inadequate  in  consequence  of  some  change 
produced  in  the  economy.  Although  cyanosis  may  not  appear  for  months  or  even 
years,  there  is  rarely  improvement  Avhen  it  is  once  established.  Appearances  of 
amendment  are  deceptive.  The  disease  when  not  stationary  is  progressive,  and  this 
explains  the  fact  that  few  survive  the  middle  period  of  life. 

Symptoms. — The  symptoms  in  cyanosis  vary  in  intensity  in  different 
patients,  and  in  the  same  patient  at  different  times,  being  milder  if  he  be 
quiet  and  the  mind  calm,  more  severe  if  active  or  if  the  mind  be  agitated. 
In  mild  cases,  in  a  state  of  rest,  they  nearly  or  quite  disappear,  so  that  a 
stranger  would  not  suspect  that  there  was  any  serious  ailment.  They  are 
aggravated  by  any  cause  which  accelerates  the  action  of  the  heart.  In  some 
patients  cyanosis  is  increased  by  the  most  trivial  disturbing  influences,  among 
which  may  be  mentioned  nursing,  dentition,  crying,  coughing,  and  slight 
emotions  of  joy,  sorrow,  or  anger.  In  more  than  one  case  it  has  been  per- 
ceptibly increased  by  the  stimulus  of  digestion,  the  color  being  deeper  after 
a  full  meal  than  before.  The  cyanotic  hue  varies  in  different  individuals 
from  duskiness  to  a  deep  purple,  almost  black,  color.  It  is  usually  most 
marked  in  the  visage,  especially  the  palpebrse,  cheeks,  nose,  and  lips,  in  the 
ears,  fingers,  and  upon  the  mucous  surfaces.  It  is  sometimes,  without  any 
assignable  cause,  confined  to  a  portion  of  the  body. 

In  a  case  related  by  Mr,  Steel  in  the  London  Lancet,  1838,  the  upper  part  of  the 
^  Medic-o-Chir.  Trans.,  vol.  xxv. 


92  DISEASES  OF  THE  NEWLY-BORN. 

bodv  was  livid  and  oedematous,  and  the  lower  part  pallid  and  shrunken,  and  yet  the 
malformation  was  of  the  kind  which  is  commonl}'  present  in  cyanosis.  In  the 
London  Medical  Times.  March  8,  1845,  copied  from  the  Gazette  viMicale,  is  the  his- 
tory of  a  child,  six  years  old,  in  whom  the  color  was  deeper  on  the  right  than  left 
side.  There  had  been,  however,  hemiplegia  of  this  side  in  infancy,  but  this  had 
entirely  passed  off.  On  the  other  hand,  in  a  case  of  rare  malformation  communi- 
cated by  Cooper  to  Farre.  in  which  the  upper  part  of  the  system  was  supplied 
chiefly  by  arterial  and  the  lower  by  venous  blood,  the  discoloration  was  general. 
In  exceptional  instances  livid  maculag,  like  those  of  purpura,  have  been  observed 
upon  the  skin. 

Those  aifected  with  cyanosis  have  generally  at  birth  been  well  formed 
and  of  the  usual  size,  and  in  most  eases  for  a  considerable  period  after  birth 
the  appetite  is  good,  bowels  regular,  and  the  system  well  nourished.  But 
when  cyanosis  becomes  so  severe,  as  it  does  sooner  or  later,  that  its  symptoms 
are  rarely  absent,  digestion  is  imperfectly  performed  and  the  body  becomes 
either  emaciated  or  stunted  and  puny.  It  may  be  stated,  as  a  rule,  that 
nutrition  is  in  inverse  proportion  to  the  gravity  of  cyanosis. 

In  33  out  of  41  cases  in  which  the  condition  of  the  system  as  regards  nutrition 
was  recorded  either  a  short  time  previously  to  death  or  at  the  autopsy,  the  body  was 
either  considerably  emaciated  or  else  diminutive,  and  those  who  were  well  nourished 
were  usually  such  as  had  died  early  or  of  some  intercurrent  disease. 

In  this  connection  may  be  mentioned  two  abnormalities  which  have  been 
observed  in  the  cyanotic.  The  chest  is  often  flattened  laterally,  with  a  pro- 
jecting sternum,  so  as  to  present  an  appearance  generally  described  in  the 
records  as  •'  pigeon-chested."  Sometimes  the  most  pi'ominent  part  is  directly 
over  the  heart,  and  in  one  or  two  cases  the  sternum  was  observed  to  be 
deflected  toward  the  left.  In  the  majority  of  the  records,  however,  no  men- 
tion is  made  of  the  external  appearance  of  the  chest. 

The  other  abnormality  is  frequently  observed  in  chronic  diseases  of  the 
heart  and  lungs,  in  which  there  is  sluggish  circulation  and  consequent  altered 
nutrition  in  the  fingers  and  toes.  In  28  of  the  cases  collated  by  myself  it  is 
stated  that  the  tips  of  the  fingers  or  toes,  or  both,  were  bulbous.  This 
hypertrophy,  if  slight,  is  likely  to  be  overlooked,  and  that  it  was  observed 
and  recorded  in  so  many  cases  renders  it  probable  that  it  was  present  in  a 
much  larger  number.  In  one  case  the  anatomical  character  of  this  enlarge- 
ment was  minutely  examined,  and  was  found  to  consist  chiefly  of  hypertro- 
phied  connective  tissue. 

The  nails  are  often  incurvated  over  the  deformity.  At  a  meeting  of  the  London 
Pathological  Society,  in  18o9,  Mr.  Ogle  narrated  the  history  of  a  laborer  fifty  years 
old  Avho  had  swelling,  numbness,  and  lividity  of  the  left  arm  from  pressure  of  an 
aneurism,  and  the  fingers  on  this  side  were  clubbed. 

An  interesting  feature  in  cyanosis  is  the  low  grade  of  animal  heat.  The  tem- 
perature of  the  body  is  in  all  cases  below  that  of  health.  This  is  especially  notice- 
able in  the  extremities.  There  has  not  been  a  sufficient  number  of  accurate  thei*- 
mometric  observations  to  determine  whether  the  internal  heat  is  usually  reduced. 
The  following  only  have  been  recorded:  Mr.  Fletcher  relates  the  history  of  a  young 
man  in  the  Medico-Chir.  Trans.,  vol.  xxv.,  in  whom  the  thermometer  placed  in  the 
mouth  did  not  stand  above  80°  Fahr.  Hodgson  reports  the  case  of  a  man,  twenty- 
five  years  old,  in  whom  the  thermometer  placed  under  the  tongue  rose  to  100°. 
Perhaps  a  more  thorough  examination  might  have  disclosed  an  intercurrent  malady 
to  cause  fever.  In  an  examination  recorded  by  Xasse  the  instrument  placed  in  the 
mouth  fell  little  if  at  all  below  the  healthy  standard  :  applied  to  external  parts,  it 
stood  at  about  21°  R6au.  =  79.2°  Fahr. 

The  lack  of  heat  is  a  source  of  great  discomfort  to  a  cyanotic  patient. 
In  mild  weather  he  requires  a  fire  to  keep  him  warm  or  an  amount  of  cloth- 
ing which   to   others  would  be  uncomfortable,  and   in   cold  weather  slight 


MALFORMATIONS.  93 

exposure  strikes  liim  witli  a  chill.  Nor  can  he  increase  his  heat  by  active 
exercise,  since  his  infirmity  disqualifies  him  for  this.  Although  the  tempera- 
ture of  the  surface  is  so  low,  the  occurrence  of  perspiration,  sometimes  pro- 
fuse, is  mentioned  in  several  of  the  records. 

In  severe  cases  of  cyanosis  the  generative  system  is  imperfecth'  devel- 
oped. In  the  female  menstruation  is  scanty  or  delayed,  and  in  the  male  signs 
of  puberty  are  feebly  manifest.  If  the  disease  be  so  mild  that  the  sj'mptoms 
are  absent  when  the  patient  is  in  a  state  of  repose,  these  organs  attain  nearly 
or  quite  their  normal  development.  The  catamenia  have  appeared  as  early 
as  the  age  of  sixteen  years,  and  a  cyanotic  patient  treated  by  Cherrier  had 
two  children,  but  both  died  of  scrofulous  affections. 

The  action  of  the  heart  is  necessarily  much  involved.  In  mild  forms 
of  the  disease,  if  the  patient  be  quiet,  this  organ  may  beat  with  considerable 
slowness  and  regularity,  but  in  all  cases  exercise  or  excitement  which  in 
a  state  of  health  would  scarcely  have  any  appreciable  effect  on  the  pulse 
embarrasses  its  movements  and  produces  palpitation.  In  severe  cases  pal- 
pitation is  rarely  absent,  and  the  pulse  is  frequent,  feeble,  and  often  inter- 
mittent. In  a  large  proportion  of  patients  bruits  are  produced  by  the  irreg- 
ular circulation  through  the  heart. 

The  respiration  corresponds  with  the  action  of  the  heart.  It  is  accele- 
rated in  proportion  to  the  frequency  of  the  pulse.  The  suffering  in  this 
disease  is  largely  due  to  paroxysms  of  palpitation  and  dyspncea.  These 
occur  sometimes  without  any  apparent  exciting  cause  and  when  the  patient 
is  quiet,  but  they  are  commonly  induced  by  those  causes  which  we  have 
already  mentioned  as  aggravating  the  symptoms  of  cyanosis.  They  come 
on  suddenly,  and  are  attended  by  increase  of  lividity,  distention  of  the  jug- 
ulars, and  sometimes  of  the  cutaneous  veins,  and  by  a  sensation  of  present 
suffocation.  They  last  only  a  few  minutes,  and  are  succeeded  by  great 
depression  of  the  vital  powers.  In  infants,  on  account  of  greater  nervous 
irritability  and  feeble  power  of  endurance,  these  paroxysms  often  end  in  con- 
vulsions which  occasionally  are  fatal.  A  cough  is  sometimes  present,  but  is 
usually  slight. 

Pain  is  not  a  common  symptom.  Some  of  the  patients  complain  occasion- 
ally of  headache,  with  or  without  vertigo,  and  occasionally  also  of  pain  in 
the  chest,  but  it  is  uncertain  to  what  extent  or  whether  these  symptoms  are 
dependent  on  the  cyanotic  disease.  The  secretions  do  not  appear  to  be  affect- 
ed, so  far  as  has  been  ascertained.  The  same  may  be  said  of  the  intellectual 
and  moral  faculties.  In  a  case  related  by  Dr.  Cheevers  the  child  was  even 
said  to  be  precocious.^  The  mind  is  capable  of  steady  application  and  acqui- 
sition, as  in  health,  provided  that  the  emotions  are  not  unduly  excited. 

The  cyanotic  are  liable  to  various  foi*ms  of  hemorrhage,  but  the  records 
show  that  this  liability  is  greater  in  youth  and  adult  life  than  in  infancy.  In 
2  cases  blood  was  vomited,  in  1  passed  by  stool,  in  1  it  escaped  from  the  gums, 
in  2  from  the  mouth,  in  8  from  the  nostrils,  and  in  16  it  was  expectorated. 
Pulmonary  phthisis  was,  however,  usually  present  in  these  last  cases.  In 
the  Western  Journal  of  Medicine  for  1829  an  interesting  case  is  related  by 
Dr.  AVilliam  M.  Voris  of  a  girl  nine  years  old  in  whom  hemorrhage  occurred 
under  the  scalp,  producing  great  tumefaction  and  nearly  closing  the  eye- 
lids. An  incision  was  made,  from  which  a  pint  and  a  half  of  dark  blood 
escaped,  and  it  was  estimated  that  more  than  half  a  gallon  was  lost  during 
the  ensuing  two  weeks,  at  the  expiration  of  which  time  the  inci-sion  closed. 
The  patient  recovered  from  the  hemorrhage,  but  not  from  the  cyanosis. 

Toward  the  close  of  life  more  or  less  anasarca  occasionally  occurs,  espe- 
cially around  the  ankles,  sometimes  in  the  eyelids  and  face,  and  rarely  to  a 

1  Lond.  Med.  Gaz.,  vol.  sxxviii. 


94 


DISEASES  OF  THE  NEWLY-BORN. 


certain  extent  over  the  -whole  bod}-.  In  certain  patients  it  coexists  with 
effusion  in  the  serous  cavities. 

It  is  evident  that  one  who  is  affected  with  the  severer  form  of  cyanosis  is 
disqualified  for  the  duties  of  active  life.  The  sports  of  childhood  and  the 
useful  labors  of  mature  years  require  an  exertion  for  which  he  is  physically 
unfit.  He  has  not  the  ability  even  to  engage  in  animated  conversations,  for 
he  is  overcome  by  emotions,  whether  of  joy  or  sorrow.  He  lives  almost 
an  idle  spectator  of  the  world  around  him.  prevented  by  his  infirmity  from 
engaging  in  its  pursuits. 

Intercurrent  diseases,  especially  those  of  childhood,  are  badly  tolerated, 
but  whooping  cough  is  the  one  which  these  patients  are  especially  ill-fitted  to 
endure.  Still,  they  sometimes  pass  safely  not  only  through  whooping  cough. 
but  through  some  of  the  most  dangerous  febrile  diseases.  It  is  a  question 
of  interest,  but  about  which  little  is  known  with  certainty,  whether  these 
intercurrent  maladies  are  influenced  by  the  cyanotic  or  venous  condition  of 
the  blood.  The  symptoms  of  these  maladies  are  no  doubt  more  alarming, 
mainly  on  account  of  the  embarrassed  action  of  the  heart,  and  not  on  account 
of  the  .state  of  the  blood  ;  still,  it  is  reasonable  to  suppose  that  malignant 
and  asthenic  diseases  are  rendered  worse  by  the  lack  of  oxygen  and  excess 
of  carbonic  acid  in  the  circulating  fluid. 

Probably  cyanosis  does  not  furni.sh  immunity  from  any  other  disease, 
although  this  statement  has  been  made  by  a  high  authority. 

Rokitansky  says:  "All  forms  of  cyanosis,  or  rather  all  the  diseases  of  the  heart, 
great  vessels,  and  lungs  adapted  to  produce  cyanosis  in  a  greater  or  less  degree, 
cannot  coexist  with  tuberculosis.  Cyanosis  affords  a  complete  protection  against  it, 
and  in  this  circumstance  may  be  found  an  explanation  of  the  immunity  from  tuber- 
culosis which  many  conditions  of  the  system,  apparently  very  different  in  their 
character,  afford.'" '  This  opinion  of  the  distinguished  pathologist,  notwithstanding 
his  ample  opportunities  for  observation  and  known  accuracy  as  an  observer,  is  not 
substantiated  by  statistics.  So  far  from  its  being  true,  the  low  degree  of  vitality  in 
cyanosis  appears  to  favor  the  occurrence  of  tubercles.  I  have  records  of  26  cases 
of  cyanosis  in  which  tuberculosis  was  also  present,  in  several  of  which  the  lungs 
contained  cavities.  This  is  about  13  per  cent,  of  the  whole  number  in  my  collection 
— a  large  proportion,  since  so  many  die  in  early  infancy,  at  which  period  the  tuber- 
cular disease  seldom  occurs.  Cyanosis  appears  also  to  favor  the  development  of 
cerebral  diseases,  especially  congestion  and  coma,  as  will  he  seen  presently. 

Prognosis. — This  is  unfavorable.  Most  cyanotic  individuals  die  young. 
The  age  which  they  attain  has  been  made  the  subject  of  statistical  inquiry 
by  Aberle. 

He  states  that  in  an  aggregate  of  159  cases,  57,  or  35  per  cent.,  died  before  the 
end  of  the  first  year ;  108,  or  more  than  two-thirds,  died  before  the  age  of  eleven 
years :  30  between  the  ages  of  eleven  and  twenty-live  years  ;  and  of  the  remaining 
21,  only  5  lived  more  than  forty-five  years. 

The  age  at  which  death  occurred  is  given  in  186  of  the  cases  collected  by  myself, 
as  follows : 


In 


17  under  the  age  of  1  week. 
10  from  1  weeix.  to  1  month. 


12 

"     1  month   to    3  months. 

11 

' '     3  months  to    6         " 

17 

"     6       "      to  12 

12 

"    .1  year  to  2  years. 

21 

"     2  vears  to  5     " 

In  21  from    5  years  to  10  vears. 
"  41     "     10      "     "  20  '    " 
"  20     "     20      "     "  40      " 
"     4  over  40       " 

186  total. 


67.  then,  or  more  than  one-third,  died  before  the  close  of  the  first  year;  121,  or 
more  than  three-fifths,  before  the  age  of  ten  years  :  only  24  survived  the  age  of 

^Handb.  der  Path.  Anat.,  Bd.  ii. 


MALFORMATIONS.  95 

twenty  years,  and  4  the  age  of  forty  years.  Of  course,  the  duration  of  life  depends 
on  the  nature  and  extent  of  the  malformations.  Some  of  these  are  such  as  render 
a  speedy  death  inevitable. 

Mode  of  Death. — The  mode  of  death  is  reported  in  95  cases,  as  fol- 
lows : 

19  died  in  a  paroxysm  of  dyspnoea. 

10  "  suddenly  (the  exact  manner  not  stated). 

]4  "  in  convulsions  (infants). 

2  "  of  apoplexy. 

7  "  from  hemorrhage. 

6  "  of  phthisis  (though,  as  we  have  seen,  20  others  had  this  disease). 

2  "  of  exhaustion,  without  hemorrhage. 

10  "  of  coma. 

2  "  of  abscesses  in  the  brain. 

One  died  of  each  of  the  following  diseases :  cerebral  irritation,  congestion  of 
brain,  effusion  in  the  cranial  cavity,  acute  hydrocephalus,  paralysis  from  acute 
softening  of  the  brain,  dysentery,  inflammation  of  heart,  syncope,  mucus  in  the  air- 
passages,  thoracic  inflammation,  choleraic  diarrhoea,  pneumonitis,  bronchitis,  scarlet 
fever,  croup  ;  1  died  in  trying  to  walk,  1  after  a  spasmodic  cough  in  pertussis,  1  after 
a  long  agony  of  ten  or  eleven  hours ;  1  is  reported  to  have  died  gradually,  and  3 
quietly. 

The  10  who  are  stated  to  have  died  suddenly  probably  died  in  paroxysms  of 
palpitation  and  dyspnoea,  which  are  easily  excited  and  of  common  occurrence  in 
cyanosis.  If  so,  this  was  the  mode  of  death  in  29  cases.  Infants  with  few  excep- 
tions, so  far  as  appears  from  the  records,  died  in  convulsions.  19  died  of  cerebral 
affections,  exclusive  of  convulsions,  and  in  13  of  these  the  cause  of  death  was  con- 
gestion, apoplexy,  or  coma.  The  hemorrhage  of  which  7  died  was  probably,  in 
most  instances,  dependent  on  phthisis,  and  6  are  said  to  have  died  directly  of 
phthisis.  We  may,  then,  regard  paroxysms  of  palpitation  and  dyspnoea,  convul- 
sions, congestive  affections  of  the  brain,  and  phthisis  as  common  modes  or  causes  of 
death  in  cyanosis. 

The  malformations  of  the  heart  and  great  vessels  which  give  rise  to 
cyanosis  are  quite  numerous.  The  following  table  exhibits  their  character 
and  relative  frequency  : 

Cases. 

1.  Pulmonary  artery  absent,  rudimentary,  impervious,  or  partially  obstructed     97 

2.  Eight  auriculo-ventricular  orifice  impervious  or  contracted 5 

3.  Orifice  of  the  pulmonary  artery  and  the  right  auriculo-ventricular  aperture 

impervious  or  contracted 6 

4.  Eight  ventricle  divided  into  two  cavities  by  a  supernumerary  septum  ...  11 

5.  One  auricle  and  one  ventricle 12 

6.  Two  auricles  and  one  ventricle 4 

7.  A  single  auriculo-ventricular  opening  ;  interauricular  and  interventricular 

septa  incomplete 1 

8.  Mitral  orifice  closed  or  contracted 3 

9.  Aorta  absent,  rudimentary,  impervious,  or  partially  obstructed 3 

10.  Aortic  and  the  left  auriculo-ventricular  orifice  impervious  or  contracted    .  1 

11.  Aorta  and  pulmonary  artery  transposed 14 

12.  The  cavje  entering  the  left  auricle 1 

13.  Pulmonaiy  veins  opening  into  the  right  auricle  or  into  the  cavse  or  az}^gos 

veins 2 

14.  Aorta  impervious  or  contracted  above  its  point  of  union  with  the  ductus 

arteriosus  ;  pulmonary  artery  wholly  or  in  part  supplying  blood  to  the 
descending  aorta  through  the  ductus  arteriosus 2 

Total  .    .' 162 

From  the  above  table  it  appears  that  in  more  than  one-half  of  the  cases 
of  cyanosis  the  congenital  vice  which  gives  rise  to  it  is  located  in  the  pul- 


96  DISEASES  OF  THE  NEWLY-BORN. 

monary  artery.  It  is  located  also,  in  general,  in  that  part  of  the  artery  which. 
is  nearest  the  heart.  Its  character  is  difierent  in  difi'erent  cases.  Sometimes 
there  is  an  arrested  development  of  this  vessel,  and  in  its  place  we  find  simply 
a  ligamentous  cord  extending  from  the  heart  as  far  as  the  ductus  arteriosus, 
while  beyond  this  point  the  artery  and  its  branches  are  pervious ;  rarely  the 
entire  artery  is  ligamentous,  and  of  course  impervious ;  in  other  cases  this 
vessel  is  open  through  its  whole  extent,  but  the  part  nearest  the  heart  is  so 
small  as  to  be  properly  considered  rudimentary  ;  in  others  still  there  is  adhe- 
sion of  the  valves  to  each  other  as  the  chief  congenital  defect ;  and  finally. 
in  rare  instances  the  obstruction  in  the  pulmonary  artery  is  due  to  an  adven- 
titious membrane  which  stretches  across  the  vessel  like  a  diaphragm.  These 
last  malformations — namely,  adhesion  of  the  valves  and  the  formation  of  an 
adventitious  membrane — are  doubtless  due  to  inflammation  occurring  in  the 
artery  before  birth,  and  some  attribute  the  arrested  development  and  lig- 
amentous state  of  the  vessel  to  the  same  cause. 

In  most  cases  of  cyanosis  due  to  obstructive  malformations  the  inter- 
auricular  and  interventricular  septa  are  more  or  less  deficient.  This  deficiency 
obviously  results  from  the  obstruction,  for  the  septa  are  formed  in  the  heart 
after  foetal  circulation  is  established,  and  the  blood,  being  prevented  by  the 
vicious  formation  from  flowing  in  its  proper  channel,  necessarily  passes  to 
the  opposite  side  of  the  heart.  More  or  less  blood  being  forced  from  one 
auricle  or  one  ventricle  to  the  opposite  cavity,  it  is  evident  that  a  permanent 
aperture  must  result  in  the  septum.  The  aperture  in  the  septtim  ventricu- 
lorum  is  ordinarily  at  its  base  ;  in  the  septum  auriculorum  it  corresponds 
with  the  foramen  ovale. 

In  most  of  the  obstructive  malformations  one,  and  rarely  two,  abnormal 
cardiac  murmurs  have  been  observed.  The  single  murmur  accompanies  the 
ventricular  systole.  As  it  has  been  observed  in  cases  of  complete  as  well  as 
incomplete  obstruction,  it  seems  to  be  due  mainly  to  the  flow  of  blood  through 
a  narrow  or  constricted  pulmonary  artery  or  the  apertures  in  the  septa. 

Modes  or  Compensation. — In  most  cases  of  cyanosis  the  congenital 
defect  is  partially  obviated  by  modes  of  compensation.  In  the  most  fre- 
quent malformation,  that  in  which  there  is  obstruction  in  the  pulmonary 
artery  and  a  considerable  part  if  not  all  the  blood  flows  directly  from  the 
right  to  the  left  side  of  the  heart,  the  ductus  arteriosus  not  only  remains 
open,  but  is  greatly  enlarged,  and  through  it  a  current  of  blood  enters  the 
pulmonary  artery  from  the  aorta,  and,  passing  to  the  lungs,  is  oxygenated. 
The  bronchial  arteries  have  also  been  found  greatly  enlarged,  and  it  is  believed 
that,  though  they  are  the  nutrient  arteries  of  the  lungs,  the  blood  which  they 
convey  to  these  organs  is  decarbonized  in  its  circuit  through  them. 

In  a  case  published  by  Mr.  Le  Gros  Clark  in  the  Medico-Chir.  Trans.,  vol.  sxx., 
the  bronchial  arteries  were  not  only  enlarged,  but  a  "  branch  from  the  internal 
mammary  artery,  which  accompanied  the  phrenic  nerve,  was  nearly  equal  in  size 
to  the  parent  trunk,  and  expended  itself  principally  in  the  adjacent  adherent  lung. 
Branches  of  the  intercostal  arteries  have  also  been  found  enlarged,  and  entering 
the  lungs  or  connecting  with  vessels  which  enter  the  lungs.'" 

By  such  modes  of  compensation  cyanosis  is  rendered  milder  and  life  is 
prolonged.  To  these  we  must  attribute  the  fact  that  some  have  very  con- 
siderable malformation  and  yet  do  not  become  cyanotic. 

Morbid  Anatomy. — This,  as  regards  the  circulatory  system,  has  been 
sufficiently  dwelt  upon.  No  chemical  analysis,  so  far  as  I  am  aware,  has  yet 
been  made  of  cyanotic  blood.  We  know  that  it  is  dark,  its  coagulability 
feeble — that  it  contains  an  excess  of  carbonic  acid  and  is  deficient  in  oxygen. 
From  the  nature  of  cyanosis  it  would  be  inferred  that  in  many  eases  there  is 
a  degree  of  passive  congestion  in  the  cavities  of  the  heart,  and  consequently 


MALFORMATIONS.  97 

in  the  capillaries  of  the  systemic  system,  giving  rise  to  more  or  less  serous 
eifusion. 

Statistics  show  that  this  is  so.  The  quantity  of  pericardial  fluid  is  in  some 
patients  increased.  I  have  records  relating  to  this  fluid  in  51  cases.  Usually  it 
was  pure  serum.  In  17  the  quantity  was  half  an  ounce  or  less,  if  we  include  in 
the  number  those  in  which  the  amount  is  expressed  in  such  terms  as  "due  quan- 
tity,"' "usual  amount,"  and  "small  amount."  In  24  cases  the  pericardial  fluid 
(serum)  exceeded  half  an  ounce,  usually  estimated  at  from  1  to  6  ounces,  hut  in 
2  it  exceeded  the  latter  quantity.  In  1  of  the  24  this  fluid  was  stained  with 
blood.  In  2  patients  the  records  state  that  there  was  a  small  quantity' of  pure 
blood  in  the  pericardium,  and  in  1  the  two  pericardial  surfaces  were  agglutinated 
by  inflammation. 

In  some  of  the  autopsies  serum  was  found  in  the  pleural  cavities,  usually 
in  connection  with  pericardial  effusion,  and  in  at  least  one  instance  this  fluid 
was  tinged  with  blood.  Old  adhesions  between  the  costal  and  pulmonary 
pleura  were  observed  in  a  few  cases.  The  condition  of  the  lungs  was 
recorded  with  more  or  less  minuteness  in  110  cases.  Mention  has  already 
been  made  of  the  large  number  affected  with  tubercular  disease,  which  was 
either  confined  to  the  lungs  or  was  chiefly  exhibited  in  these  organs.  In  35 
patients  the  records  state  that  the  lungs  were  of  small  size,  either  by  com- 
pression or  sometimes,  apparently,  from  the  continuance  of  the  foetal  state 
over  a  greater  or  less  portion  of  the  organ.  The  compression  was  produced 
either  by  the  distended  pericardium  or  by  effusion  in  the  pleural  cavities.  In 
35  cases  the  lungs  presented  a  dark  color.  This  hue  in  some  specimens 
accompanied  the  unexpanded  or  foetal  state  of  the  organ,  but  in  others  there 
was  the  normal  inflation,  and  the  dark  color  was  due  to  engorgement  or  con- 
gestion. In  other  cases  the  lungs  are  stated  to  have  been  natural  except  the 
color.  In  9  emphysema  was  present  in  a  part  of  the  lungs,  in  2  pneumo- 
nitis ;  in  2  the  color  of  the  lungs  was  pale,  in  1  a  bright  crimson  ;  in  1  the 
lungs  were  larger  than  natural,  in  1  the  right  lung  was  absent,  and  in  17 
these  organs  were  recorded  healthy. 

I  have  records  of  the  state  of  the  liver  in  26  cases,  in  16  of  which  it  was 
enlarged,  and  in  4  of  these  it  was  congested.  Congestion  of  the  liver  was 
present  in  8  other'  cases  in  which  no  mention  is  made  of  its  volume.  The 
substance  of  the  liver  had  a  natural  appearance  in  9  cases,  but  in  some  of 
these  this  organ  was  enlarged.  From  these  statistics  it  is  probable  that  the 
liver  is  commonly  enlarged  in  cyanosis,  and  not  infrequently  congested.  In 
a  few  cases  the  condition  of  the  other  abdominal  viscera  is  mentioned — in 
.some  as  heathly,  in  others  as  congested.  Fifteen  examinations  of  the  brain 
were  made,  in  7  of  which  congestion  is  recorded,  and  in  3  abscesses  in  the 
cerebral  substance,  in  1  of  which  cases  the  lateral  ventricle  was  also  filled  with 
pus  ;  in  2  softening  of  a  portion  of  the  brain  had  occurred,  in  3  the  brain  was 
firm  or  compact,  in  3  the  quantity  of  fluid  in  the  cranial  cavity  exceeded  the 
normal  amount,  and  in  1  it  was  less  than  normal. 

Theories  relating  to  the  Etiology  of  Cyanosis. — Although  in  nearly  all 
cyanotic  patients  there  are  direct  communications  between  the  two  sides  of  the 
heart,  it  is  shown  by  many  observations  that  these  communications  or  apertures 
are  not  sufficient  in  themselves  to  produce  cyanosis.  This  opinion  was  expressed 
half  a  century  ago  by  Louis,  who  puljlished  an  excellent  monograph  on  the  subject 
of  these  communications,  basing  his  remarks  on  an  analysis  of  twenty  cases.  Since 
the  publication  of  this  paper  the  belief  has  been  pretty  general  in  the  profession — 
and  observations  continue  to  substantiate  it — that  although  the  apertures  may  be 
of  considerable  size,  if  the  two  sides  of  the  heart,  with  their  orifices  and  vessels,  are 
in  their  normal  state,  so  that  they  act  symmetrically  and  without  obstruction,  the 
blood  is  sufficiently  oxygenated  and  decarbonized,  and  cyanosis  does  not  occur.  In 
proof  of  the  correctness  of  this  opinion  many  cases  might  be  cited  of  a  pervious 
7 


98  DISEASES  OF  THE  NEWLY-BORN. 

and  some  of  a  largely  dilated  foramen  ovale  without  the  cyanotic  hue — cases  which 
have  been  published  in  the  journals  since  the  appearance  of  Louis's  monograph. 
Still,  in  cases  of  obstructive  malformation,  unless  the  obstruction  be  complete, 
cyanosis  is  more  likely  to  occur  in  consequence  of  these  apertures,  for  were  they 
absent  a  larger  amount  of  blood  would  be  propelled  through  the  narrow  orifice  of 
the  pulmonary  artery,  and  a  larger  amount  consequently  be  oxygenated. 

Allusion  has  already  been  made  to  the  two  theories  which  prevail  in  the  pro- 
fession :  the  one  attributing  the  non-oxygenation  of  the  blood  and  its  highly  venous 
character,  so  as  to  cause  the  cyanotic  hue,  to  the  intermingling  of  venous  and  arte- 
rial blood :  the  other  to  obstruction  at  the  centre  of  circulation,  and  consequent 
venous  congestion.  There  are  serious  objections  to  the  acceptance  of  either  theory 
as  an  explanation  of  all  cases.  That  admixture  of  the  two  kinds  of  blood  is  not 
essential  to  the  production  of  cyanosis  is  apparent  from  the  following  facts :  In  one 
case  in  the  Fourth  Malformation  there  was  no  communication  between  the  two  sides 
of  the  heart,  and  the  ductus  arteriosus  was  closed,  so  that  admixture  was  impossible. 
Again,  in  the  Eleventh  Malformation,  or  that  in  which  the  aorta  and  pulmonary 
artery  are  transposed,  the  blue  disease  evidently  does  not  depend  on  the  admixture 
of  the  two  currents.  On  the  other  hand,  in  this  curious  state  of  the  heart  the  more 
the  admixture  the  less  the  cyanosis,  since  the  only  way  in  which  the  systemic 
current  of  blood  can  be  oxygenated  is  by  passing  to  the  opposite  side  of  the  heart. 
An  argument  against  this  doctrine  may  also  be  found  in  the  fact  that  the  modes 
of  compensation  are  not  such  as  in  any  way  to  diminish  or  obviate  the  admixture. 
It  is  admitted  that  in  the  more  frequent  malformations  cyanosis  is  increased  by  the 
apertures  which  allow  the  intermingling  of  the  venous  and  arterial  currents,  but 
it  is  more  reasonable  to  consider  the  intermingling  and  the  cyanosis  as  the  direct 
results  of  the  malformation,  neither  having  the  precedence  of  the  other,  than  to 
consider  that  they  are  related  to  each  other  as  cause  and  effect  or  as  proximate  and 
remote  results.  Viewed  in  this  light,  the  admixture  must  be  considered  simply  a 
concomitant  of  the  cyanosis. 

The  second  theory,  that  of  venous  congestion,  has  numbered  among  its  advocates 
many  who  have  given  special  attention  to  the  subject,  as  Morgagni,  Louis,  and 
Stille,  but  it  seems  to  have  even  less  claim  for  acceptance  than  the  theory  of  admix- 
ture. It  has  been  seen  that  in  nearly  all  cases'of  cyanosis  the  two  sides  of  the  heart 
communicate  freely,  so  that  if  the  current  of  blood  meets  with  an  obstruction,  as  it 
commonly  does,  it  readily  escapes  to  the  opposite  side,  Avhere  the  artery  is  large  and 
gives  it  free  passage.  In  this  way  congestion,  if  not  prevented,  is  greatly  dimin- 
ished. Again,  it  will  be  seen  that,  although  certain  of  the  viscera  are  frequently 
found  at  the  autopsy  more  or  less  congested,  congestion  is  not  uniformly  present 
in  the  organs,  as  it  would  probably  be  were  it  the  proximate  cause  in  all  cases  of 
cyanosis. 

Moreover,  in  some  patients  the  malformation  is  not  obstructive.  The  cavities 
and  their  orifices  are  of  the  normal  size,  and  cyanosis  is  due  entirely  to  malposition 
of  the  vessels.  It  cannot  be  said  that  in  these  cases  there  is  venous  congestion  from, 
arrest  at  the  centre  of  circulation.  If  there  be  any  congestion,  it  must  be  due  to 
the  fact  that  venous  blood  does  not  circulate  as  readily  as  the  arterial  in  the  capil- 
laries. It  is  true  that  in  the  paroxysms  of  dyspnoea  there  is  sometimes  more  or 
less  congestion — the  distention  of  the  jugulars  shows  this — but  it  subsides  with  the 
paroxysms,  and  it  probably  is  no  more  than  usually  occurs  when  respiration  is 
greatly  embarrassed. 

In  fine,  attempts  to  express  the  immediate  pathological  state  producing  cyanosis 
in  the  terms  of  a  general  law  have  failed.  However  plausible  the  above  theories 
may  appear  in  regard  to  certain  cases,  there  are  others  to  which  they  are  manifestly 
inapplicable.  Those  who  advocate  these  theories  seem  to  lose  sight  of  the  obvious 
fact  that  the  chief  want  of  the  economy  in  cyanosis  is  decarbonization  of  the  blood, 
and  it  is  hardly  supposable  that  there  can  be  any  correct  theory  of  its  causation 
which  is  not  founded  on  this  fact.  With  this  physiological  state  in  view,  it  does 
not  seem  difficult  to  express  a  theory  in  comprehensive  terms  which  is  applicable  to 
all  cases,  such  as  the  following :  Cyanosis  is  due  to  malformations  of  the  heart  and 
the  great  vessels  in  immediate  relation  with  the  heart,  which  prevent  the  proper 
flow  of  blood  to  and  from  the  lungs,  so  that  the  oxygenation  and  decarbonization 
of  this  fluid  are  inadequate.  So  comprehensive  a  statement  includes  not  only  cases 
of  malformation  and  malposition  of  the  heart  and  its  vessels,  but  also  those  few 
cases  in  which  the  lungs  are  in  fault.     In  most  patients,  as  we  have  seen,  the  cur- 


MALFORMATIONS.  99 

rent  of  blood  toward  the  lungs  is  obstructed,  and  the  current  of  blood  from  the 
lungs  is  obstructed  in  those  comparatively  rare  cases  in  which  the  malformation  is 
on  the  left  side. 

Treatment. — From  the  nature  of  cyanosis  it  is  evident  that  the  treat- 
ment should  he  more  hygienic  than  medicinal.  The  patient  should  be  warm- 
ly clad  and  kept  in  a  warm  room,  and  all  agencies  calculated  to  embarrass  or 
disturb  the  functions  of  the  body  or  excite  the  emotions,  and  thereby  accel- 
erate the  heart's  action,  should  be  studiously  avoided.  The  diet  should  be 
nutritious,  but  simple  and  easily  digested. 

Those  who  have  attributed  cyanosis  wholly  to  apertures  in  the  inter- 
auricular  and  interventricular  septa,  and  the  consequent  flow  of  blood  from  the 
right  to  the  left  side  of  the  heart,  have  considered  it  an  important  part  of 
the  treatment  to  keep  the  patient  reclining  on  the  right  side,  so  as  to  dimin- 
ish this  flow  by  the  effect  of  gravitation.  The  reader,  however,  must  be 
convinced  from  the  nature  of  the  malformations  that  little  benefit  can  accrue 
from  following  such  advice.  Still,  patients  are  sometimes  less  cyanotic  and 
more  comfortable  in  one  position  than  in  another. 

In  a  case  reported  by  Mr.  Howslip^  "the  only  easy  and  indeed  comfortable 
position  in  which  the  child  could  remain  was  that  usual  in  nursing.  When  erect 
the  dusky  color  of  the  face  and  neck  became  a  dark-blue."  In  a  case  related  by 
Mr.  Spackman  ^  the  patient  was  easiest  on  the  hands  and  knees.  Louis  reports  a 
case  *  in  which  the  selected  position  was  with  the  head  elevated ;  Wm.  Hunter  a 
case*  in  which  the  patient  avoided  paroxysms  by  lying  on  the  left  side.  Struthers 
and  King  each  report  a  case  in  which  the  patient  seemed  most  comfortable  while 
lying  on  the  right  side;^  but,  on  the  other  hand.  Professor  White  of  Buffalo®  and 
Dr.  James  Carson '  report  cases  in  which  position  on  the  right  side  failed  to  pro- 
duce any  alleviation  of  symptoms.  Other  similar  observations  might  be  cited,  but 
enough  have  been  mentioned  to  show  that  no  one  position  should  be  recommended 
for  cyanotic  patients.  Some  obtain  most  relief  by  lying  oh  the  back,  others  on  the 
right  side,  others  on  the  left ;  some  when  on  the  hands  and  knees,  some  when  reclin- 
ing on  either  side  indifferently,  while,  finally,  others  suffer  least  when  erect. 

There  was  a  time  when  the  paroxysms  were  treated  by  venesection,  but 
depletion  has  long  since  been  abandoned.  Physicians  now  rely  on  stimu- 
lants, antispasmodics,  friction  to  the  chest,  and  mustard  pediluvia  to  relieve 
the  urgent  symptoms,  although  this  treatment  is  but  partially  successful. 
It  is  probable  that  of  all  internal  remedies  digitalis  is  the  most  useful,  from 
the  fact  that  it  is  an  efficient  heart-tonic  and  more  than  any  other  medicine 
gives  strength  and  equality  to  the  heart-beats.  In  the  cities  where  oxygen 
gas  can  be  procured  for  daily  inhalation  the  urgent  symptoms  may  in  some 
instances  be  partially  relieved  by  the  use  of  this  agent. 

Caput  Succedaneum. 

During  the  birth  of  the  child  extravasation  of  blood  frequently  occurs 
in  the  part  of  the  scalp  which  presents.  It  results  from  the  passive  conges- 
tion which  occurs  in  presenting  parts,  and  is  greatest  in  amount  when  the 
labor  has  been  protracted  and  the  labor-pains  unusually  severe.  Caput  snc- 
cedaneum  is  the  term  employed  to  designate  the  swelling  thus  produced.  Its 
seat  is  in  the  loose  connective  tissue  between  the  scalp  and  pericranium,  and 
it  consists  partly  of  extravasated  blood,  but  largely  of  serum  which  has 
transuded  from  the  congested  vessels  before  that  degree  of  congestion 
required  to   affect  the  transudation   of  corpuscles  or  rupture  of  capillaries 

1  Edin.  Med.  Journ.,  1813.  ^  Land.  Med.  Gaz.,  1833. 

^  -De  la  Commun.  des  Cav.,  etc.  *  Med.  Obs.  and  JEnq.,  vol.  vi. 

*  Monthly  Journ.  of  Med.  Sci.  ®  Buf.  Med.  Journ.,  1855. 

^  Amer.  Journ.  of  Med.  Soi.,  1857. 


100  .  DISEASES  OF  THE  NEWLY-BORN. 

was  reached.  I  have  repeatedly  had  an  opportunity  to  examine  this  tumor 
in  stillborn  infants,  and  have  found  when  it  was  slight  that  it  consisted  almost 
entirely  of  serum,  but  ordinarily  when  dissected  it  presented  the  appearance 
of  a  bruise,  with  a  large  proportion  of  serum,  the  blood  and  serum  infiltrat- 
ing the  scalp  to  a  greater  or  less  distance  beyond  the  appreciable  limits  of 
the  tumor.  Caput  succedaneum  requires  no  treatment.  As  it  lies  in  the 
loose  connective  tissue  -^f  the  scalp,  its  liquid  permeates  the  open  interspaces 
in  this  tissue  in  every  direction,  and  is  rapidly  absorbed,  with  the  disappear- 
ance of  the  tumor.  Its  subsidence  is  usually  complete  within  twenty-four 
hours. 

C  ephalhsematoma. 

Occasionally  during  birth  blood  is  extravasated  under  the  pericranium, 
detaching  it  from  the  bone.  This  commonly  occurs  in  connection  with  caput 
succedaneum,  and  is  observed  when  the  latter  declines.  Its  common  seat  is 
upon  the  occipital  or  parietal  bone,  near  the  posterior  fontanel,  most  fre- 
quently upon  the  parietal,  where  the  pressure  during  labor  is  greatest.  Prof. 
Henoch  states  that  the  tumor  does  not  obtain  its  maximum  size  immediately, 
but  gradually  increases  by  the  continued  escape  of  blood  until  the  third  day. 
The  tumor  may  extend  over  the  entire  surface  of  the  bone,  but  it  does  not 
pass  beyond  the  suture.  Cases  of  bilateral  cephalhaematoma  have  been 
reported,  but  they  are  rare.  The  tumor  is  fluctuating,  and  the  skin  covering 
it  has  the  normal  appearance  or  a  bluish  tinge,  or  it  may  exhibit  infiltrations 
of  blood  like  a  bruise.  Since  the  pericranium  elevated  by  the  blood  does  not 
lose  its  vitality,  it  begins  to  secrete  from  its  under  surface  preparatory  to  the 
formation  of  bone.  In  a  few  days  we  are  able  to  detect  by  pressure  with 
the  fingers  a  hard  projecting  rim  at  the  border  of  the  tumor,  the  result  of 
the  secretion  and  bony  formation  at  the  point  where  the  pericranium  is 
in  part  detached  and  in  part  adherent.  If  the  tumor  is  tense,  we  are  unable 
to  detect  the  bone  underneath  by  pressure,  and  the  hard  elevated  rim  resem- 
bles the  edge  of  an  opening  in  the  skull.  The  cephalhasmatoma  when  not 
disturbed  apparently  causes  little  or  no  sufl^ering,  but  the  infant  evinces  pain 
if  pressure  be  made  upon  it.  Usually  in  the  second  week  absorption  is  so  far 
advanced  that  the  tumor  is  less  tense,  and  on  pressure  the  bone  can  be  felt 
underneath  it.  Complete  absorption  of  the  blood  which  has  remained  liquid 
usually  occurs  in  four  or  five  weeks. 

Not  infrequently,  when  absorption  occurs  slowly,  a  thin  layer  of  bony 
substance  forms  in  a  few  weeks  on  the  under  surface  of  the  pericranium. 
This  causes  a  creaking  sound  when  pressure  is  made  upon  it.  In  a  case  in  my 
practice  the  child  died  about  two  months  after  birth,  and  the  blood  constitu- 
ting the  tumor,  which  had  been  in  great  part  absorbed,  was  completely  encased 
by  the  old  bone  below  and  the  new  bony  formation  above.  As  the  blood 
becomes  absorbed  the  pericranium,  having  perhaps  a  bony  formation  on  its 
under  surface,  gradually  sinks ;  the  cavity  at  length  becomes  obliterated  ; 
and  there  only  remains  some  thickening  of  that  part  of  the  cranium  which 
corresponds  with  the  site  of  the  tumor. 

A  cephalhaematoma  might  be  mistaken  by  the  inexperienced  for  a  con- 
genital meningocele,  since  the  ridge  described  above  which  forms  along  its 
border  resembles  so  closely  the  edge  of  an  opening,  and  both  tumors  are 
fluctuating ;  but  a  meningocele  rarely  occurs  upon  the  part  of  the  head 
occupied  by  the  cephalhgematoma ;  and  if  there  be  any  doubt  in  the  diagnosis 
at  first,  it  will  be  dispelled  in  a  few  days  by  the  changes  which  it  undergoes. 

The  TREATMENT  should  be  expectant,  except  that  a  soft  covering  of  cot- 
ton should  be  placed  over  the  tumor  to  prevent  injury.  Neither  incision  nor 
aspiration  is  advisable. 


HEMATOMA   OF  THE  STEBNO-CLEIBO-MASTOID  MUSCLE.       101 


CHAPTER    II. 

LOCAL  DISEASES. 

Haematoma  of  the  Sterno-cleido-mastoid  Muscle. 

We  sometimes  observe  in  infants,  usually  between  tlie  ages  of  one  and 
six  weeks,  a  hard  tumor  upon  the  antero-lateral  aspect  of  the  neck  cor- 
responding to  the  site  of  the  sterno-cleido-mastoid  muscle,  and  evidently 
developed  in  this  muscle,  It  is  round  or  more  frequently  elongated,  varying 
from  the  size  and  shape  of  a  pi|-eon's  egg  to  that  of  the  little  finger,  occupy- 
ing the  anterior  border  of  the  muscle.  Sometimes  the  tumor,  hard  like 
cartilage  to  the  touch,  extends  over  the  anterior  half  of  the  muscle ;  and  it 
is  stated  to  occur  more  frequently  in  the  right  than  in  the  left  muscle.  Prof. 
Henoch  observed  it  on  the  right  side  in  16  cases  and  on  the  left  side  in  5 
cases. 

The  following  was  a  typical  case:  On  July  19,  1887,  I  attended  Mrs.  S ,  a 

primipara,  in  her  confinement.  Her  labor,  which  was  tedious,  was  terminated  by 
the  forceps,  without  any  appreciable  injury  of  mother  or  child.  About  one  month 
after  her  confinement  the  mother  stated  that  she  had  observed  during  the  last  two 
weeks  an  unusual  swelling  passing  obliquely  along  the  side  of  the  neck  of  the  child. 
I  found  the  anterior  portion  of  the  sterno-cleido-mastoid  muscle  thickened  and 
hard  from  a  point  about  tAvo  lines  above  its  lower  attachment  nearly  its  entire 
length.  The  swelling  was  of  the  size  and  shape  of  the  little  finger  of  a  child  of 
twelve  years.  It  was  tender  to  the  touch,  never  had  been  red,  and  the  infant's  con- 
dition was  normal  in  every  other  respect.  At  the  age  of  nine  weeks  the  tumor  was 
still  appreciable,  but  had  nearly  disappeared.  Sometimes  the  tumor  is  not  continu- 
ous, but  the  muscle  is  thickened  and  hardened  in  two  or  three  different  places. 
Occasionally  the  child's  head  is  turned  to  one  side,  either  from  the  pain  in  holding 
it  erect  or  because  the  function  of  the  muscle  is  impaired. 

The  ETIOLOGY  and  nature  of  this  tumor  are  apparent  from  the  history. 
In  a  majority  of  the  cases  the  birth  of  the  infants  affected  with  this  ailment 
is  tedious,  and  in  many  the  presentation  at  birth  is  abnormal.  This  tumor 
is  especially  liable  to  occur  after  breech  presentations,  which  necessitate  trac- 
tion upon  the  neck.  In  head  presentations,  when  there  is  delay  in  liberating 
the  shoulders  and  traction  is  made  on  the  head,  and  especially  if  forcible 
rotation  is  made,  the  more  superficial  and  exposed  fibres  in  the  sterno-cleido- 
mastoid  muscle  are  liable  to  rupture  ;  and  when  this  occurs  a  local  myositis 
results,  causing  the  tenderness,  infiltration,  and  swelling.  Certain  writers 
state  that  more  or  less  extravasation  of  blood  takes  place  at  the  time  of  the 
accident  and  before  the  inflammation  supervenes,  and  hence  the  term  "  haema- 
toma  "  which  has  been  employed  to  designate  the  disease. 

The  PROGNOSIS  is  good.  Suppuration  does  not  occur  unless  under  very 
unusual  circumstances,  and,  though  probably  more  or  less  cicatricial  tissue 
results  at  the  seat  of  injury,  the  function  of  the  muscle  is  not  appreciably 
impaired  when  the  inflammation  and  swelling  abate.  No.  perceptible  contrac- 
tion or  deformity  results. 

But  little  TREATMENT  is  required  ;  indeed,  patients  do  well  without  treat- 
ment. But  it  is  best  for  the  infant  that  it  maintain  so  far  as  possible  a  hori- 
zontal position,  with  the  head  resting  on  a  pillow  and  with  the  avoidance  of 
rotation  so  long  as  the  disease  is  in  its  active  state  and  the  tumor  is  tender 
to  the  touch.  Probably  cool  lotions  recommended  by  some  are  as  likely  to 
do  harm  as  benefit  by  giving  cold  to  the  child  and  producing  nasal  or  other 


102  DISEASES  OF  THE  NEWLY-BORN. 

catarrhs.     Inunction  with  an  ointment  of  iodide  of  potassium  has  been  recom- 
mended for  the  purpose  of  promoting  absorption,  as  the  following : 

R.  lodidi  potass., 

Aquae,  da.  1  part ; 
Adipis,  2  parts ; 

Lanolin,  6-8  parts. 

But  without  this  treatment  absorption  is  progressive  and  cure  complete  within 
a  few  weeks. 

Mastitis. 

In  newly-born  infants  the  secretion  of  a  milk-like  substance  begins  at  about 
the  fourth  day  in  the  mammary  glands.  It  increases  until  the  tenth  day,  when 
it  gradually  diminishes,  and  disappears  at  about  the  twentieth  day.  It  is 
attended  with  some  swelling  of  the  glands  dilring  the  period  of  their  activity, 
and  after  the  secretion  ceases  the  enlai'gement  gradually  abates.  A  section 
of  the  gland  in  which  this  secretion  has  occurred,  made  near  the  surface, 
shows  epithelium.  At  a  greater  depth  the  canals  enlarge,  divide,  and  end  in 
cavities  which  are  filled  with  a  liquid  having  the  appearance  and  character 
of  colostrum.  This  glandular  activity,  it  is  said,  may  begin  before  birth,  and 
continue  six  or  eight  weeks  after  birth,  but  the  period  of  greatest  enlarge- 
ment and  most  active  secretion  of  the  gland  is  usually  between  the  fourth 
and  tenth  days  after  birth,  as  stated  above. 

In  exceptional  instances  the  enlargement  of  the  gland  and  its  functional 
activity  result  more  seriously.  The  gland  becomes  inflamed,  and  an  abscess 
may  occur  as  in  the  adult  female.  The  nurse  may  produce  this  result  by 
rubbing  and  pressing  the  gland,  so  that  rude  manipulation  of  it  should  be 
avoided.  An  abscess  destroys  the  gland-structure,  which  is  a  serious  result 
if  the  infant  be  a  female. 

M.  Bouchut,  in  his  practical  treatise  on  diseases  of  the  newly -born  (p.  719,  1867), 
relates  a  fatal  case  of  mastitis  in  which  the  inflammation  extended  to  the  connective 
tissue,  and  ulceration  so  extensive  occurred  that  the  pectoral  muscle  was  exposed, 
and  death  resulted  from  prostration.     Jacobi  has  observed  similar  cases.^ 

Therefore  in  treating  the  enlarged  and  secreting  gland  of  early  infancy 
very  gentle  and  unirritating  measures  should  be  employed,  so  that  mastitis 
may,  if  possible,  be  prevented.  The  dress  should  be  loose,  so  as  to  avoid 
pressure  on  the  gland.  If  no  inflammation,  or  inflammation  in  its  commence- 
ment, be  present,  absorbent  cotton  or  cotton  soaked  with  sweet  oil  should  be 
applied,  and  covered  with  oil  silk.  It  is  proper  also  to  apply  a  mild  lead  wash 
to  the  enlarged  mammary  gland,  especially  if  it  be  hot.  If  it  be  indolent, 
iodide  of  potassium  in  glycerin,  one  part  of  the  former  to  ten  of  the  latter, 
may  be  used.  If  the  gland  be  hot,  and  especially  if  it  be  red,  a  soft  emol- 
lient poultice  should  be  applied,  as  of.  bread  and  milk  or  flaxseed  and  water. 
If,  unfortunately,  suppuration  occur,  an  early  incision  should  be  made  as  far 
as  possible  from  the  nipple.  In  the  subsequent  treatment  mild  antiseptic 
washes,  as  boric  acid  or  listerine  and  water,  should  be  used.  Corrosive  sub- 
limate should  not  be  employed,  as  young  infants  are  readily  poisoned  by  it, 
and,  for  the  same  reason,  carbolic  acid  should  not  be  used  or  be  used  in  a  very 
weak  solution.  Iodoform  should  also  not  be  used,  or  used  largely  diluted  by 
the  addition  of  starch. 

Conjunctivitis. 

Diff'erent  forms  of  conjunctival  inflammation  occur  in  the  newly-born.  In 
the  mildest  variety  no  appreciable  swelling  of  the  lids  occurs,  and  only  a  little 
viscid  secretion  collects  between  the  lids,  which  agglutinates  them  in  sleep, 

^  Archives  of  Pediatrics,  March,  1888. 


OPHTHALMIA  NEONATORUM.  103 

and  which  the  nurse  readily  removes  by  bathing  them  with  tepid  water  or 
milk  and  water,  and  in  a  few  days  effects  a  cure.  On  the  other  hand,  the 
purulent  form  of  conjunctivitis,  which  is  observed  on  the  second  or  third  day 
after  birth,  and  which  arises  from  the  reception  between  the  lids  of  the  vagi- 
nal secretion  of  the  mother,  always  involves  great  danger  to  the  eye,  speedily 
producing  opacity  or  destruction  of  the  cornea,  unless  promptly  and  properly 
treated.  Between  these  two  extremes  conjunctivitis  neonatorum  occurs  in 
different  grades  of  severity. 

Mild  or  Catarrhal  Conjunctivitis. — This,  as  the  name  indicates,  is  a  simple 
catarrh,  attended,  as  stated  above,  by  a  slight  viscid  secretion  from  the  lids 
and  by  little  or  no  swelling.  The  secretion  collects  in  the  angles  of  the  lids 
and  along  their  margin.  This  mild  conjunctivitis  requires  very  simple  treat- 
ment. Warm  water  or  milk  and  water  should  be  gently  applied  by  a  large 
camel's-hair  pencil,  so  as  to  wash  away  the  secretion  as  soon  as  it  forms,  and 
sweet  oil  or  vaseline  should  then  be  applied  between  the  lids.  With  these 
simple  measures  this  mild  conjunctivitis  disappears  in  a  few  days. 

If  the  secretion  be  more  abundant  and  the  lids  perceptibly  swollen,  more 
active  measures  are  required. 

Prof.  Noyes  states  that  there  is  a  variety  of  catarrhal  ophthalmia  neonatorum 
which  requires  active  treatment.  In  the  cases  alluded  to  the  ocular  surface  is  but 
slightly  involved,  having  little  or  no  hypersemia,  but  the  palpebral  conjunctiva  is 
hypersemic  and  the  fornix  thickened  and  swollen.  The  swelling  of  the  fornix  is  the 
most  marked  anatomical  character.  The  secretion  has  a  watery  appearance,  and 
the  lids  are  but  slightly  tumefied.  The  cornea  does  not  become  hazy  and  the  sight 
is  not  impaired,  but  the  watery  discharge  and  the  viscid  secretion  on  the  borders 
of  the  lids  continue  for  weeks,  unless  the  case  be  promptly  attended  to.  Noyes 
recommends  for  this  form  of  catarrhal  ophthalmia  neonatorum  the  application  sev- 
eral times  daily  of  the  boric-acid  solution : 

R.  Acidi  borici,  gr.  xv  ; 

Aquse  destillat.,        §j. — M. 

He  adds  :  "  But  if  a  child  is  a  month  old  and  the  discharge  continue,  and  the  fornix 
exhibit  decided  swelling,  I  have  been  obliged  to  use  solutions  of  tannin  and  glycerin 
as  strong  as  Qij  ad  5J  before  the  condition  would  yield.  I  had  tried  nitrate  of 
silver  in  mild  solution,  and,  unwilling  to  make  it  more  caustic,  had  taken  a  solution 
of  tannin  gr.  x  ad  glycerinum  §j,  but  this  had  only  a  temporary  good  efiect,  and 
the  disease  was  not  subdued  until  the  strong  solution  was  applied.  It  was  done 
every  second  day  to  the  everted  lid,  and  was  of  course  quite  painful." 

Purulent  Ophthalmia  Neonatorum;  Gonorrhceal  Ophthalmia  Neonato- 
rum.— This  is  one  of  the  most  important  diseases  to  which  the  neonati  are 
liable,  since,  if  not  promptly  and  properly  treated,  it  is  very  damaging  to  the 
eye,  permanently  impairing  or  totally  destroying  vision.  It  is  produced  by 
the  lodgement  in  the  eye  of  irritating  matter,  usually  the  gonorrlaoeal  vaginal 
secretion  of  the  mother.  A  minute  amount  of  the  virulent  matter  is  sufficient 
to  set  up  the  inflammation.  Recent  observations  seem  to  show  that  in  a  con- 
siderable number  of  cases  the  poisonous  matter  is  received,  not  during  birth, 
but  in  the  washing,  or  subsequently  from  the  fingers  of  the  nurse  or  mother, 
or  through  the  medium  of  soiled  towels  or  linen. 

Andrews  [Neiv  York  Medical  Journal^  1886)  quotes  the  following  table  from 
Theremin,  showing  the  time  of  commencement  in  476  cases,  as  follows : 

First  to  fourth  day  after  birtli 57  cases. 

Fourth  to  eighth  day  after  birth 134      " 

Eighth  to  fourteenth  day  after  birth    . 94      " 

Later 104     " 


104  DISEASES  OF  THE  NEWLY-BOBN. 

When  the  disease  begins  subsequently  to  the  first  week  after  birth,  it  is  evi- 
dent that  the  infection  occurs  post-natum,  the  poison  being  conveyed  to  the 
eyes  through  the  soiled  fingers  or  sponges  or  cloths  employed  in  the  nursery, 
as  stated  above. 

Gonorrhoeal  ophthalmia  neonatorum,  as  well  as  gonorrhoeal  inflammation 
in  other  parts,  is  caused  by  a  micrococcus  designated  the  gonococcus.  It 
occurs  free  and  also  enclosed  in  leucocytes  in  the  various  inflammations 
resulting  from  gonorrhcea,  as  well  as  in  the  secretions  of  gonorrhoea.  It 
occurs,  therefore,  in  the  ovarian,  perimetritic,  tubal,  arthritic,  and  conjunc- 
tival secretions  and  exudates  having  a  gonorrhoeal  origin,  as  well  as  upon  the 
surfaces   primarily  aff"ected  with   gonorrhcea.     The   gonococcus   is   generally 

FiC4.  10.  Fig.  11. 


Gonococci  free.  Gonococci  within  a  leucocyte. 

most  abundant  during  the  active  stage  of  the  inflammation,  and  not  infre- 
quently it  is  associated  with  pyogenic  cocci. 

In  acute  gonorrhoea  usually  no  other  or  but  few  other  bacteria  except  the 
gonococcus  are  observed ;  but  in  chronic  gonorrhoea  of  both  sexes  other 
microbes  are  commonly  present  in  addition  to  the  gonococcus.  That  the 
contagious  and  virulent  property  of  gonorrhoeal  pus  is  due  to  the  gonococcus 
seems  to  be  fully  established,  but  were  the  action  of  this  organism  limited 
to  cases  of  gonorrhoea,  it  would  be  less  important  as  a  pathological  factor. 
Microscopic  examinations  show  its  presence  in  the  pus  of  ophthalmia  neona- 
torum, as  well  as  in  the  vulvitis  of  childhood  when  of  gonorrhoeal  origin, 
and  the  intense  inflammation  and  rapid  destruction  of  sight  in  the  former 
disease  are  believed  to  be  due  entirely  to  its  agency. 

Dr.  Gayet,  professor  of  ophthalmic  surgery,  Lyons,  France,  says  that  the  detec- 
tion of  the  gonococcus  in  infected  pus  is  as  simple  and  easy  as  that  of  albumen  in 
albuminuria.  He  places  a  particle  of  pus  on  a  glass  slide,  covers  it  by  another  slide, 
and  presses  the  two  together.  They  are  then  separated,  and  stained  by  dropping 
on  them  an  alcoholic  solution  of  methyl-blue  mixed  with  an  equal  quantity  of  water. 
After  two  minutes  the  slides  are  washed  freely  with  water,  and  each  leucocyte  is 
seen  to  have  two,  three,  or  four  nuclei,  "  this  being  a  special  character  of  the  disease, 
the  increase  in  the  number  of  nuclei  heralding  the  approach  of  the  gonococci,  which 
will  be  observed  as  intensely  blue  spherical  bodies  in  the  interior  of  some  of  the 
leucocytes."  ^  If  the  gonococcus  be  found  in  a  single  leucocyte,  of  course  the  diag- 
nosis is  established. 

Stellwagon  says  :  "  The  period  of  incubation  after  successful  inoculation  of  the 
contagious  material  varies  between  some  hours  and  days.  The  outbreak  of  the 
blennorrhoea  follows  the  more  quickly  the  more  favorable  are  the  conditions  for 
the  inoculation — i.  e.  the  more  powerfully  the  secretion  is  able  to  act." 

In  most  instances  when  infection  occurs  during  birth  some  evidence  of  the 
disease  appears  as  early  as  the  second  or  third  day.  The  inflammation  is  from 
the  first  severe.     The  conjunctiva,  ocular  and  palpebral,  is  intensely  hyper- 

^ La  Province  medicale;  Lond.  Lancet,  June  IS,  1887. 


OPHTHALMIA  NEONATORUM.  105 

semie;  chemosis  soon  occurs  in  most  instances,  and  an  abundant  muco-purulent 
or  purulent  secretion  flows  between  the  lids  mixed  with  tears.  The  inflam- 
matory hyperemia  not  only  extends  over  the  entire  conjunctiva,  but  also  to 
the  connective  tissue  and  the  integument  of  the  lids,  causing  in  the  latter  a 
dusky  or  bluish-red  tint.  At  a  later  stage  the  tint  may  be  yellowish-red.  The 
eyelids  swell  rapidly  in  consequence  of  the  looseness  of  their  connective  tissue 
and  the  great  amount  of  infiltration,  so  that  they  appear  as  projecting  tumors 
pressing  against  each  other  and  upon  the  eye,  concealing  the  latter  from  view. 
The  ocular  conjunctiva,  from  the  great  amount  of  serous  exudation  under- 
neath, rises  up  like  a  circular  wall  around  the  cornea,  which  appears  sunken 
in  the  centre  of  the  swelling,  and  sometimes  only  its  central  part  is  visible  in 
consequence  of  the  bulging  of  the  swollen  conjunctiva  over  it.  The  palpe- 
bral conjunctiva  is  so  swollen  from  the  serous  infiltration  that  it  bulges  for- 
ward on  attempting  to  separate  the  lids,  and  eversion  of  them  is  liable  to 
occur.  From  the  great  amount  of  tumefaction  of  the  lids  the  palpebral  fis- 
sure is  closed,  and  the  upper  lid  may  project  over  the  lower  so  as  to  nearly 
cover  it. 

The  danger  to  the  eye  results  chiefly  from  the  chemosis,  or  hard  and  tense 
oedema,  of  the  subconjunctival  areolar  tissue,  which  by  its  pressure  may  ob- 
struct circulation.  The  eye  is  photophobic,  tender  to  the  touch,  and  the  seat 
of  severe  pain.  The  intensity  of  the  inflammation  gives  rise  to  active  fever. 
The  inflammation,  having  reached  its  maximum,  soon  begins  to  abate  under 
correct  treatment ;  the  bright-red  erysipelatous  hue  of  the  lids  changes  to  a 
bluish  color  ;  the  heat  and  tenderness  abate.  The  secretion  is  abundant,  and 
is  constantly  escaping  from  the  conjunctival  sac  and  flowing  over  the  cheek, 
which  is  often  reddened  in  consequence  of  its  extreme  acridity.  If  in  the 
height  of  the  inflammation  we  attempt  to  separate  the  lids,  which  are  firmly 
pressed  together  not  only  in  consequence  of  the  great  amount  of  tumefac- 
tion, but  also  fi'om  the  spasmodic  contraction  of  the  orbicularis  palpebrarum, 
the  purulent  secretion  gushes  forth,  consisting  of  greenish  or  grayish  pus — 
a  thick  liquid  containing  flocculi  of  epithelial  cells  and  muco-pus.  Occasion- 
ally, when  the  inflammation  is  intense,  these  flocculi  contain  also  fibrin.  The 
discharge,  consisting  chiefly  of  muco-pus  mixed  with  tears,  has  a  creamy 
appearance,  but  if  the  lachrymation  be  abundant  it  may  resemble  whey  in 
color  and  consistence,  especially  in  the  declining  stage. 

Purulent  conjunctivitis  usually  begins  in  one  eye,  and,  unless  the  sound 
eye  be  immediately  and  efilciently  protected,  the  inflammation  ordinarily  soon 
attacks  this  eye.  Of  course  both  eyes  may  be  simultaneously  afi"ected,  but 
in  a  large  proportion  of  patients  there  is  an  interval  of  a  day  or  two  in  the 
commencement  of  the  inflammation  in  the  two  eyes,  that  secondarily  infected 
receiving  the  virus  from  the  one  first  attacked. 

In  the  milder  cases  the  inflammatory  symptoms,  the  hyperaemia,  tumefac- 
tion, heat,  and  secretion,  increase  gradually,  and  it  is  not  until  the  fifth  or 
sixth  day  that  they  attain  their  maximum.  In  severe  cases  the  symptoms 
reach  their  height  by  the  close  of  the  second  or  third  day.  The  inflamma- 
tion, having  attained  its  maximum,  as  indicated  by  the  heat,  swelling,  and 
abundant  secretion  which  wells  up  between  the  lids,  soon  begins  to  abate 
under  correct  treatment.  But  several  weeks  elapse  before  the  normal  state  is 
restored,  a  simple  catarrhal  inflammation  continuing  after  the  purulent  and 
infective  secretion  has  ceased. 

Prognosis. — The  danger  to  the  eye  depends  upon  the  severity  of  the 
inflammation.  If  the  chemosis  be  not  great,  and  the  swelling  be  more  oede- 
matous  than  indurated,  and  the  amount  of  secretion  moderate,  the  eye  is 
usually  saved  by  timely  and  correct  treatment.  In  severe  inflammation 
characterized  by  great  chemosis,  hyperaemia  and  heat,  and  an  abundant  puru- 


106  DISEASES  OF  THE  NEWLY-BOBN. 

lent  discliarge,  the  peril  to  the  eye  is  imminent,  since  the  inflammation  is 
likely  to  extend  from  the  conjunctiva  to  the  cornea,  and  ulceration  result. 
"When  the  cornea  becomes  cloudy  in  places  the  danger  to  the  eye  is  extreme, 
but  the  sight  may  be  preserved,  though  abscesses  and  ulcers  occur,  provided 
that  they  are  small  and  involve  only  a  part  of  the  cornea.  Abscesses  and 
ulcers  near  the  margin  of  the  cornea  are  less  dangerous  than  those  in  the 
centre,  but  crescentic  peripheral  ulcers  are  of  bad  import,  since  they  are 
likely  to  increase.  If  marginal  softening  and  a  central  abscess  or  ulcer 
coexist,  the  sight  will  probably  be  lost.  Of  course  the  more  quickly  the 
inflammation  is  subdued  the  better  the  prognosis. 

At  a  meeting  of  the  Blind  Congress,  held  in  Paris  in  1879,  F.  Dumas  stated  that 
of  1178  blind  patients  whom  he  had  treated,  1070  became  blind  from  curable 
diseases,  and  of  this  number,  817,  or  69  per  cent.,  lost  their  sight  from  ophthalmia 
neonatorum. 

According  to  Horner,  of  the  blind  children  treated  in  the  institutions  of  Ger- 
many and  Austria,  from  20  to  79  per  cent,  lost  their  sight  from  this  disease.^  This 
was  Jjefore  the  efficient  prophylactic  measures  now  in  use  were  employed. 

Prevextion. — Inasmuch  as  this  malady  is  produced  by  the  infective 
vaginal  secretion  of  the  mother  coming  in  contact  with  the  eye  of  the  infant 
at  birth,  the  use  by  the  mother  of  antiseptic  and  disinfectant  vaginal  douches 
before  and  during  parturition  is  suggested  as  the  appropriate  preventive 
treatment  in  case  she  have  a  muco-purulent  discharge.  For  this  purpose 
carbolized  vaginal  injections  have  been  employed,  with  the  result  of  diminish- 
ing the  number  of  cases  of  ophthalmia  neonatorum. 

Mules  ^  advises  the  following  very  judicious  and  important  preventive  measures: 
''  1st.  Cure  all  cases  of  chronic  vaginal  discharge  before  labor.  2d.  Irrigation  of 
the  vagina  during  the  second  stage  of  labor  when  vaginitis  is  known  to  exist.  The 
solution  used  forthis  purpose  in  Queen  Charlotte's  Hospital  is  corrosive  sublimate 
(1  :  2000).  The  copious  secretion  of  a  clear  vaginal  fluid  before  and  during  labor, 
and  the  flow  of  the  liquor  amnii  just  before  the  birth,  diminish  the  danger.  3d. 
Assist  the  foetal  eyes  to  pass  beyond  the  perineal  edge  without  resting.  This  is 
easily  done  by  hooking  around  the  perineal  edge  with  the  fingers  and  drawing  it 
down.  4th.  By  wiping  the  eyes  with  a  clean  cloth  at  birth  of  head.  5th.  By  in- 
stilling an  antiseptic  solution  into  the  eyes  at  birth  if  the  mother  has  a  discharge. 
6th.  Crede's  method:  to  wash  the  face  first,  never  in  water  in  which  the  body  has 
been  washed.  7th.  To  retain  one  sponge  or  flannel  especially  for  the  child's  face, 
and  insist  on  scrupulous  cleanliness.  8th.  The  nurse  to  wash  her  hands  after 
adjusting  the  mother  before  touching  the  child.  9th.  Not  to  expose  child  unduly 
to  draughts,  bright  light,  etc.  10th. 'To  protect  the  child  from  flies  with  a  thin  veil. 
11th.  To  remove  carefully  the  child  from  the  presence  of  another  similarly  alfected ; 
strict  isolation  of  an  infected  case.  12th.  To  guard  the  one  eye  if  the  other  be 
affected."  The  10th  and  11th  rules  are  evidently  applicable  to  cases  in  maternity 
wards,  rather  than  to  those  in  private  practice. 

But  in  order  to  gain  the  highest  degree  of  success  by  preventive  measures  it 
has  been  found  necessary  to  treat  the  eyes  of  the  infant  immediately  after  birth,  if 
there  be  the  least  reason  to  suspect  the  presence  of  an  infective  vaginal  discharge 
in  the  mother,  so  as  to  destroy  the  poison  if  it  have  lodged  in  them.  In  the  lying- 
in  asylum,  where,  in  consequence  of  the  prevalence  of  gonorrhoea  in  the  mothers, 
ophthalmia  neonatorum  of  a  severe  form  has  been  prevalent,  antiseptic  treatment 
of  the  eyes  of  all  the  newly-born  has  either  entirely  prevented  this  disease  or  ren- 
dered it  of  rare  occurrence.  To  Crede  of  Leipzig  more  than  to  any  other  physician 
the  credit  belongs  of  having  established  this  treatment.  Its  efficacy  is  now  univer- 
sally recognized. 

Bathing  the  eyes  of  infants  immediately  after  birth  was  previously  practised  by 
Abegg,  who  employed  only  water,  and  by  Olshausen,  who,  through  Von  Graefe's 
advice,  employed  a  1  per  cent,  solution  of  carbolic  acid.     Although  this  treatment 

^  ArcMv  fur  Gyndkologie,  1883. 

^  Prize  Essay,  3Ianchester  Chronicle,  Jan.,  1888. 


OPHTHALMIA  NEONATORUM.  107 

diminished  the  number  of  cases  of  ophthalmia,  it  was  far  surpassed  in  efficiency  by 
that  recommended  by  Crede.  who  in  1880  began  to  treat  the  eyes  of  the  newly-loorn 
in  the  following  manner :  The  external  surface  of  the  lids  was  first  washed  with 
plain  water :  the  lids  were  then  separated,  and  a  single  drop  of  a  2  per  cent,  solution 
of  nitrate  of  silver  was  allowed  to  fall  upon  the  cornea  from  the  end  of  a  glass  rod. 
From  1880  to  April  1,  1883,  Crede  treated  1160  infants  in  this  way,  and  only  4 
became  affected  with  ophthalmia  neonatorum.  This  treatment  by  nitrate  of  silver, 
employed  in  other  institutions  in  Europe  and  in  this  country,  has  been  followed  by 
signal  success.  Thus.  Dr.  Garrigues  of  Xew  York  employed  Crede's  treatment  in 
the  Maternity  Hospital  on  Blackwell's  Island,  where  ophthalmia  neonatorum  had 
previously  been  of  common  occurrence,  and  of  351  infants  born  consecutively  "  not 
a  single  one  was  affected.''  '  Dr.  Garrigues  adds  that  in  these  cases  occasionally  a 
thin  discharge  like  serum  followed  the  application  of  nitrate  of  silver,  due  appar- 
ently to  its  irritating  action,  and  chat  the  first  cases  in  which  he  observed  this  dis- 
charge he  treated  with  iced  compresses  and  the  instillation  of  a  saturated  solution 
of  boric  acid.  But  afterward  he  found  that  they  quickly  recovered  without  such 
measures.  Occasionally  so  many  drops  of  the  nitrate  were  inserted  by  accident  that 
a  black  ring  was  produced  upon  the  eyelids,  without  any  ill  effect  to  the  eye.  Dr. 
Garrigues  recommends  Crede's  method  of  employing  a  glass  rod,  to  which  a  single 
drop  of  the  solution  adheres,  so  that  there  is  no  risk  that  more  than  this  amount 
will  be  instilled.  The  application  should  be  made  as  soon  as  the  infant  is  removed 
from  the  bed  to  the  lap  of  the  nurse.  She  should  first  clean  the  eyelids  and  the  face, 
and  in  washing  them  should  be  careful  that  none  of  the  wash  enters  the  eyes.  A 
weaker  solution  of  nitrate  of  silver  has  been  emplo^'ed  without  the  good  results 
which  follow  the  use  of  the  2  per  cent,  solution.  Crede  made  tentative  use  of 
borate  of  sodium  (1  :  60),  and  found  it  greatly  inferior  as  a  preventive  to  the  nitrate 
of  silver.^ 

Preventive  treatment  of  this  kind  should  not  be  recommended  in  general 
midwifery  practice,  except  when  there  is  evidence  or  strong  suspicion  that  the 
mother  has  gonorrhoea.  Moreover,  much  can  be  done  toward  diminishing  the 
number  of  cases  of  blindness  resulting  from  ophthalmia  neonatorum  by  dis- 
seminating among  the  masses  a  knowledge  of  the  imminent  danger  to  the 
sight  of  the  newlj-born  infant  when  a  purulent  discharge  occurs  from  its 
eyes,  so  that  instead  of  employing  domestic  remedies  the  parents  will  seek 
at  once  the  advice  of  the  accoucheur  or  family  physician. 

Treatment. — If  proper  measures  be  employed  sufficiently  early  and  per- 
sistently, the  eye  can  nearly  always  be  saved.  Since  this  malady  has  a 
mierobic  origin,  it  is  evident  that  an  efficient  germicide  is  required  in  the 
treatment — an  agent  that  does  not  injure  the  eye,  while  it  destroys  the  cause 
of  the  inflammation.  Various  germicides  have  been  employed  for  this  pur- 
pose, but  the  two  which  have  been  found  safest,  and  at  the  same  time  most 
efficient,  are  corrosive  sublimate  and  nitrate  of  silver. 

We  again  call  attention  to  the  necessity  in  this  disease,  more  than  in  almost  any 
other,  of  employing  faithful  and  attentive  nurses,  who  will  carry  out  punctually  the 
directions  given.  Two  nurses  are  required — one  to  serve  by  day  and  the  other  by 
night — since  it  is  essential  that  the  eye  be  frequently  cleaned  and  the  secretion 
washed  away. 

If  the  conjunctivitis  be  purulent,  but  mild,  and  attended  by  a  slight  dis- 
charge and  little  or  no  appreciable  swelling  of  the  conjunctiva,  two  drops  of  a 
2  per  cent,  solution  of  nitrate  of  silver  should  be  instilled  once  between  the 
lids,  and  the  lids  moved  to  ensure  its  flowing  underneath  them  : 

R.  Argent,  nitrat  ,  gr.  vj  ; 

Aquse  destillat-,  ^v. — M. 

In  the  subsequent  treatment  a  strong  solution  of  boric  acid — some  recom- 
mend a  saturated  solution — should  be  instilled  every  half  hour,  the  lids  being 

^  Amer.  Journ.  of  Med.  Sci.,  Oct.,  1884.  ^  Arch.  f.  Gyndk.,  xxi.  p.  193. 


108  DISEASES  OF  THE  NEWLY-BORN. 

drawn  widely  apart.  The  frequent  wide  separation  of  the  lids,  which  can  be 
accomplished  without  undue  pressure  upon  the  eye,  is  useful  in  allowing  the 
pus  to  escape,  as  well  as  in  facilitating  the  application  of  the  wash.  I  prefer, 
however,  unless  the  disease  yields  quickly,  the  use  of  a  weak  solution  of  cor- 
rosive sublimate  in  place  of  the  boric  acid,  employing  the  following  formula : 

R.  Hydrarg.  chlor.  corros.,  gr.  j-ij  ; 

Aquse  destillat. ,  Oj. — M. 

The  use  of  this  mild  solution  of  the  sublimate  every  second  hour  after  a 
single  employment  of  the  nitrate  of  silver  usually  suffices  to  cure  mild  cases 
in  a  few  days.  If  the  disease  be  more  severe,  but  still  mild,  and  accompanied 
by  moderate  tumefaction  and  a  moderately  increased  secretion,  a  single  daily 
application  of  the  nitrate  of  silver  suffices  during  the  active  period  of  the 
inflammation.  In  severe  forms  of  the  disease,  accompanied  by  much  tume- 
faction and  the  frequent  gushing  out  between  the  lids  of  a  thick,  purulent 
secretion,  the  nitrate-of-silver  solution  should  be  used  as  often  as  every  six 
hours. 

Dr.  David  Webster  of  the  Manhattan  Eye  and  Ear  Hospital  states  that  he  has 
employed  the  nitrate  of  silver  in  these  severe  cases  five  times  in  twenty-four  hours 
with  great  benefit.  As  regards  the  frequency  of  the  application  of  nitrate  of  silver, 
and  the  time  to  desist  from  its  use,  Andrews  writes :  "  The  only  guide  which  I  know 
is  the  condition  of  the  conjunctiva.  When  there  is  slight  hypersemia  only,  the 
slough  produced  by  the  nitrate  of  silver  requires  a  long  time  to  be  cast  off,"  and  it 
is  very  irritating.  But  if  there  be  a  more  severe  inflammation,  with  much  swelling, 
the  slough  is  thrown  ofi"  in  a  few  hours.  The  use,  therefore,  of  nitrate  of  silver  at 
intervals  of  a  few  hours  should  be  practised  only  in  the  most  severe  forms  of  the 
inflammation,  while  in  the  milder  cases  it  should  be  used  only  once  or  at  long  inter- 
vals. In  the  declining  period  of  the  disease  the  application  of  a  solution  of  boric 
acid  or  a  weak  solution  of  corrosive  sublimate,  gr.  1  to  the  pint  of  distilled  water, 
suffices  to  effect  a  cure. 

Umbilical  Vegetations. 

Not  infrequently  small  excrescences  sprout  out  from  the  base  of  the 
umbilical  depression  at  the  time  or  soon  after  the  fall  of  the  cord.  They 
have  the  appearance  of  those  vegetations  which  arise  from  open  sores.  They 
have  been  designated  in  different  languages  by  many  appellations,  as  fungous 
excrescence  of  the  umbilicus  (Condie),  excrescence  of  the  umbilicus  (Cooper, 
Foster),  warty  tumor  of  the  umbilicus  (Holmes),  bourgonnement  de  Tombilie 
(Depaul),  granulome  de  I'ombilie  (Dechamber),  vegetation  ombilicale  (Guer- 
sant). 

The  size  attained  by  these  growths  is  always  small.  Many  of  them  are 
not  larger  than  a  pea  in  their  greatest  development.  Their  form  appears  to 
be  determined  in  a  measure  by  the  external  pressure.  Some  are  rounded, 
and  others  are  elongated  or  cylindrical.  Their  color  varies  from  a  pale  red 
to  a  red  of  a  deeper  tinge,  according  to  the  degree  of  vascularity,  and  they 
are  always  moist. 

This  outgrowth  is  distinguished  by  its  irreducibility  and  its  consistence. 
Digital  pressure  may  cause  it  to  disappear  in  the  umbilical  fossa :  it  dis- 
appears by  depressing  the  floor  of  the  fossa.  It  reappears  in  its  entirety  by 
the  resiliency  of  the  walls  of  the  fossa  as  soon  as  the  pressure  is  removed. 
It  has  the  soft  consistence  of  fungous  tissue,  so  that  it  is  depressed  and  flat- 
tened and  its  shape  changed  even  by  slight  pressure.  It  arises  in  most 
instances  from  the  inferior  part  or  floor  of  the  umbilical  fossa,  and  it  con- 
trasts in  appearance  with  the  cutaneous  folds  of  the  umbilicus  by  its  softness 


UMBILICAL  HEMORRHAGE. 


109 


and  reddish  tinge.  It  exhibits  no  tendency  to  ulceration  or  to  hemorrhage, 
but  a  sanguinolent  serum  exudes  from  it  and  stains  the  linen  unless  the 
growth  be  small.  The  thin  irritating  discharge  from  the  surface  or  base 
of  the  vegetation  sometimes  causes  small  excoriations  upon  the  edge  of  the 
fossa. 

Progress. — This  vegetation  in  the  first  days  or  weeks  increases  more 
rapidly  than  subsequently.  It  may  attain  half  the  size  or  the  full  size  of  a 
pea,  or  even  a  greater  development,  by  successive  sprouting  of  granulations. 
It  may  increase  slowly  during  many  weeks  or  months,  or  it  may  come  to  a 
standstill  and  show  no  tendency  to  diminish  or  atrophy.  In  time,  according 
to  several  writers,  it  is  likely  to  shrivel  and  skin  grow  over  it,  and  thus  be 
cured.     But  more  frequently  surgical  interference  is  required. 

Treatjient. — Cauterization  by  nitrate  of  silver  acts  slowly,  but  some- 
times destroys  the  vegetation  if  small.  More  efficacious  and  preferable 
treatment  is  to  remove  the  growth  by  the  scissors  or  ligature.  Saint-Ger- 
main operates  as  follows :  The  fold  of  the  skin  surrounding  the  umbilicus 
is  depressed,  while  slight  traction  is  made  on  the  excrescence  by  the  forceps. 
The  pedicle  is  then  strongly  tied  by  a  silk  thread  previously  dipped  in  a  solu- 
tion of  carbolic  acid.  Slight  traction  then  suffices  to  remove  the  growths, 
and  they  sometimes  drop  off  in  the  tying.  After  the  removal  a  little  iodo- 
form should  be  dusted  into  the  umbilical  fossa,  and  the  umbilicus  covered  by 
a  pledget  of  surgeon's  lint  retained  in  place  by  strips  of  adhesive  plaster. 

Umbilical  hemorrhage  occurring  at  birth  or  soon  after  from  too  loose 
ligation  of  the  cord,  or  from  its  laceration,  is  so  well  known  and  its  cause 
so  apparent  that  it  need  only  be  alluded  to  in  this  connection.  Bouchut 
relates  a  case  in  which  death  took  place  from  this  cause  even  before  birth. 
The  child  was  attached  to  the  placenta  by  a  navel-string  so  short  that  it  pre- 
vented delivery  till  it  parted  by  the  traction  of  the  forceps.  The  bleeding 
from  the  umbilical  vessels  was  so  profuse  that  the  child  was  pallid  and  life- 
less when  born. 

But  umbilical  hemorrhage  of  the  new-born  sometimes  occurs  when  the 
cord  is  properly  tied,  is  uninjured,  and  the  subsequent  treatment  of  the  um- 
bilicus is  judicious  and  correct.  The  following  table  gives  the  ages  at  which 
this  hemorrhase  commenced  in  99  cases : 


Age.  No. 

On  the  1st  day 5 

"     "   2d    "      7 

"     "   3d    " 6 

"     "   4th  " 3 

5th  to  7th  dav,  inclusive  ......  32 


Age.  No. 

8th    to  10th  day,  inclusive 25 

11th  to  15th    "  "  16 

16thto2Ist    "  "  4 

22d  to  56th    "  "  ^ 

99 


These  statistics  are  interesting  as  showing  the  relation  of  the  hemorrhage  to 
the  umbilical  cord.  In  the  18  cases  in  which  the  hemorrhage  occurred  under 
the  age  of  three  days  it  appears  from  the  records  that  the  cord  was  attached, 
and  the  blood  escaped  from  the  walls  of  the  umbilical  fossa  outside  of  the 
line  of  its  attachment.  Immediately  after  the  fifth  day,  or  after  the  time 
when  the  cord  falls,  there  was  a  large  increase  in  the  number  of  cases,  so 
that  from  the  fifth  to  the  fifteenth  day  after  birth  was  the  period  of  greatest 
liability  to  the  hemorrhage. 

Etiology. — Since,  as  many  observations  have  shown,  in  a  large  propor- 
tion of  these  hemorrhagic  cases  the  blood  has  feeble  coagulability,  it  seems 
probable  that  the  umbilical  vein  and  the  umbilical  and  hypogastric  arteries 
may  not  have  been  occluded  by  fibrinous  coagula  in  at  least  some  of  these 
patients,  as  they  commonly  are  in  the  healthy,  and  that  the  hemorrhage 
occurred  in  part  from  these  vessels.     This  hypothesis  is  rendered  more  plau- 


110  DISEASES  OF  THE  NEWLY-BORN. 

sible  by  the  fact  that  from  the  general  ill-health  present  in  many  cf  these 
infants,  probably  the  walls  of  the  veins  and  arteries  were  lacking  in  contrac- 
tility, so  that  they  remained  more  patulous  than  in  robust  and  healthy  infants. 
Hemorrhage  from  the  umbilicus,  as  well  as  from  other  parts  in  the  newly- 
born,  must  be  referred  to  a  faulty  composition  of  the  blood,  especially  its 
feeble  coagulability,  or  to  an  abnormal  state  of  the  walls  of  the  minute  vessels, 
or  to  both  these  causes.  The  hemorrhage  is  sometimes  referable  to  the 
hemorrhagic  diathesis  or  hgemophilia,  which  may  be  inherited  or  may  result 
from  obscure  causes  in  children  born  of  healthy  parents. 

In  the  New  York  Infant  Asylum  a  well-developed  and  apparently  healthy 
mulatto  woman  gave  birth  to  her  first  infant  on  November  30,  1886.  She  stated 
that  her  family  were  healthy  and  that  the  father  of  the  child  was  also  in  excellent 
health.  The  birth  was  easy  and  natural,  and  nothing  unusual  was  observed  in  the 
infant,  which  weighed  nearly  ten  pounds,  except  a  swelling  from  extravasated  blood 
above  and  in  front  of  the  right  ear.  At  7  a.  m.  on  the  next  day  severe  umbilical 
hemorrhage  occurred,  which  was  checked  by  styptics ;  then  slight  epistaxis  took 
place.  At  11  A.  M.  bleeding  from  the  navel  returned,  and  appeared  to  come  from 
several  points  at  the  margin  of  separation  of  the  floor  of  the  umbilicus  from  the 
cord.  The  tumor  above  the  ear  increased,  purpuric  spots  appeared  upon  the  integu- 
ment, and  death  occurred  from  exhaustion  on  December  2d.  The  infant  lost  one 
pound  in  weight  during  the  two  days  of  its  existence.  At  the  autopsy  a  few  small 
superficial  erosions  could  be  made  out  in  the  umbilical  fossa  at  the  point  of  union 
with  the  cord.  The  umbilical  vein,  traced  to  the  liver,  and  the  hypogastric  arteries, 
traced  to  the  iliac  arteries,  contained  no  blood,  were  patulous,  and  apparently  nor- 
mal. Extravasations  of  blood  were  found  under  the  skin,  in  the  abdominal  cavity, 
and  at  numerous  points  in  the  lungs,  etc.  The  organs  had  an  exsanguine  appear- 
ance, and  everywhere  the  blood  was  without  clots,  its  fluidity  being  a  notable  pecu- 
liarity. The  cause  of  the  haemophilia  in  this  child  was  not  apparent.  Its  parents, 
so  far  as  could  be  ascertained,  were  healthy  ;  still,  there  may  have  been  latent 
syphilis. 

Syphilis  is  one  of  the  recognized  causes  of  the  hemorrhagic  diathesis  in 
the  newly-born.  In  1871,  I  was  requested  to  visit  a  neonatus  that  was  a 
bleeder,  whose  father  was  unmistakably  syphilitic,  and  whose  mother  was 
suspected  to  have  contracted  syphilis  from  her  husband.  The  child  was 
fairly  developed,  and  the  cord  separated  on  the  sixth  day.  A  constant  oozing 
of  blood  from  the  navel  commenced  on  the  seventh  day,  on  account  of  which 
I  was  summoned  to  the  case.  I  finally  succeeded  in  arresting  the  bleeding 
by  the  application  of  the  plaster-of-Paris  dressing,  but  immediately  intestinal 
hemorrhage  commenced,  of  which  the  child  died  in  twenty-four  hours.  The 
parents  were  induced  to  take  antisyphilitic  remedies  for  a  considerable  time, 
and  they  have  since  had  four  healthy  children.  In  another  instance  observed 
by  me  an  infant,  puny  and  apparently  premature,  was  at  birth  observed  to 
have  several  blebs  of  pemphigus,  from  which  blood  soon  began  to  ooze,  but 
the  umbilical  hemorrhage  from  which  the  child  died  did  not  begin  until  about 
the  fourteenth  day. 

Two  elements  or  factors  appear  to  be  present  in  producing  syphilitic 
hemorrhage  in  the  newly-born.  We  have  already  alluded  to  abnormal  fluidity 
of  the  blood,  for  when  it  escapes  it  does  not  coagulate  or  its  coagulation  is 
very  inadequate.  The  other  factor  is  abnormalities  in  the  minute  vessels. 
Many  years  ago  the  eminent  obstetrician  Sir  James  Y.  Simpson  of  Edin- 
bui'gh  met  cases  of  hemorrhage  in  the  newly-born  which  he  attributed  to 
inflammation  of  the  vessels,  arterial  or  venous,  or  both,  from  which  the  blood 
escaped.  The  inflammation,  in  his  opinion,  caused  thickening  and  infiltration 
in  the  walls  of  the  vessels,  loss  of  tonicity,  and  consequently  a  patulous  state. 
Simpson  does  not  seem  to  refer  in  particular  to  the  hemorrhage  due  to  syph- 
ilis, but  to  that  from  other  causes  as  well.     Dr.  Mracek,  lecturer  on  syphilis 


UMBILICAL  HEMOBBHAGE.  Ill 

in  the  University  of  Vienna,  reported  19  cases  of  hemorrhagic  syphilis  in 
neonati.^  None  of  the  mothers  had  undergone  antisyphilitic  treatment.  One 
of  the  infants  was  born  dead,  while  the  others  lived  from  half  an  hour  to 
forty-eight  hours.  The  capillaries,  the  vasa  vasorum,  the  venules,  and  arte- 
rioles were  filled  with  morbid  products,  having  caused  local  troubles  of  circu- 
lation and  sanguineous  effusions. 

Andronico  states  his  belief  that  hemorrhages  in  syphilitic  neonati  are  due 
not  only  to  "  diminished  power  of  coagulation  of  the  blood,"  but  to  a  "  vas- 
cular ectasis,  particularly  in  the  small  cutaneous  veins."  Bleeding  from  the 
navel  also  sometimes  occurs  as  a  symptom  or  compHcation  of  jaundice. 
Writers  who  have  collected  records  of  this  hemorrhage  have  remarked  the 
frequent  occurrence  of  the  icteric  hue  both  before  and  during  the  bleeding, 
even  in  those  who  do  not  present  the  history  of  syphiUs.  It  is  not  improb- 
able that  in  certain  instances  the  jaundice  is  hgematogenous,  arising  from 
destruction  of  the  red  globules  and  liberation  of  the  haematin — a  not  unusual 
result  of  a  profound  dyscrasia  even  when  there  is  no  syphilitic  taint.  In 
other  instances  the  jaundice  proceeds  from  the  liver,  and  the  bleeding  occurs 
from  the  altered  state  of  the  blood,  which  is  produced  by  abnormalities  in 
the  liver  or  its  appendages. 

Thus  in  at  least  five  of  the  cases  of  umbilical  hemorrhage  collated  by  Jenkins 
the  marked  jaundice  which  was  present  was  found  to  be  due  to  congenital  occlusion 
of  the  common  bile-duct,  and  of  course  all  the  bile  secreted  which  did  not  remain 
in  the  liver  entered  the  blood.  The  biliary  acids  in  the  blood  probably  diminish 
the  amount  of  its  fibrin  and  increase  its  fluidity. 

Poor  health  in  the  mother  and  impoverishment  of  her  blood  during  gesta- 
tion, whether  from  chronic  disease,  as  tuberculosis,  or  antihygienic  conditions, 
also  cause  impoverishment  and  increase  the  fluidity  of  the  blood,  and  there- 
fore act  to  a  certain  extent  as  a  predisposing,  if  not  as  a  direct,  cause  of  the 
hemorrhage.  In  exceptional  instances  no  adequate  cause  of  the  bleeding 
can  be  detected  either  in  the  child  or  the  health  of  its  parents. 

Prognosis. — Statistics  show  that  5  in  every  6  perish.  The  prognosis  is 
most  unfavorable  when  an  obvious  dyscrasia  is  present.  Those  who  have 
jaundice  or  hgemophilia  with  very  few  exceptions  perish.  Those  are  most 
likely  to  recover  who  have  a  healthy  parentage,  no  obvious  dyscrasia,  and  in 
whom  the  hemorrhage  occurs  late  and  is  not  profuse.  The  average  duration 
of  the  hemorrhage  in  82  cases  in  Jenkins's  collection  was  three  and  a  half 
days,  the  minimum  being  only  three  hours.  Death  usually  occurs  from  ex- 
haustion. 

Treatment. — A  compress  of  surgeon's  lint  or  a  sponge  saturated  with 
the  liquor  ferri  subsulphatis  should  be  firmly  pressed  over  the  umbilicus  and 
retained  by  a  bandage.  If  the  bleeding  do  not  cease,  the  umbilicus  should 
be  covered  by  a  thick  layer  of  plaster  of  Paris,  supported  by  the  hand  until 
it  hardens,  and  then  retained  in  place  by  the  bandage  passing  around  the 
body.  In  the  case  related  above,  occurring  in  my  own  practice,  this  treat- 
ment arrested  the  bleeding  from  the  navel,  but  it  was  followed  by  fatal 
intestinal  hemorrhage.  If  the  hemorrhage  continue,  the  needles  with  lig- 
ature may  be  employed.  Bouchut  indeed  states  that  this  is  the  only  effectual 
treatment.  Two  needles  are  passed  through  the  umbilicus  at  right  angles, 
and  a  waxed  thread  wound  around  each  in  the  form  of  the  figure  8.  If  the 
patient  survive,  the  needles  should  be  removed  in  four  or  five  days  and 
iodoform  or  a  poultice  applied.  It  is  important,  so  far  as  time  will  permit, 
to  treat  the  dyscrasia,  and  a  laxative  of  calomel  is  often  indicated,  especially 
if  constipation  be  present.     A  laxative  is  useful  for  its  effect  on  the  hepatic 

1  Berlin,  klin.  Woch.,  No.  46,  p.  807,  Nov.  15,  1886. 


112  DISEASES  OF  THE  NEWLY-BORN. 

circulation  and  as  a  derivative.  During  the  continuance  of  the  hemorrhage 
four  or  five  drops  of  brandy  in  breast-milk  frequently  administered  are  useful 
as  a  stimulant. 

Icterus,  or  a  yellowish  discoloration  of  the  skin,  is  common  in  the  newly- 
born.  It  has  even  been  said  that  in  its  mildest  form  it  is  present  in  the 
majority  of  infants,  and  it  arises  from  a  considerable  number  of  anatomical 
and  pathological  conditions.  It  occurs  in  its  worst  and  most  intractable  form 
-when  there  is  congenital  obliteration  of  the  bile-ducts ;  it  is  believed  to  occur 
sometimes  in  the  youngest  infant  from  the  same  cause  as  that  which  produces 
the  usual  form  of  adult  jaundice — to  wit,  catarrh  of  the  duodenum  extend- 
ing by  propagation  into  the  bile-ducts  and  narrowing  or  occluding  their 
lumina.  Congenital  syphilis  is  another  cause,  the  icterus  being  probably 
produced  by  the  newly-formed  connective  tissue  which  compresses  the  bile- 
ducts.  The  modus  operandi  of  the  causes  related  above  is  easily  understood, 
but  a  large  proportion  of  the  neonati  who  have  the  icteric  hue  in  a  slight  or 
mild  form  do  not  appear  sick,  and  fully  recover  after  a  few  days.  The  cause 
in  such  cases  is  probably  of  a  trivial  nature,  else  it  would  produce  a  more 
profound  impression  on  the  system.  West  says  of  these  mild  cases  in  which 
there  is  no  appreciable  impairment  of  the  health  that  the  yellow  tinge  of  the 
skin  comes  on  about  the  third  day.  deepens  for  a  day  or  two.  and  subsides 
gradually,  ''  the  bowels  acting  properly  and  the  urine  not  being  high-colored : 
though  to  this  condition  the  name  of  jaundice  has  been  applied,  it  is  yet  no 
real  jaundice,  but  is  merely  the  result  of  the  changes  which  the  blood  in  the 
over-congested  skin  is  undergoing,  the  redness  fading,  as  bruises  fade,  through 
shades  of  yellow  into  the  genuine  flesh  color."  A  yellow  coloring  of  the  skin, 
the  result  of  cutaneous  hyperaemia,  is  not  accompanied  by  the  diagnostic 
signs  of  true  jaundice,  such  as  a  yellow  conjunctiva,  clay-colored  stools,  and 
biliary  coloring  matter  in  the  urine.  Inasmuch  as  the  liver  and  other  internal 
organs  are  not  concerned  in  producing  this  orm  of  icterus,  West  says  it  has 
been  proposed  to  designate  it  by  the  term  "  local  icterus."  It  would  be 
interesting  to  ascertain  in  cases  in  which  there  is  a  deposit  of  pigment  in  the 
skin,  while  all  the  other  organs,  including  the  liver,  are  in  their  normal  state 
and  have  their  normal  functional  activity,  whether  there  has  been  a  cutaneous 
plethora  due  to  late  ligature  of  the  cord.  Zweifel  states  that  the  placenta 
before  the  uterus  contracts  after  the  expulsion  of  the  child,  and  the  cord  is 
still  beating,  contains  six  ounces  of  blood,  but  if  the  cord  have  ceased  to 
beat  and  the  uterus  be  firmly  contracted,  half  of  this  amount  of  blood,  or 
three  ounces,  passes  through  the  cord  and  augments  to  this  extent  the  quan- 
tity of  blood  in  the  vessels  of  the  foetus.  Late  ligature,  therefore,  when  there 
is  firm  uterine  contraction  increases  the  fulness  of  the  blood-vessels  in  the 
child,  and,  according  to  Park,  babies  with  distended  blood-vessels  exhibit  a 
more  intense  jaundice. 

H.  Quincke  advances  another  and  in  some  respects  a  plausible  theory  of  the 
etiology  of  the  common  form  of  icterus  neonatorum.^  He  attributes  the  jaundice 
to  the  continued  patency  of  the  ductus  venosus.  Henry  Ashby  says'^  that  in  a 
minority  of  cases  of  jaundice  of  the  new-born  the  clinical  history  or  post-mortem 
examinations  reveal  the  cause,  as  when  it  arises  from  congenital  defects,  syphilitic 
hepatitis  or  cirrhosis,  septicaemia  or  hjemaglobinuria.  But  the  usual  form  of 
infantile  jaundice,  Avhich  begins  on  the  second  or  third  day,  and  commonly  ends 
favorably,  Ashby  states,  has  "nothing  in  common  with  the  above  fatal  forms.  He 
does  not  acceptAVesfs  and  Murchi'son's  theory  of  a  merely  cutaneous  icterus,  and 
believes  that  Quincke's  theory  is  the  most  plausible  yet  presented  for  consideration. 
The  ductus  venosus  normally  closes  between  the  second  and  fifth  days  after  birth, 
but  if  it  remain  pervious  and  the  circulation  from  any  cause  be  retarded,  bile, 

^  Archivfiir  experimentelle  Pathologie  und  Pharmakoiogie,  xix.  1  and  2. 
^  Lond.  Med.  Times  and  Oaz.,  April  25,  1885. 


ICTERUS.  113 

according  to  the  above  theory,  enters  the  branches  of  the  portal  vein  and  finds  its 
way  into  the  general  circulation  through  the  ductus  venosus.  In  one  case,  says 
Ashby,  an  infant  had  jaundice  from  the  second  to  the  eleventh  day,  and  at  the 
autopsy  the  ductus  venosus  was  large  enough  to  admit  an  ordinary  director.  This 
theory  also  comports  with  the  fact  that  feeble  infants  are  more  liable  to  become 
jaundiced  than  the  robust,  for  those  vascular  canals  which  pertain  to  the  foetal 
state  and  are  obliterated  after  birth  are  more  likely  to  remain  a  longer  time  pervi- 
ous in  the  feeble  than  the  robust. 

Dr.  Alois  Epstein  ^  made  many  experiments  in  order  to  determine  whether  bile- 
pigment  occurs  in  the  urine  of  icteric  newly-born  infants.  He  agitated  the  urine 
with  lime-water,  filtered  it  with  alcohol,  and  added  sulphuric  acid.  If  bile-pigment 
be  present,  a  green  color  results.  He  discovered  in  the  urine  a  pigment  in  the  crys- 
talline or  amorphous  state,  and  of  a  yellow  or  yellowish-red  color.  It  occurred  in 
the  various  forms  of  tufted  needles  or  small  tables,  yellowish  or  brownish,  and  in 
yellowish-red  amorphous  granulations.  Epstein  was  able  to  distinguish  by  chemi- 
cal reactions  this  pigment  from  uric  acid  and  the  urates.  On  further  investigation 
he  states  that  he  found  this  pigment  in  all  the  organs,  abundantly  in  the  kidneys, 
and  also  in  the  blood.  Does  this  pigment  have  an  hepatic  or  hsemic  orgin?  Epstein 
is  led  by  his  investigation  to  believe  that  this  crystalline  or  amorphous  pigment 
results  from  changes  occurring  in  the  blood,  and  probably  from  the  liberation  of 
the  coloring  matter  by  the  destruction  of  the  red  corpuscles,  which  Neumann,  Kolli- 
ker,  Denis,  Hayem,  and  others  have  shown  to  occur  so  abundantly  in  the  neonati. 

Epstein  believes  that  any  marked  impairment  of  the  important  functions  in  the 
system  tends  to  increase  the  destruction  of  the  red  corpuscles,  the  consequent  release 
of  its  coloring  matter,  and  the  formation  of  the  crystalline  or  amorphous  pigment 
described  above,  which  in  icterus  escapes  into  the  tissues.  Marked  impairment  of 
respiration,  circulation,  and  calorification,  artificial  alimentation,  prematurity,  pro- 
tracted and  difficult  birth,  taking  cold,  and  similar  agencies,  in  proportion  as  they 
impair  the  general  health  and  produce  perturbation  in  the  system,  increase  the 
destruction  of  red  corpuscles,  and  thereby  act  as  causes  of  icterus.  Epstein  also 
mentions  the  well-known  fact  that  the  children  of  parents  who  have  grave  con- 
stitutional diseases  or  live  under  bad  hygienic  conditions  are  especially  liable  to 
become  icteric,  and  that  septic  infection  is  an  important  cause  of  those  alterations 
in  the  blood  which  give  rise  to  icterus. 

The  peculiar  character  of  the  blood  of  the  newly-born  is  believed  by  good 
observers  who  have  investigated  this  subject  to  predispose  to  the  occurrence  of 
jaundice.  According  to  Hofmeier,  the  red  blood-corpuscles  in  the  neonati  are  more 
spherical  than  in  adults,  and  do  not  show  a  tendency  to  form  rouleaux.  The  white 
corpuscles  are  often  more  numerous  than  in  adults ;  they  are  viscid,  deliquescent, 
easily  destroyed,  and  have  a  tendency  to  aggregate  in  rouleaux.  The  investiga- 
tions of  Ponfick  and  Silbermann^  show  that  the  red  corpuscles  of  the  new-born 
readily  part  with  their  coloring  matter,  the  hsemaglobin,  under  disturbing  agencies, 
such  as  syphilis,  burns,  taking  cold,  injudicious  nursery  management,  and  even  by 
the  action  of  certain  medicinal  agents,  as  glycerin  and  pyrogallic  acid.  The  red 
corpuscles  which  have  lost  their  coloring  matter  by  its  transference  to  the  plasma 
either  disintegrate  and  disappear,  or  they  appear  under  the  microscope  as  pale 
rings  which  have  been  designated  shadows.  This  transference  of  the  coloring 
matter  from  the  red  corpuscles  to  the  liquor  sanguinis,  and  the  disintegration  of 
red  corpuscles,  which  characterize  the  first  few  days  of  infant  life,  lead  to  an  increase 
of  hjemaglobin  in  the  plasma  (hgemaglobinhaemia)  and  of  fibrin  ferment.  Silber- 
mann  summarizes  his  views,  derived  from  an  examination  of  the  character  of  the 
blood  and  the  blood-changes  occurring  in  the  newly-born,  as  follows :  "  The  blood 
of  the  newly-born  holds  corpuscles  which  vary  greatly  in  size,  aud  also  the  so-called 
shadows  :  it  is  richer  in  fibrin-ferment  than  the  blood  of  adults  :  these  peculiarities 
are  due  to  the  liberation  of  hasmaglobin  and  its  transfer  into  the  plasma  :  the  rich- 
ness in  fibrin-ferment  of  the  blood  of  the  newly-born  predisposes  to  disease  :  all  dis- 
ease-processes in  the  newly-born  which  involve  great  destruction  of  the  albumen  in 
the  circulation  are  especially  dangerous  to  life."  These  investigations  relating  to  the 
blood  will  aid  to  an  understanding  of  the  views  of  Silbermann  regarding  icterus. 

^  "Ueber  die  Gelbsucht  bei  Xeugeboren  Kindern,"  Sammlung  klinischer  Vorfrdge, 
No.  80,  1880. 

^  "Zur  Hamatologie  der  Xeugeborenen,"  Jahrbuchfur  Kinderheilkunde,  1887. 


114  DISEASES  OF  THE  NEWLY-BORN. 

Dr.  Silbermaun  concludes  ^  an  elaborate  paper  on  icterus  neonati  with  the  fol- 
lowino;  aphorisms  :  "  1st.  Icterus  of  the  newly-born  is  an  icterus  of  absorption.  2d. 
The  biliary  engorgement  has  its  seat  in  the  biliary  capillaries  and  the  interlobular 
bile-ducts,  which  are  compressed  by  the  dilated  branches  of  the  portal  vein  and  the 
capillary  blood-vessels  of  the  liver.  3d.  This  engorgement  in  the  vessels  is  effected 
by  the  change  in  the  circulation  of  the  liver  which  occurs  soon  after  birth,  and  is 
one  of  the  indications  of  a  general  change  in  the  blood-plasma.  4th.  This  change, 
which  is  induced  by  the  destruction  of  many  blood-corpuscles  soon  after  birth,  con- 
sists of  a  kind  of  blood-fermentation.  5th.  The  more  feeble  the  infant  the  more 
intense  will  be  the  icterus,  for  in  such  a  child  the  destruction  of  corpuscles,  and  the 
consequent  blood-changes,  will  be  much  more  decided  than  in  a  vigorous  child.  6th. 
As  the  consequence  of  the  destruction  of  so  many  red  corpuscles  there  is  abundant 
material  for  the  formation  of  biliary  coloring  matter,  and  under  the  influence  of  the 
fermentation-process  alluded  to  this  accumulates  in  considerable  quantity.'"  There- 
fore, according  to  this  theory,  free  coloring  matter  in  the  blood,  derived  from  the 
abundant  destruction  of  the  red  corpuscles  which  attends  the  first  days  of  infancy, 
occurs  in  such  quantity  that  it  cannot  be  disposed  of  in  the  biliary  secretion  or 
otherwise  eliminated,  and  is  deposited  in  the  tissues,  causing  the  icteric  hue. 

Birch-Hirschfeld '"^  attributes  icterus  of  the  new-born  to  oedema  of  the  capsule 
of  Glisson,  and  consequent  compression  of  the  bile-ducts.  This  oedema  he  believes 
is  due  to  diminution  of  pressure  in  the  portal  system  consequent  on  section  of  the 
cord. 

That  feebleness,  insanitary  conditions,  and  exposure  are  a  cause  of  jaundice, 
however  they  may  act  to  produce  such  a  result,  is  shown  by  many  observations. 
West,  as  we  have  stated  above,  describes  a  local  or  cutaneous  icterus  resulting  from 
plethora  of  the  skin,  and  having  no  special  interest  or  importance,  and  a  systemic 
or  general  icterus,  which  he  states  "  does  not  aflfect  perfectly  healthy  children  who 
have  been  born  at  the  full  time,  have  been  nourished  exclusively  at  the  mother's 
breast,  and  being  sheltered  from  cold  without  being  overburdened  with  clothing  or 
confined  in  a  vitiated  atmosphere."  In  corroboration  of  this  statement  he  alludes 
to  the  fact  that  in  the  Dublin  Lying-in  Hospital,  where  the  utmost  care  is  bestowed 
on  the  foundlings,  icterus  is  rare,  while  it  is  so  common  in  the  Foundling  Hospital 
of  Paris  that  few  escape.  In  the  latter  institution,  as  compared  with  the  former, 
the  exposures  are  much  greater  and  the  conditions  as  regards  hygiene  are  greatly 
inferior. 

M.  Bouchut  says  that  icterus  is  observed  in  80  to  90  per  cent,  of  the  new-born  ; 
that  Levret,  Breschet,  Billard,  and  Valleix  regard  it  as  the  result  of  ecchymosis  of 
the  skin  following  congestion — an  opinion  which  he  considers  erroneous.  He 
believes  that  it  almost  always  results  from  a  mild  or  severe  hepatitis  consequent 
on  ligature  of  the  cord.  The  ligature,  he  says,  produces  a  mild  inflammation  which 
is  propagated  to  the  liver  and  causes  obstruction  of  the  bile-ducts.  In  his  articles 
on  hepatitis  of  the  new-born  he  repeats  his  belief  in  this  theory. 

The  obvious  inference  from  the  above  resume  of  opinions  is  that  icterus 
neonatorum  results  from  different  causes  in  different  instances,  and  that  it  is 
a  mild  or  grave  disease  according  to  its  etiology.  The  various  causes  admit 
of  classification  in  two  groups:  1st,  the  haematogenous ;  2d,  the  hepatoge- 
nous. The  hgematogenous  theory,  which  attributes  the  common  form  of 
icterus  of  the  newly-born  to  the  destruction  of  the  red  blood-corpuscles  in 
the  first  days  of  life,  and  the  escape  of  the  coloring  matter  into  the  circula- 
tion, is  advocated  by  such  men  as  Billard,  Virchow,  Breschet,  Porak,  Violet, 
and  Epstein.  The  hepatogenous  theory  has  also  advocates  of  equal  reputa- 
tion. The  etiology  of  this  disease  certainly  requires  further  investigation, 
and  when  it  is  better  understood  it  will  probably  be  seen  that  distinct  patho- 
logical states  in  the  newly-born  have  been  described  under  the  term  "  icterus." 

Prognosis. — This  depends  on  the  nature  of  the  cause  as  well  as  the 
present  state  of  the  infant.  If  the  cause  be  susceptible  of  removal,  as  in  the 
common  mild  form  of  icterus,  a  favorable  prognosis  is  justified.     The  most 

^  Archivfiir  Kinderheilkunde,  1887. 
^  Virchow's  Arch.,  1882,  Band  Ixxxvii. 


SEPTICEMIA.  115 

unfavorable  cases  are  those  in  whicli  there  is  absence  of  the  biliary  ducts  or 
their  permanent  occlusion.  In  severe  forms  of  the  disease  in  which  the  con- 
nective tissue,  the  secretions,  and  transuded  serum  have  the  yellow  hue  the 
prognosis  should  be  guarded. 

The  common  mild  form  of  icterus,  appearing  on  the  second  or  third  day 
after  birth,  disappears  or  is  scarcely  appreciable  at  the  close  of  the  second 
week.  Severe  icterus,  continuing  longer  without  any  abatement  in  its  inten- 
sity, is  due  as  a  rule  to  permanent  anatomical  conditions  which  prevent  the 
flow  of  bile  into  the  intestine,  and  is  probably  incurable.  In  these  cases  the 
stools  remain  clay-colored,  the  icterus  increases,  and  vomiting  may  occur. 

The  TREATMENT  is  simple,  and  to  a  considerable  extent  expectant.  Gen- 
tle friction  over  the  liver  may  perhaps  in  some  cases  aid  in  removing  the 
obstructive  disease  in  the  bile-ducts.  The  use  of  hydrarg.  cum  creta  in 
small  doses,  as  recommended  by  West,  is  of  doubtful  efl&cacy.  It  is  evident 
that  preventive  measures  are  more  important  and  more  efficacious  than  the 
curative,  since  every  measure  which  promotes  a  healthy  parentage  and  the 
health  and  robustness  of  the  infant  tends  to  diminish  the  frequency  of  this 
disease.  Those  who,  like  Porak,  believe  that  congestion  of  the  skin  at  birth 
is  a  common  cause  of  the  simple  form  of  jaundice  recommend  an  early  liga- 
ture of  the  cord,  when  the  umbilical  arteries  are  still  beating  or  have  just 
ceased  to  beat,  since  when  the  arteries  are  beating  an  equilibrium  is  main- 
tained in  the  circulation,  whereas  in  a  late  ligature,  when  the  uterus  is  firmly 
contracted  and  the  arteries  have  for  some  time  ceased  to  beat,  a  plethoric 
state  of  the  vessels  is  more  likely  to  occur. 

Septicaemia  of  the  New-born.^ 

The  manner  in  which  sepsis  or  septicaemia  occurs  is  sometimes  obscure. 
Leube  in  1878  relates  two  cases  ^  in  which  the  examination  failed  to  disclose 
the  source  or  mode  of  infection.  He  designates  such  cases  cryptogenetic, 
expressive  of  the  unknown  or  occult  origin.  Wunderlich  and  Schlitzenbcrger 
allude  to  similar  cases.  But  in  septicaemia  of  the  newly-born  it  is  the  com- 
mon and  apparently  correct  belief  that  the  septic  poison  usually  enters  the 
system  at  the  umbilicus.  The  cases  which  I  am  about  to  relate  are  in  har- 
mony with  this  theory. 

It  is  not  my  intention  to  discuss  the  nature  of  the  septic  poison,  but  there 
can  be  little  doubt,  from  the  examinations  which  were  made,  that  in  the  fol- 
lowing cases  it  consisted  of  microbes  and  the  toxines  caused  by  them. 

Cases  of  septicaemia  of  the  newly-born  may  be  conveniently  classified  as 
follows : 

First  Group. —  Cases  of  umbilical  phlegmon,  winch  is  a  local  septic  dis- 
ease^ the  poison  entering  the  system,  from  an  umhiUcal  sore  and  being  con- 
veyed by  lymphatics. 

The  New  York  Infant  Asylum  at  Sixty-first  street  and  Tenth  avenue  has, 
during  the  twenty-three  years  of  its  existence,  been  remarkably  free  from 
contagious  and  infectious  diseases,  but  since  September  1,  1887,  seven  cases, 
in  which  septicaemia  was  diagnosticated,  occurred  in  new-born  infants  in  the 
maternity  ward  of  this  institution.  It  is  proper  to  state  that  at  the  same 
time  diphtheria  was  epidemic  in  the  asylum,  and  that  five  of  the  newly-born 
infants  had  diphtheria,  the  pseudo-membrane  appearing  in  its  usual  situation 
on  the  pharyngeal,  nasal,  and  laryngo-tracheal  surfaces,  and,  in  one  or  two 
of  the  patients,  also  lining  the  oesophagus.     Moreover,  two  of  the  five  infants 

^  Read  before  the  Pediatric  Section  of  the  New  York  Academy  of  Medicine,  Medi' 

cal  Neu's,  Sept.  8,  1888. 

^  Deutseh.  Archiv  fur  klin.  Med. 


116  DISEASES  OF  THE  NEWLY-BORN. 

with  diphtheria  had  umbilical  phlegmon  of  a  few  days'  duration,  when  the 
diphtheritic  exudate  appeared  upon  the  faucial  surface. 

The  question  is  therefore  a  proper  one,  whether  in  these  two  cases  the 
phlegmons  were  a  local  manifestation  of  diphtheria,  or  whether  the  umbili- 
cal phlegmon  and  diphtheria  were  distinct  diseases  having  a  different  microbic 
origin. 

Case  1. — Victor  M was  born,  after  normal  labor,  on  January  5,  1888,  and 

the  umbilicus  was  dressed  with  borated  cotton.  The  mother  did  well,  and  was  able 
to  leave  her  bed  on  the  seventh  or  eighth  day.  Nothing  unusual  was  noticed  in  the 
infant  until  January  11th,  when  a  little  suppuration  was  observed  in  the  umbilical 
fossa  at  or  around  the  point  of  attachment  of  the  cord,  but  on  examination  the  walls 
of  the  umbilicus  were  found  thickened  and  indurated.  The  appearance  indicated 
the  commencement  of  an  umbilical  phlegmon,  and  the  skin  covering  it  was  red  as 
in  erysipelas.  The  phlegmon  extended  in  area  until  January  14th,  when  the  thick- 
ening and  infiltration  reached  to  the  distance  of  about  one  and  a  half  inches  in  every 
direction  from  the  umbilicus,  so  that  the  form  of  the  phlegmon  was  circular  or 
wheel-shape.  Its  thickness  or  depth  near  the  umbilicus  was  perhaps  three-fourths 
of  an  inch,  but  near  its  margin  the  thickening  and  infiltration  were  less.  The  pulse 
on  the  13th  varied  from  132  to  144,  and  the  rectal  temperature  was  101.8°. 

The  case  was  carefully  watched  by  Drs.  Davis  and  Cook,  the  resident  physicians, 
whose  records  I  employ,  and  the  faucial  surface  was  daily  inspected  by  them.  On 
January  14th,  the  baby  being  nine  days  old,  they  observed  for  the  first  time  the 
grayish-white  exudate  of  diphtheria  on  each  side  of  the  fauces,  and  a  day  or  two 
later  also  upon  the  Schneiderian  surface,  so  closing  the  nostrils  that  respiration 
through  them  was  impossible.  The  baby,  on  attempting  to  draw  the  nipple,  became 
cyanotic  and  was  obliged  to  relinquish  its  hold.  During  the  14th  and  15th  the  tem- 
perature fell  to  98.5°  and  98°,  the  pulse  was  very  feeble  and  too  rapid  to  be  counted 
accurately,  and  the  respiration  varied  from  24  to  48.  Death  occurred  on  the  15th 
at  the  age  of  ten  days. 

The  autopsy  revealed  a  diphtheritic  pseudo-membrane  upon  the  faucial  surface 
on  both  sides,  extending  downward,  so  as  to  cover  both  surfaces  of  the  epiglottis, 
the  entrance  of  the  larynx,  and  the  laryngeal  surface,  completely  concealing  the 
vocal  cords  and  the  portion  of  the  larynx  above  them.  The  trachea  and  bronchial 
tubes  were  free  from  the  exudate.  The  lungs  in  nearly  every  part  were  thickly 
mottled  with  points  of  extravasated  blood,  and  less  abundant  extravasations  were 
observed  in  and  upon  other  organs.  The  umbilical  phlegmon,  removed  entire,  and 
in  a  frozen  state  from  the  intensity  of  the  cold  in  the  dead-house,  was  sent  to  the 
laboratory  of  the  College  of  Physicians  and  Surgeons,  where  it  was  carefully  exam- 
ined by  Dr.  Prudden.  He  reports  that  the  umbilical  vessels  were  in  their  normal 
state,  showing  no  evidence  of  disease,  except  the  mouth  of  the  umbilical  vein  or 
that  portion  of  the  vein  which  was  next  to  and  in  immediate  relation  with  the 
umbilicus.  Plugging  the  mouth  of  the  vein  and  extending  a  few  lines  along  the 
lumen  of  this  vessel  was  a  thrombus  or  blood-clot,  from  which  .Dr.  Prudden  was 
able  to  obtain  cultures,  and  in  the  culture-bed  two  forms  of  cocci  were  developed — 
to  wit,  the  staphylococcus  pyogenes  aureus,  occurring  in  the  usual  form  in  groups, 
and  the  streptococcus  pyogenes,  producing  beautiful  and  delicate  chains.  The  por- 
tion of  the  vein  enclosing  the  thrombus  or  clot  had  preserved  its  integrity,  so  that 
the  clot  was  entirely  distinct  from  the  phlegmon  which  covered  the  vein.  It  did 
not  seem  possible  that  microbes,  toxines,  or  elements  of  the  blood  could  pass  from 
one  to  the  other,  on  account  of  the  firm  coats  of  the  vein  which  were  interposed 
between  them. 

Portions  of  the  phlegmon  placed  in  culture  media  developed  the  same  forms 
of  cocci  as  those  produced  from  the  clot  that  plugged  the  mouth  of  the  vein.  We 
infer  that  the  cocci  were  the  septic  agents,  since  no  other  cause  of  the  septicEemia 
was  discovered,  and  that  they  were  received  from  the  umbilical  sore.  Some  entered 
the  thrombus,  and  others,  taken  up  by  lymphatics,  entered  the  tissues  which  sur- 
rounded the  umbilicus  and  gave  rise  to  the  phlegmonous  inflammation. 

It  is  easy  to  understand  how  micro-organisms  may  enter  the  umbilical 
vein  after  the  fall  of  the  cord,  when  there  may  not  be  complete  closure  of 
the  mouth  of  the  vessel.     But  it  can  scarcely  be  doubted  that  in  the  above 


SEPTICEMIA.  117 

case,  as  well  as  in  cases  whicli  I  am  about  to  relate,  the  septic  infection  took 
place  through  the  raw  and  denuded  surface  of  the  umbilical  fossa,  the  lyni- 
phatics  being  the  carriers  of  the  poison.  We  know  how  frequently  granu- 
lations sprout  out  from  the  umbilicus  of  the  new-born,  and  wherever  there  is 
a  surface  denuded  of  cuticle  from  which  these  may  arise  there  is  a  surface 
from  which  microbes  or  toxic  agents  may  be  absorbed.  The  umbilicus,  too, 
is  a  receptacle  in  which  microbes,  conveyed  in  the  floating  dust  of  an  apart- 
ment, in  foul  water  used  for  bathing,  in  dirty  sponges,  or  abdominal  binders 
or  umbilical  dressings,  would  be  likely  to  lodge.  M.  Bouchut,  in  his  remarks 
on  the  fall  of  the  umbilical  cord,  says :  "  Cords  voluminous,  soft,  and  plump 
dry  slowly,  and  often  suppurate  at  their  base  before  they  fall  (les  cordons 
volumineux,  mous  et  gras,  se  dessechent  lentement  et  suppurent  souvent 
a  leur  base  avant  de  tomber)."  ^  With  conditions  so  favorable  for  septic 
infection  it  is  perhaps  surprising  that  it  does  not  more  frequently  occur, 
especially  in  hospital  or  asylum  wards. 

The  patient  whose  case  I  have  related  evidently  had  systemic  infection. 
The  numerous  points  of  extravasated  blood  in  the  lungs  and  elsewhere 
showed  this.  But  doubt  must  arise  whether  this  general  infection  occurred 
from  the  phlegmon,  in  which  there  was  intense  hyperaemia  and  an  active  cir- 
culation, as  shown  by  the  inflammatory  redness  of  the  cuticle,  or  whether  it 
resulted  from  and  was  connected  with  the  diphtheria.  But  we  will  relate 
cases  of  systemic  infection  in  which  there  was  no  diphtheria  and  in  which 
the  septic  agent  or  agents  entered  the  system  through  the  umbilicus. 

The  volume  of  the  Transactions  of  the  London  Pathological  Society  for 
1879  contains  the  report  of  the  committee  appointed  by  that  society  to 
investigate  pyeemia,  septicaemia,  and  purulent  infection.  Their  report  is 
based  on  the  examination  of  the  records  of  156  cases  occurring  in  the  London 
hospitals,  and  it  throws  light  on  the  cause  of  hemorrhagic  extravasations 
occurring  in  cases  of  septicsemia.  They  remark  :  "  On  microscopical  examina- 
tion of  diff"erent  organs  micrococci  were  found  in  all,  or  at  least  in  some,  of 
the  viscera.  They  were  nearly  all  in  the  blood-vessels,  completely  plugging 
the  capillaries ;  in  masses  which  sometimes  produced  varicosities,  or  even 
rupture  of  the  vessels,  and  extended  into  the  contiguous  tissues."  ^ 

Case  2. — Hilda  M ,  born  February  28,  1888,  was  plump  and  robust,  weigh- 
ing eight  pounds  and  seven  ounces.  The  mother  appeared  to  be  well  until  March 
3d,  when  she  had  fever  and  symptoms  which  were  apparently  due  to  pelvic  cel- 
lulitis, probably  of  septic  origin.  The  infant  was  fretful  on  March  3d  and  4th, 
and  on  March  5th  a  small  ulcer  was  observed  in  the  umbilical  fossa.  The  skin 
surrounding  the  umbilicus,  over  an  area  the  size  of  a  silver  dollar,  had  a  deep- 
red  color,  and  the  tissues  underneath,  constituting  the  abdominal  walls,  were 
infiltrated  and  thickened.  The  phlegmon  gradually  extended  in  every  direction 
from  the  umbilicus,  so  that  on  March  6th  it  nearly  reached  the  ensiform  cartilage 
above  and  the  pelvis  below.  The  fauces  had  been  inspected  daily,  and  at  5  p.  m., 
March  6th,  the  grayish-white  exudate  of  diphtheria  was  observed  for  the  first  time, 
covering  the  tonsillar  portion  of  the  fauces  on  each  side.  On  March  7th  the  exudate 
had  increased,  the  cry  was  hoarse,  the  fingers  livid  at  times,  and  fluid  regurgitated 
through  the  nostrils.  The  phlegmon  occupied  nearly  the  entire  abdominal  walls 
anteriorly.  March  8th,  surface  cyanotic;  respiration  labored,  and  at  times  accom- 
panied by  the  expiratory  moan  ;  a  diphtheritic  pseudo-membrane  in  the  right  nostril. 
Death  occurred  at  6.30  a.  m.,  March  9th,  at  the  age  of  ten  days,  on  the  fourth  or 
fifth  day  of  the  phlegmon  and  on  the  third  day  of  the  diphtheritic  exudate  upon 
the  fauces.  The  rectal  temperature  varied  from  99.8°  to  102.8°  until  the  last  day, 
when  it  was  subnormal,  being  96.6° :  the  pulse  varied  from  99  to  112,  and  the  res- 
piration from  40  to  60.  Both  the  pulse  and  respiration  gradually  increased  in 
frequency  until  death,  this  increase  being  probably  largely  due  to  the  double  pneu- 

^  Traite  pratique  des  Maladies  des  Nouveau-nes,  etc. 
'^Brit.  Med.  Journ.,  January  24,  1880. 


118  DISEASES  OF  THE  XEWLY-BORN. 

monia.  The  tincture  of  the  chloride  of  iron  in  glycerin,  brandy,  and  breast-milk 
were  given  internally,  iodoform  and  carbolized  iron  applied  to  the  umbilicus,  and 
antiseptic  sprays  employed  for  the  fauces  and  nostrils. 

Prof.  T.  M.  Prudden  kindly  consented  to  conduct  the  autopsy,  which  was  made 
with  sterilized  instruments  and  under  conditions  designed  to  prevent  access  to  the 
body  of  adventitious  germs.     The  following  are  his  notes : 

Autopsy. — The  umbilical  orifice  was  covered  by  a  dry,  brownish  scab,  beneath 
which  was  a  small,  rough-edged  cavity  containing  a  yellowish  semi-solid  mass.  The 
abdominal  wall,  for  about  three  centimetres  around  the  umbilicus  on  all  sides,  was 
hard,  thickened,  and  dusky  red.  A  section  through  the  abdominal  wall  in  the  line 
of  the  umbilicus  showed  that  the  wall  was  thickened  to  about  1.5  centimetres  imme- 
diately around  the  latter. 

Both  the  umbilical  vein  and  the  hypogastric  arteries,  to  the  distance  of  about 
1.3  centimetres  from  their  attachment  to  the  abdominal  wall,  were  much  thickened, 
red  and  hard,  and  their  inner  layers  were  converted  into  a  soft,  yellowish,  friable 
material.  Beyond  this  point  all  of  these  vessels  were  filled  with  blood-clots  and 
appeared  healthy.  There  was  no  peritonitis,  and  all  of  the  abdominal  organs  were 
normal. 

The  heart  was  normal.  The  pharynx,  larynx,  and  trachea  showed  soft,  reddish 
friable  patches  of  diphtheritic  membrane  partially  covering  their  free  surfaces. 
This  membrane  did  not  extend  into  the  bronchi.  The  lungs  exhibited  broncho- 
pneumonia in  both  lower  lobes,  with  considerable  consolidation. 

The  microscopical  examination  of  the  parts  about  the  umbilicus  showed  that  at 
the  point  of  attachment  of  the  cord  was  a  small  pus-cavity  whose  walls  were  infil- 
trated with  small  spheroidal  cells,  with  a  few  rod-like  bacteria  and  with  large 
numbers  of  spheroidal  bacteria.  Similar  spheroidal  bacteria  were  found  in  the 
purulent  detritus  contained  in  the  cavity,  as  well  as  within  the  lumina,  and  infil- 
trating the  walls  of  the  adjacent  ends  of  the  umbilical  vein  and  the  hypogastric 
arteries. 

The  tissues  of  the  abdominal  walls  about  the  umbilicus  were  infiltrated  with 
serum,  fibrin,  and  a  moderate  amount  of  pus.  Spheroidal  bacteria  were  rather 
scantily  scattered  in  the  lymph-spaces  of  the  swollen  tissues,  being  most  abundant 
near  the  umbilical  vessels. 

Biological  examination  of  the  contents  of  the  inflamed  portion  of  the  umbilical 
vessels  showed  the  presence  of  several  species  of  bacteria.  The  species  which  was 
by  far  the  most  abundant  was  readily  identified  as  the  staphylococcus  pyogenes 
aureus. 

The  anatomical  diagnosis,  then,  is  diphtheria  of  the  pharynx,  larynx,  and 
trachea,  with  double  broncho-pneumonia,  localized  septic  inflammation  of  the 
umbilical  vein  and  hypogastric  arteries  and  of  the  abdominal  wall  surrounding 
them. 

As  the  evidence  of  local  infection  is  so  great,  it  seemed  desirable  to  gain  some 
data  as  to  the  purity  of  the  air  in  the  wards.  Accordingly,  such  analyses  as  time 
permitted  were  made  by  Dr.  T.  M.  Cheeseman,  Jr.,  who  presented  the  following 
report :  "A  biological  examination  of  the  air  in  the  lying-in  ward  of  the  New  York 
Infant  Asylum,  made  on  March  7,  1888,  showed  a  very  large  number  of  living 
bacteria  of  many  diiferent  kinds.  Among  them  the  staphylococcus  pyogenes  aureus 
was  of  frequent  occurrence.  A  second  examination,  made  immediately  after  the 
usual  sulphur  disinfection,  showed  a  large  number  of  living  germs.'' 

Case  3. — Janse  J ,  born  January  3,  1888,  was  wet-nursed  by  its  mother, 

and  apparently  did  well  until  January  16th,  when  the  attention  of  the  resident 
physician  was  directed  to  it,  and  an  umbilical  phlegmon  was  discovered  as  large 
as  a  twenty-five-cent  piece,  the  skin  covering  it  being  intensely  red  ;  temperature 
98.5°.  The  dressing,  after  the  discovery  of  the  phlegmon,  consisted  in  dusting  with 
iodoform  and  the  application  of  carbolized  oil  (one  part  of  carbolic  acid  to  twenty- 
five  of  sweet  oil).  January  17th,  phlegmon  not  extending  and  its  surface  less  red. 
The  redness,  thickening,  and  infiltration  gradually  abated,  and  on  January  21st 
the  patient  was  removed  from  quarantine.  In  this  case  there  was  no  record  of  an 
umbilical  sore ;  the  fauces  remained  normal,  so  that  the  diagnosis  of  diphtheria  was 
excluded.-    The  mother  continued  well. 

Case  4. — George  C was   born  in  the  maternity  ward  January  14th.     On 

January  25th  the  nurse  observed  a  small  vesicle  upon  the  border  of  the  umbilicus, 
and  removed  the  cuticle  coverins;  it.     Some  hours  afterward  the  attention  of  the 


SEPTIGMMIA.  119 

resident  physician,  Dr.  Davis,  was  called  to  it,  who  found  thickening  and  infiltra- 
tion of  the  umbilical  wall,  most  marked  on  the  side  which  had  been  occupied  by 
the  vesicle.  The  same  treatment  was  employed  as  in  Case  3.  The  records  of  Jan- 
uary 26th  and  27th  state  that  the  redness  and  infiltration  are  abating,  and  on  the 
29th  the  umbilicus  had  returned  to  the  normal  state. 

Case  5. — John  S ,  born  October  14,  1887,  the  mother  being  a  healthy  prim- 

ipara.  The  child  was  well  developed,  weighing  nine  pounds  and  four  ounces.  The 
cord  fell  on  the  sixth  day,  and  a  small  ulcer  with  indurated  edges  was  observed  in 
the  umbilical  fossa  at  the  point  of  attachment  of  the  cord.  The  induration  in  and 
around  the  umbilicus  increased  slowly  until  the  ninth  day.  On  the  ninth  day  the 
child  was  restless,  and  on  examination  the  ulcer  was  found  enlarged  and  surrounded 
by  a  zone  of  inflamed  tissue  half  an  inch  in  width.  The  inflammation,  accompanied 
by  the  usual  infiltration  and  swelling,  gradually  extended,  so  that  on  the  15th  the 
diameter  of  the  inflamed  area  was  two  inches.  The  ulcer  had  also  increased.  On 
the  twentieth  day  after  birth  the  ulcer  had  attained  the  diameter  of  two  inches  and 
the  depth  of  three-eighths  of  an  inch,  but  the  induration  had  begun  to  abate.  From 
this  time  improvement  was  progressive,  and  no  notes  were  taken  after  the  twenty- 
fourth  day.  The  rectal  temperature,  ascertained  each  day  from  the  ninth  to  the 
twenty-fourth  day,  varied  from  the  normal  to  102°.  During  the  active  period  of 
the  phlegmon  it  was  usually  from  100°  to  101.5°,  and  the  emaciation  was  pro- 
gressive, the  loss  of  weight  being  estimated  at  two  pounds.  The  treatment  con- 
sisted in  dusting  with  iodoform  and  the  use  of  a  compress  of  absorbent  cotton 
soaked  with  a  solution  of  carbolic  acid.  During  the  second  week,  under  the  advice 
of  the  attending  physician.  Dr.  George  P.  Fowler,  calomel  was  also  dusted  on  the 
sore.  On  the  twenty-fourth  day  the  infant  was  removed  to  the  Post-Graduate 
School,  and  its  subsequent  history  is  unknown.  The  mother  had  no  unfavorable 
symptom. 

Case  6. — Joseph  D ,  born  October  22,  1889,  well  developed,  weighing  seven 

pounds  thirteen  ounces.  The  cord  fell  on  the  eighth  day,  leaving  a  small  ulcer  at 
its  point  of  attachment  with  an  indurated  border.  Two  days  later,  the  tenth  day 
after  birth,  the  ulcer  had  increased  slightly,  being  one-quarter  of  an  inch  in  diameter. 
The  surrounding  tissues  to  the  distance  of  one  inch  were  thickened  and  indurated 
from  inflammation.  At  no  time  was  the  temperature  above  99.1°,  and  the  child, 
though  restless,  nursed  well.  The  tumefaction  and  hardness  surrounding  the  um- 
bilicus remained  about  the  same  until  the  sixteenth  day,  after  which  they  gradually 
abated.  The  ulcer  had  healed  at  the  end  of  the  fourth  week.  The  mother  on  the 
third  day  after  confinement  had  elevation  of  temperature  which  continued  four 
days,  and  six  weeks  after  the  birth  of  the  child  she  had  diphtheria  in  the  usual 
form.  During  the  same  month — October — twenty-seven  obstetrical  cases  were 
under  observation,  but  all  except  this  patient  convalesced  without  any  unfavorable 
symptom. 

Second  G-roup. —  Cases  in  ivMch  septicsemia  prohahly  occurred  hy  absorp- 
tion of  mfectioiis  matter  through  the  iiinhilical  vein. 

Case  1. — In  May,  1884,  an  infant  died  of  septicsemia  at  the  New  York  Infant 
Asylum  at  the  age  of  fifteen  days.  It  was  apparently  well  until  about  the  close 
of  the  first  week,  when  the  umbilicus  was  observed  to  be  raw,  and  a  slight  oozing 
of  a  puriform  liquid  occurred  from  it.  During  the  second  week  the  abdomen  was 
hard  and  tender,  and  peritonitis  was  diagnosticated.  The  cord  fell  on  the  seventh 
day.  During  the  second  week  the  abdomen  was  apparently  painful ;  the  tempera- 
ture three  days  before  death  Avas  100.6°,  and  two  days  before  death  102.4°.  Exam- 
ination of  the  chest  gave  a  negative  result.  The  post-mortem  examination  was 
made  by  Dr.  W.  H.  Welch,  now  professor  of  pathology  in  Johns  Hopkins  Univer- 
sity. The  abdomen  contained  six  ounces  of  turbid  serum  with  flakes  of  fibrin. 
The  portion  of  the  peritoneum  covering  the  umbilical  vein  and  along  the  under  sur- 
face of  the  liver,  especially  at  the  transverse  fissure,  was  covered  with  fibrin,  but 
the  peritoneum  generally  did  not  exhibit  any  notable  hypersemic  or  inflammatory 
appearance.  Lymphatic  vessels  filled  with  purulent-appearing  substance  could  be 
seen  in  the  under  surface  of  the  diaphragm,  showing  in  what  way  septic  infection 
extends  along  the  lymphatics.  The  lymphatics  of  the  diaphragm  open  upon  the 
pleural  surface,  and  it  is  probable,  had  the  patient  lived  longer,  that  septic  pleuritis. 


120  DISEASES  OF  THE  XEWLY-BOEy. 

perhaps  on  both  sides,  would  have  occurred.  The  umbilical  vein  was  filled  from  the 
umbilicus  to  the  transverse  fissure  of  the  liver  with  a  grayish  softened  detritus  con- 
sistino;  of  broken-down  thrombi  with  a  considerable  proportion  of  pus.  Softened 
thrombi  could  be  traced  the  entire  length  of  the  umbilical  vein,  the  walls  of  which 
were  thickened  and  infiltrated  from  inflammation.  No  thrombi  were  seen  in  the 
portal  vein  or  vena  cava;  the  pericardium  contained  more  than  the  normal  amount 
of  serum  with  flakes  of  fibrin  :  hemorrhagic  points  were  observed  in  the  posterior 
portions  of  the  lungs  under  the  endocardial  surface,  under  the  peritoneal  coverings 
of  the  kidneys  and  mucous  covering  of  the  calices.  The  mother  did  well,  giving 
no  evidence  of  disease  of  any  kind. 

Case  2. — This  infant,  born  in  the  New  York  Infant  Asylum,  the  date  not  being 
given,  was  well  developed  at  birth,  weighing  eight  pounds  six  ounces.  When  four 
or  five  days  old  it  became  feverish,  the  temperature  rising  to  104.6°.  The  cord 
separated  at  the  usual  time,  and  the  umbilicus  seemed  healthy.  At  the  age  of  two 
weeks  an  abscess  appeared  upon  the  scalp,  another  upon  the  back,  and  another 
upon  the  nates,  which  raised  the  suspicion  of  septic  poisoning.  At  the  age  of  four 
weeks  orchitis  on  one  side  occurred,  which  continued  three  weeks,  when  it  abated. 
When  the  child  was  two  months  old  a  prominence  appeared  about  half  an  inch 
above  the  umbilicus,  which  Dr.  Parker,  the  resident  physician,  punctured,  and  bile 
flowed  from  the  incision.  Subsequently  the  incision  closed,  and  bile  flowed  from 
the  umbilicus,  and  continued  to  flow  until  death,  which  occurred,  in  a  state  of  much 
emaciation  and  weakness,  at  the  age  of  eight  months. 

At  the  autopsy,  made  by  Prof.  AVelch,  remains  of  old  abscesses  were  found  upon 
the  trunk  and  extremities,  and  an  abscess  holding  four  drachms  of  pus  was  found 
over  the  occipital  bone.  Underneath  the  abscess  the  bone  was  carious  and  the  dura 
mater  thickened.  The  umbilical  vein  was  much  larger  than  normal,  its  walls  being 
infiltrated  and  thickened,  and  its  lumen  of  about  twice  its  usual  diameter.  It 
contained  thickened  bile.  One  of  the  branches  of  the  vein,  traced  into  the  liver, 
opened  into  an  abscess  the  size  of  a  walnut  which  contained  thickened  pus  with 
bile.  The  abscess  was  in  the  right  lobe  near  its  posterior  border.  The  mother 
remained  well. 

Case  3. — Lizzie  C ,  born  September  21, 1887,  robust,  weighing  eight  pounds, 

seemed  well,  taking  the  breast  and  having  normal  evacuations,  until  September 
28th,  when  she  became  restless  and  refused  the  breast.  Her  temperature,  rectal, 
was  101.4°,  and  her  respiration  was  accelerated  and  accompanied  by  the  expiratory 
moan.  September  20th,  temperature  103.6° ;  respiration  accelerated  and  painful 
and  abdomen  distended  ;  no  cough.  The  diagnosis  of  peritonitis,  probably  of  septic 
origin,  was  made,  but  the  umbilicus  was  of  usual  appearance,  and  the  desiccation 
and  fall  of  the  cord  seemed  normal.  The  elevation  of  temperature,  even  to  104.4°, 
the  distention  of  abdomen,  and  the  hurried  respiration  with  expiratory  moan  con- 
tinued until  death,  which  occurred  September  30th. 

At  the  autopsy  three  ounces  of  sero-purulent  liquid  containing  flakes  of  fibrin 
escaped  from  the  peritoneal  cavity.  All  the  abdominal  organs  were  covered  b}^  a 
fibrinous  exudation,  the  intestines  being  matted  together  by  it.  The  umbilical  vein 
was  pervious  :  it  contained  clots  of  blood  and  dirty-looking  pus,  but  the  umbilicus 
"was  apparently  normal.  A  segment  of  the  aortic  valve  was  thickened  and  rigid, 
and  attached  to  it  was  a  fibrinous  mass.  The  appearance  indicated  an  endocarditis 
of  slight  extent.  Under  the  microscope  the  walls  of  the  umbilical  vein  presented 
their  normal  appearance,  but  its  dirty-looking  and  disintegrating  contents  probably 
contained  septic  matter.  The  hepatic  cells  exhibited  the  peculiar  cloudiness  observed 
in  protracted  febrile  diseases.  Otherwise  the  organs  seemed  healthy.  In  this  case 
also  the  mother  remained  well. 

Case  4. — A.  B ,  born  January  22,  1868;  father  healthy,  but  mother  stru- 
mous, though  in  good  health  during  her  gestation.  The  infant,  born  after  an  easy 
labor,  was  apparently  well  at  birth  and  it  had  sufficient  breast-milk.  When  it  was 
thirteen  days  old  I  was  requested  to  visit  it,  as  it  had  not  been  doing  well,  and  I 
found  it  suffering  from  subcutaneous  abscesses.  Abscesses  had  occurred  upon  both 
legs,  in  the  chest-walls  of  the  right  mammary  region,  in  and  around  the  metatarso- 
phalangeal articulations  of  one  foot,  and  over  both  knee-joints.  The  child  had 
fever,  but  its  respiration  was  good  until  February  8th,  when  it  suddenly  had  a 
severe  attack  of  dyspnoea,  Avhich  continued  until  death,  ten  hours  subsequently.  On 
the  following  day  Dr.  Charles  A.  Leale  and  myself  made  the  autopsy.  The  body 
was  moderately  emaciated.     About  one  ounce  of  pus  escaped  from  the  right  knee- 


SEPTICEMIA.  121 

joint.  Pus  was  also  found  in  the  joint  of  the  great  toe  on  one  side,  and  about  two 
ounces  in  an  abscess  under  the  right  pectoral  muscle.  A  thin  layer  of  tissue  con- 
stituted the  internal  wall  of  the  a]3scess,  so  that  had  life  been  prolonged  a  few  days 
it  would  probably  have  broken  through  into  the  pleural  cavity.  The  right  lung 
was  completely  collapsed,  and  the  pleura  lining  this  lung,  as  well  as  that  lining  the 
thoracic  walls  on  the  same  side,  was  covered  by  a  fibrinous  exudation.  The  left 
lung  contained  the  normal,  or  perhaps  more  than  normal,  amount  of  air,  so  that  it 
filled  the  pleural  cavity,  but  there  was  a  small  amount  of  fibrinous  exudate  upon 
the  parietal  pleura  in  this  cavity. 

The  trachea  and  lungs  attached  were  removed,  and  on  practising  insufflation  of 
these  organs  air  escaped  from  three  openings  in  the  posterior  part  of  the  right  lung. 
These  openings,  through  which  air  had  passed  into  the  pleural  cavity,  causing 
collapse  of  the  entire  lung,  were  found  on  examination  to  have  been  produced  by 
small  abscesses  in  the  tissue  of  the  lung  near  its  posterior  surface.  By  the  rupture 
of  these  abscesses  the  pus  which  they  contained  escaped  into  the  pleural  cavity, 
producing  intense  general  pleuritis  and  pneumothorax.  Numerous  minute  ab- 
scesses were  found  in  both  lungs,  but  only  the  three  alluded  to  had  been  ruptured. 
It  seemed  certain  that  had  the  patient  lived  longer  other  abscesses  would  have 
ruptured. 

Case  5. — In  the  following  case  bacteria  were  found  making  their  way  along  the 
umbilical  vein  at  a  distance  fi'om  the  umbilicus,  and  also  in  the  tissues  involved  in 
the  umbilical  phlegmon.  Those  in  the  phlegmon  were  apparently  derived  from  the 
umbilicus  and  conveyed  by  the  lymphatics.  This  case,  therefore,  might  be  placed 
in  the  first  group  as  well  as  the  second : 

Anne was  born  in  the  New  York  Foundling  Asylum  on  May  18, 1888.     A 

few  days  after  birth,  and  before  the  cord  dropped,  the  umbilicus  was  observed  to  be 
foul  from  secretion  or  exudation  in  it,  indicating  a  sore  at  the  base  of  the  fossa.  On 
the  seventh  day  an  umbilical  phlegmon  was  noticed,  small  and  confined  to  the 
umbilical  walls.  Three  white  patches  were  also  observed  on  the  roof  of  the  palate 
near  the  velum,  not  raised  and  apparently  not  diphtheritic,  resembling  superficial 
ulcers.  All  the  infants  born  in  the  maternity  ward  of  the  Foundling  Asylum  were 
receiving  C rede's  treatment,  designed  to  prevent  purulent  conjunctivitis,  one  drop 
of  a  2  per  cent,  solution  of  nitrate  of  silver  being  instilled  between  the  eyelids  of 
each  eye.  Although  this  child  was  thus  treated,  she  had  a  pretty  active  purulent 
conjunctivitis  of  the  left  eye,  to  which  our  attention  was  now  called  for  the  first 
time  on  the  seventh  day.  Crede's  treatment  was  immediately  reapplied  to  this  eye, 
one  drop  being  introduced  between  the  lids.  This  was  followed  by  the  corrosive- 
sublimate  treatment  recommended  by  the  late  Prof.  Samuel  D.  Gross.  A  solution 
of  the  sublimate,  two  grains  to  the  pint,  was  dropped  between  the  lids  every  hour 
to  two  or  three  hours,  four  or  five  drops  being  used  each  time.  The  conjunctivitis 
rapidly  abated,  and  in  less  than  a  week  had  nearly  or  quite  disappeared.  But  the 
phlegmon  presented  a  very  angry  appearance,  and  the  umbilical  walls  were  greatly 
swollen,  red,  and  denuded  of  cuticle.  The  inflamed  area  had  a  diameter  of  about 
four  inches,  with  the  umbilicus  at  the  centre.  Iodoform  and  carbolized  oil  were 
applied  to  the  umbilicus  and  iron  and  stimulants  given  internally.  The  rectal  tem- 
perature, taken  May  26th,  was  98°.     Death  occurred  May  27th. 

Autopsy^  thirteen  hours  after  death. — Body  well  nourished ;  no  rigor  mortis  ;  no 
external  lesion  except  the  umbilical ;  the  phlegmon  definitely  outlined  and  hard,  its 
central  half  brown  and  dry  ;  the  infiltrated  abdominal  wall  had  twice  its  normal 
thickness ;  peritoneal  surface  of  phlegmon  congested  and  adherent  to  omentum ; 
from  this  point  to  the  transverse  colon  was  a  leash  of  dilated  vessels,  one  inch  in 
width  and  three  or  four  inches  in  length  ;  peritoneum  injected,  and  a  few  petechias 
observed  in  the  parietal  layer  and  the  mesentery  ;  mesentery  deeply  injected  ;  liver 
and  spleen  normal;  kidneys  soft  and  flabby;  points  of  hemorrhagic  pneumonia  in 
all  the  pulmonary  lobes ;  abundant  tenacious  mucus  covering  the  surface  of  the 
stomach  and  intense  injection,  showing  acute  gastritis  ;  cerebral  pia  mater  finely 
injected,  but  without  exudation ;  brain  normal.  Diagnosis :  umbilical  phlegmon, 
peritonitis,  acute_  gastritis,  hemorrhagic  pneumonia. 

Microscopical  and  Biological  Examination.,  by  Prof.  Prudden  at  the  Laboratory 
of  the  College  of  Physicians  and  Surgeons. — The  small  ragged  cavity  at  the  umbili- 
cus contained  a  moderate  amount  of  pus,  cell-detritus,  and  enormous  numbers  of 
bacteria  of  various  forms,  the  spheroidal  form  predominating.  The  tissues  of  the 
abdominal  wall  about  the  umbilicus  were  infiltrated  with  fluid,  fibrin,  and  pus ; 


122  DISEASES  OF  THE  NEWLY-BORN. 

scattei'ed  about  in  this  exudation-mass  were  small  spheroidal  bacteria.  The  hypo- 
gastric arteries  and  the  umbilical  vein  were  plugged  with  clots  extending  from  one- 
half  to  three-quarters  of  an  inch  from  their  origin  ;  their  walls  were  greatly  thick- 
ened by  infilti'ation  with  inflammatory  exudate.  Both  in  the  lumina  of  these  vessels, 
alone  the  sides  of  the  clots,  and  in  the  lymph-spaces  in  their  walls  were  enormous 
numbers  of  small  spheroidal  bacteria.  These  bacteria  were  present  in  the  umbilical 
vein  beyond  the  limits  of  the  clots  in  the  direction  of  the  liver. 

The  kidneys  showed  moderate  parenchymatous  degeneration.  The  consolidated 
areas  in  the  fungs  were  due  to  a  nearly  complete  filling  of  the  air-spaces  and  the 
smaller  bronchi  with  blood. 

Cultures  made  from  the  inflamed  tissue  about  the  umbilicus  and  from  the  edges 
of  the  sloughing  cavity  showed  several  species  of  bacteria  common  in  the  air  and  in 
the  fgeces  of  children.  In  addition  to  these  the  staphylococcus  pyogenes  aureus  was 
present  in  large  numbers.  A  set  of  cultures  from  the  inside  of  the  umbilical  vein, 
at  a  little  distance  from  the  sloughing  cavity,  revealed  the  presence  of  staphylococ- 
cus pyogenes  aureus  and  streptococcus  pyogenes,  together  with  other  forms.  Cul- 
tures from  the  liver  showed  large  numbers  of  staphylococcus  pyogenes  aureus,  with 
considerable  numbers  of  a  stout  bacillus  similar  to  one  abundant  in  the  sloughing 
cavity.  From  the  lung-tissue  from  the  consolidated  regions  enormous  numbers  of 
bacilli  developed  in  a  nearly  pure  culture,  which  corresponded  in  its  biological 
characters  to  the  bacterium  lactis  aerogenes  of  Escherich. 

Bemarks. — This  child  would  thus  seem  to  have  been  the  victim  of  infection 
with  the  ordinary  ''  suppurative  bacteria"  and  with  faeces.  We  infer  that  fecal  matter 
in  some  way  came  in  contact  with  the  umbilicus. 

Third  Group. — It  seems  prohahle  that  in  exceptional  instances  the  septic 
poison  of  the  neioJy-horn  is  received  in  other  ways  or  other  channels  than  the 
wmbilical  vessels. 

If  septicaemia  of  the  newly-born  occur  through  absorption  from  an  umbili- 
cal sore,  may  it  not  also  from  a  sore  located  elsewhere  ?  Decomposing  and 
disintegrating  animal  tissue,  wherever  located,  may  be  the  source  of  septic 
infection.  Moreover,  medical  literature  contains  histories  of  epidemics  of 
puerperal  fever  in  which  newly-born  infants  perished  with  what  was  often 
designated  erysipelas,  but  which  the  modern  pathologist  would  unquestion- 
ably designate  septicaemia.  The  disease  which  I  have  described  as  um- 
bilical phlegmon,  a  local  septic  disease,  was  commonly  regarded  by  the  older 
writers  as  a  form  of  erysipelas.  Dr.  Condie,  in  his  Treatise  on  Diseases  of 
Children,  described  in  the  following  lines  what  we  would  now  designate 
septicaemia. 

"  Erysipelas  of  infants  very  commonly  occurs  during  the  prevalence  of  epidemic 
puerperal  fever.  Children  of  mothers  who  become  affected  with  the  fever  are  often 
born  with  erysipelatous  inflammation ;  others  are  attacked  almost  immediately  after 
birth.  AVhether  in  these  cases  the  disease  is  to  be  referred  to  a  morbid  matter 
applied  to  the  skin  in  the  womb,  or  to  the  same  endemic  or  epidemic  influence 
which  gives  rise  to  the  disease  of  the  parent,  it  is  difficult  to  say.  According  to 
M.  Trousseau,  infantile  erysipelas  is  principally  observed  when  puerperal  fever 
prevails  in  the  wards  of  the  lying-in  hospitals  of  Paris." 

Q'he  late  Dr.  Folsom  of  this  city  furnished  me  with  the  following  sketch  of  cases 
which  occurred  in  his  practice  and  that  of  his  partner  :  "  About  the  year  1840, 
being  then  in  practice  in  New  Bedford,  Mass.,  I  was  called  to  visit  a  man  who 
comjilained  of  pain  in  the  knee.  The  next  morning  he  was  easier,  but  the  follow- 
ing evening  his  symptoms  grew  worse,  and,  as  I  was  engaged  in  a  case  of  obstet- 
rics, my  partner.  Dr.  E.  C,  now  dead,  visited  him.  At  my  call,  next  morning,  I 
unexpectedly  found  the  patient  dying.  The  disease  was  obscure,  and  at  the  autopsy 
next  day  no  lesion  was  discovered.  In  making  the  examination  Dr.  C.  pricked  his 
finger,  and,  experiencing  little  inconvenience  from  it  at  first,  he  attended  a  case  of 
confinement  on  the  following  morning.  A  few  hours  subsequently  he  was  taken 
sick,  and  I  took  charge  of  the  lady,  who  died  in  three  days,  having  the  tumid  abdo- 
men and  symptoms  of  childbed  fever.  The  infant  of  the  patient  was  seized  when 
two  days  old  with  erysipelas  appearing  on  the  face  and  in  spots  on  the  trunk  and 
limbs,  and  terminating  fatally  in  one  day.      Dr.  C.'s  finger  became  swollen  and 


THRUSH.  123 

painful,  and  the  lymphatics  of  the  forearm  and  arm  became  inflamed,  presenting 
red  lines,  and  the  axillary  glands  suppurated.  Though  feverish  and  much  pros- 
trated, there  was  no  appearance  of  erysipelas  in  his  case.  In  about  two  weeks  he 
resumed  practice,  and,  as  at  that  time  physicians  in  this  country  were  not  fully 
aware  of  the  danger  of  communicating  puerperal  fever,  he  attended  two,  three,  or 
four  obstetrical  cases  each  week  until  the  number  reached  fifteen.  All  the  mothers 
died  with  symptoms  of  metro-peritonitis,  and  all  the  infants  had  erysipelas,  com- 
mencing on  the  face  or  some  part  of  the  body,  generally  on  the  second  or  third  day 
after  birth,  and  in  all  terminating  fatally  within  a  week.  This  sad  record  was 
finally  ended  by  the  doctor  temporarily  retiring  from  practice." 

What  better  description  could  be  given  of  a  malignant  form  of  septic  infec- 
tion ?  It  will  be  observed  that  the  unfortunate  doctor  did  not  have  erysipe- 
las, but  inflammation  of  the  lymphatics  occurring  from  the  poisoned  finger, 
and  the  infant  who  first  contracted  the  disease  and  died  of  one  day's  sickness 
exhibited  red  spots  upon  the  trunk  and  limbs  of  an  erysipelatous  appear- 
ance. Did  the  doctor  poison  the  mothers  and  infants  at  the  same  time  by 
his  digital  examinations  ?  did  he  poison  the  mothers  by  his  infected  fingers, 
and  they  in  turn  poison  the  babies  through  the  placental  circulation  ?  For- 
tunately, the  profession  are  now  fully  aware  of  the  danger  of  septic  infection, 
so  that  no  intelligent  and  prudent  accoucheur  would  attend  an  obstetrical 
case  after  making  a  post-mortem  examination  or  visiting  a  case  of  puerperal 
fever  without  change  of  clothing  and  thorough  personal  disinfection,  and  con- 
sequently cases  belonging  to  our  third  group  are  much  more  rare  than 
formerly. 

It  is  evident  that  septicaemia  of  the  newly-born  might  be  prevented  in  a 
large  proportion  of  instances  by  proper  antiseptic  dressing  of  the  navel. 
Boric  acid  is  a  feeble  and  inefficient  antiseptic,  and  the  borated  cotton  which 
was  employed  in  dressing  the  navel  when  the  cases  in  the  maternity  ward 
occurred  which  have  been  related  above  was  inadequate  to  prevent  infection. 
Probably  umbilical  phlegmon  might  be  prevented  in  maternity  wards  by 
bathing  daily  the  umbilicus  with  a  solution  of  the  sublimate,  gr.  ij  to  the 
pint,  or  the  use  of  some  other  antiseptic. 

When  an  umbilical  phlegmon  has  commenced  we  have  employed  dusting 
with  iodoform,  the  application  to  the  navel  every  two  hours  of  carbolized 
sweet  oil  (1  :  30),  and  bathing  the  navel  with  a  solution  of  corrosive  subli- 
mate, two  grains  to  the  pint  of  distilled  or  boiled  water.  In  some  of  the 
cases  thus  treated  when  the  phlegmons  were  small  the  patients  gradually 
recovered,  but  in  most  of  the  cases  the  phlegmons  were  so  large,  and  the 
microbes  at  such  a  distance  from  the  umbilicus  in  the  tissue  of  the  abdomi- 
nal wall,  that  antiseptics  applied  upon  and  around  the  umbilicus  were  not 
curative.  Newly-born  infants  are  probably  too  young  and  feeble  to  be  satis- 
factorily treated  by  incisions  in  the  phlegmon  and  the  application  of  antisep- 
tics to  the  incised  surfaces,  else  this  treatment  might  be  more  efficient  than 
treatment  without  such  incisions. 


Thrush. 

The  terms  thrush,  sprue,  and  muguet — the  last  from  the  French — are 
synonymous.  They  are  used  to  designate  a  form  of  inflammation  of  the 
mucous  surfaces  the  peculiar  feature  of  which  is  the  presence  of  points  or 
patches  of  a  curd-like  appearance  on  the  inflamed  surface.  The  usual  seat 
of  thrush  is  the  buccal  membrane,  but  occasionally  it  occurs  on  the  faucial 
and  oesophageal  surfaces.  It  is  very  rare  in  the  subdiaphragmatic  portion 
of  the  digestive  tube,  but  a  few  such  cases  have  been  reported  by  Billard 


124  DISEASES   OE  THE  XEWLY-BOBN. 

and  others.  It  never  occurs  upon  the  membrane  of  the  nostrils,  larynx,  or 
bronchial  tubes,  and  it  very  seldom  occurs  upon  any  other  surface  without 
also  being  present  upon  the  buccal  mucous  membrane.  Thrush,  then,  is  a 
stomatitis,  pharyngitis,  oesophagitis,  or  gastro-enteritis  with  the  additional 
element  which  I  have  mentioned. 

Causes. — The  younger  the  infant  the  greater  is  the  liability  to  thrush 
when  the  causes  favorable  for  its  occurrence  are  present.  It  is  therefore 
common  in  infants  under  the  age  of  six  weeks,  and  a  majority  of  the  cases 
occur  under  the  age  of  six  months.  The  common  causes  of  this  disease  are 
such  as  ordinarily  develop  a  stomatitis,  prominent  among  which  are  improper 
feeding,  indigestion,  gastro-enteritis,  and  the  cachectic  state,  whether  arising 
from  prematurity,  congenital  weakness,  or  enfeebling  diseases.  The  most 
common  and  obvious  of  the  causes  alluded  to  is  the  use  of  indigestible  and 
improper  food,  which  produces  a  gastro-intestinal  catarrh,  soon  followed  by 
stomatitis.  Thrush  is  therefore  a  common  disease  among  foundlings  in  insti- 
tutions where  these  unfortunates  are  received,  since  they  not  only  breathe 
an  atmosphere  which  is  often  impure,  but  are  deprived  of  the  mother's  milk, 
and  are  so  frequently  given  a  diet  which  is  a  poor  substitute  for  it.  Infants 
in  crowded  tenement-houses  of  the  cities  and  in  destitute  families,  whose 
diet  is  often  very  unsuitable,  are  much  more  liable  to  thrush  than  infants 
well  fed  and  well  cared  for  in  well-to-do  families. 

In  infants  under  the  age  of  three  months  the  cause  of  thrush  is  often 
mild,  and  soon  removed  by  better  hygienic  conditions  and  improvement  in 
the  diet.  An  improper  diet  for  a  few  days,  or  a  slight  gastro-intestinal  catarrh 
which  quickly  subsides  when  the  cause  ceases,  is  sufficient  to  develop  the 
disease.  In  the  newly-born  the  frequent  use  of  sweetened  carminatives  or 
of  sweetened  dietetic  mixtures  administered  by  the  nurse  often  gives  rise  to 
sprue,  which  ceases  when  these  drinks  are  withheld  and  a  proper  mouth-wash 
applied.  But  after  the  age  of  six  months,  and  especially  after  the  age  of 
one  year,  the  condition  giving  rise  to  sprue  is  much  more  serious.  After  the 
age  of  twelve  months  sprue  is  comparatively  rare,  and  when  it  does  occur  it 
is  usually  in  the  later  stages  of  a  protracted  and  exhausting  disease ;  and  in 
such  cases  it  is  an  unfavorable  prognostic  sign.  Under  such  circumstances 
it  occurs  even  in  childhood,  youth,  and  adult  life,  and  is  justly  regarded  as  a 
complication  of  grave  import.  Thrush,  being  a  parasitic  disease,  is  com- 
municable by  contact,  like  the  parasite  skin  diseases.  Thus  in  the  wards  of 
a  foundling  asylum  the  tip  of  a  nursing-bottle  used  by  different  foundlings, 
if  not  properly  cleaned  after  its  use,  may  be  the  means  of  communicating  it. 
Thrush  is  so  common  in  young  infants  when  the  buccal  surface  is  in  a  state 
favorable  for  its  occurrence  that  it  is  probable  that  the  specific  germ  may 
also  be  received  from  the  atmosphere. 

Anatomical  Characters.- — The  first  stage  of  thrush  is  that  of  simple 
inflammation  of  the  mucous  surface.  The  mixed  salivary  and  mucous  secre- 
tions in  the  mouth,  which  are  normally  alkaline,  become  acid.  There  next 
appear  upon  the  mucous  surface  minute  semi-transparent  points  or  granules, 
which,  increasing,  soon  become  white  and  opaque.  Some  of  them  remain  as 
points,  while  others,  extending  and  perhaps  coalescing  with  those  adjoining, 
form  patches  of  greater  or  less  extent.  The  white  points  or  patches  are 
unequally  elevated.  Their  central  part,  which  was  first  formed,  is  most 
raised,  while  their  circumference  projects  but  little  above  the  epithelium. 
Their  highest  elevation  is  ordinarily  not  more  than  a  line  above  the  surface. 
They  resemble  closely  in  color  and  con.sistence  portions  of  curdled  milk,  and 
the  nurse  often  mistakes  them  for  such  and  neglects  to  call  attention  to  the 
state  of  the  mouth.  They  are  readily  detached  by  a  little  force,  when  the 
mucous  membrane  underneath  is  seen  to  be  in  its  integrity.     Their  color  in 


THRUSH. 


125 


the  first  days   of  sprue  is  white,  and   sometimes  this  color  continues.     In 
other  cases  they  assume,  if  the  disease  be  protracted,  a  yellowish  hue. 

Their  true  nature,  long  unknown,  was  finally  revealed  by  microscopy. 
They  consist  in  part  of  epithelial  cells  and  in  part  of  a  vegetable  growth. 
This  parasite  is  the  O'idium  albicans^  discovered  by  Berg  of  Stockholm,  but 
more  fully  described  by  Gruby  and  Charles  Robin.  The  roots  of  the  parasite 
are  transparent,  and  they  penetrate  the  epithelial  layer,  sometimes  even  to 
the  basement  membrane.  The  branches  arising  from  these  rootlets  divide 
and  subdivide  at  an  acute  angle,  and  under  the  mici'oscope  are  seen  to  con- 
sist of  elongated  cells  with  one  or  two  nuclei.  The  branches  or  the  mycelium 
is  formed  by  the  union  of  the  cells  at  their  extremities.  Numerous  spherical 
or  ovoid  spores  are  also  present  surrounding  the  mycelium  and  covering  the 
epithelial  cells.  Haller  states  that  he  has  identified  this  parasite  with  the 
O'idium  lactis,  which  occurs  in  milk  undergoing  acid  fermentation.  The 
spores  are  primarily  developed,  and  are  found  in  the  scraping  of  the  mucous 
surface  in  the  vicinity  of  the  patches  of  sprue.  In  two  instances  in  examin- 
ing the  product  of  thrush  removed  from  the  oesophagus  I  found  that  the 
parasitic  plant  was  the  Penicillium  glaucum  or  a  conferva  closely  resem- 
bling it. 

We  have  described  the  ordinary  form  of  thrush  as  it  occurs  in  young 
children,  but  if  the  patches  are  of  large  size  and  abundant,  and  the  buccal 
surface  generally  of  a  deep-red  color,  there  is  usually  some  severe  prostrating 
malady  on  which  the  thrush  has  supervened. 

We  have  already  alluded  to  the  fact  that  Fig.  12. 

thrush  in  its  severe  forms  often  complicates 
protracted  gastro-intestinal  catarrh  or  chronic 
pulmonary  malady.  Hence  some  writers 
who  have  observed  thrush  in  foundling 
asylums  regard  it  as  one  of  the  most  serious 
maladies  of  early  life.  Valleix,  in  a  book  of 
more  than  seven  hundred  pages  relating  to 
the  diseases  of  children,  devotes  more  than 
one-third  of  it  to  the  consideration  of  mu- 
guet,  but  those  pathological  conditions  per- 
taining to  the  digestive  apparatus  which 
most  observers  regard  as  distinct  from 
sprue,  though  sustaining  a  causal  relation  to 
it,  he  includes  in  the  description  of  muguet. 
Of  2-1  cases  the  records  of  which  he  pub- 
lishes, 22  died,  but  their  death  was  in  most 
instances  due  to  gastro-intestinal  inflamma- 
tion, which  the  author  describes  under  the 
term  '•  muguet."  Most  writers  properly  re- 
strict, as  stated  above,  the  term  thrush, 
sprue,  or  muguet  to  those  inflammations 
of  mucous  surfaces  which  are  accompanied 
by  the  peculiar  parasitic  outgrowth,  regard- 
ing the  severe  subdiaphragmatic  inflamma- 
tions from  which  Valleix's  patients  died  as 
distinct  from  muguet,  though  sustaining  a 
causal  relation  to  it.  In  the  post-mortem 
examinations  which  I  have  witnessed  in  the 
Nursery  and  Child's  Hospital,  Infant  Asylum, 
and  Foundling  Asylum  of  New  York  City, 
of  those  having  thrush  at  the  time  of  death,  who  for  the  most  part  have  been 


Pavement  epithelium  covered  by 
spores  of  the  O'idium,  albicans  (Ch. 
Robin). 


126 


DISEASES  OF  THE  NEWLY-BOBN. 


infants  under  the  age  of  three  months,  I  have  frequently  found  evidences  of 
inflammation  in  every  division  of  the  alimentary  canal.  The  parasitic  growth 
was,  however,  never  seen  below  the  oesophagus.  Parrot,  however,  states  that 
he  has  discovered  it,  in  rare  instances,  in  the  larynx,  stomach,  and  intestines. 
Symptoms. — Thrush  in  itself  does  not  give  rise  to  any  symptoms  except 
those  that  pertain  to  the  surface  which  is  the  seat  of  the  parasitic  growth. 
Other  symptoms  are  not  referable  to  it,  but  to  the  diseases  in  the  course  of 
which  it  is  developed  and  which  it  complicates.  Sprue  is  preceded  and 
accompanied  by  the   symptoms  of  gastro-intestinal   catarrh   or   some   other 

Fig.  13. 


Spores  and  branches  of  the  O'idiiim  albicans  (Ch.  Robin). 

disease  which  affects  the  digestive  apparatus  and  causes  acidity  of  the  buccal 
surface.  The  mucous  membrane,  upon  which  the  cryptogam  is  soon  to 
appear,  becomes  red,  hot,  tender  to  the  touch.  As  we  have  stated  above,  it 
gives  the  acid  reaction  more  or  less  marked  to  litmus-paper,  and  in  the  scrap- 
inf  from  its  surface  placed  under  the  microscope  the  spherical  or  oval  spores 
of'^the  Oidium  albicans  are  observed.  A  few  hours  later  small  white  points 
appear,  at  first  scarcely  visible,  produced  by  the  cryptogamic  growth  and  the 
epithelial  and  amorphous  matter  adherent  to  it. 

These  points  enlarge,  and  within  a  day  or  two  present  the  well-known 
appearance  of  small  masses  or  patches  of  curdled  milk.  They  are  fragile 
and  readily  detached,  but  are  soon  replaced  by  others  so  long  as  the  cause 
continues.  In  the  worst  forms  of  thrush  the  surface  upon  which  the  crypt- 
ogam appears  not  only  presents  the  ordinary  features  of  severe  inflammation, 
such  as  heat,  redness,  and  tenderness,  but  it  is  sometimes  deficient  in  the 
natural  secretion,  so  as  to  present  a  dry  or  parched  appearance.  In  these 
severe  cases  there  is  usually  in  young  infants  obstinate  and  protracted 
inflammation  of  the  subdiaphragmatic  portions  of  the  digestive  tube.  The  24 
cases  related  by  Valleix,  alluded  to  above,  22  of  which  were  fatal,  were  of 
this  kind.  But  the  gravity  of  such  cases,  in  which  thirst,  anorexia,  restless- 
ness, vomiting,  diarrhoea,  and  progressive  emaciation  occur,  is  due,  as  stated 
above,  to  the"  primary  disease  which  has  produced  the  conditions  favorable 
for  the  occurrence  of  sprue.  If  sprue  occur,  its  symptoms  should  be  dif- 
ferentiated from  the  more  pronounced  symptoms  of  the  disease  which  it  com- 
plicates. 


THRUSH.  127 

Diagnosis. — This  is  not  difl&cult  so  far  as  relates  to  thrusli  of  the  buccal 
surface,  for  simple  inspection  reveals  its  presence.  If  a  particle  of  one  of 
the  patches  be  placed  under  the  microscope,  the  mycelium  and  spores  of  the 
O'idium  albicans  are  readily  detected.  Only  the  inexperienced  could  mistake 
the  diphtheritic  exudate  for  the  growth  of  sprue  or  vice  versa.  The  diph- 
theritic pellicle  penetrates  the  mucous  membrane,  from  which  it  is  detached 
with  difficulty,  leaving  underneath  a  raw  and  bleeding  surface,  and  it  is 
thick  and  tough,  contrasting  in  these  particulars  with  the  product  of  sprue. 
Enlargement  of  the  cervical  glands  is  also  common  in  diphtheria  and  is  absent 
in  sprue. 

Particles  of  coagulated  casein  upon  the  tongue  and  gums  bear  a  close 
resemblance  to  the  patches  of  thrush,  but  their  relation  to  the  mucous  mem- 
brane is  simply  that  of  contact,  and  they  are  removed  by  a  spoonful  of  water. 

Prognosis. — The  duration  of  thrush  varies  according  to  the  duration  and 
nature  of  the  primary  disease  which  it  complicates.  In  young  infants  who 
have  indigestion  or  slight  gastro-intestinal  catarrh  it  is  quickly  cured  by 
appropriate  local  treatment  if  the  nutriment  given  be  of  the  proper  kind  and 
the  stomach  and  intestines  be  restored  to  their  normal  state.  On  the  other 
hand,  thrush  occurring  in  the  course  of  chronic  and  highly  debilitating  dis- 
eases is  not  so  quickly  cured,  or  if  cured  is  likely  to  return.  It  does  not 
materially  increase  the  gravity  of  the  malady  in  the  course  of  which  it 
occurs,  but  when  it  complicates  a  chronic  disease  it  indicates  a  reduced  state 
of  the  system,  an  impairment  of  the  general  nutrition,  which  if  it  continue 
is  likely  to  end  fatally. 

Sprue  is  a  bad  omen  if  the  tongue  and  buccal  surface  be  dry,  hot,  and 
highly  injected,  the  coating  of  the  tongue  of  brownish  color,  the  infant  fret- 
ful, with  the  appearance  of  suffering  in  its  physiognomy,  and  having  progres- 
sive loss  of  flesh  and  strength.  Such  symptoms  indicate  in  most  instances  a 
fatal  form  of  gastro-intestinal  catarrh.  On  the  other  hand,  in  young  infants, 
since  indigestion  and  slight  gastro-intestinal  derangements  are  adequate  to 
cause  an  acid  state  of  the  buccal  surface  and  the  development  and  extension 
of  the  O'idium  albicans,  the  large  majority  of  the  cases  of  thrush  in  which 
the  general  condition  is  good  and  the  stomatitis  mild  are  quickly  cured  by 
appropriate  treatment. 

Treatment. — Since  the  common  cause  of  thrush  in  infancy  is  the  use  of 
indigestible  or  improper  food,  the  physician  should  ascertain  the  nature  and 
mode  of  preparation  of  the  infant's  diet,  and,  if  it  be  faulty,  should  direct 
one  that  is  better.  If  the  infant  be  bottle-fed,  the  mother's  milk  or  that  of 
a  wet-nurse  should,  if  practicable,  be  substituted  for  the  artificial  feeding  ; 
but  if  this  be  impossible,  a  diet  should  be  selected  which  bears  the  closest 
possible  resemblance  to  the  mother's  milk  in  digestibility  and  nutritive 
properties. 

There  is  often  in  thrush  an  excess  of  acidity  in  the  digestive  tube,  and 
an  alkali  is  required.  Trousseau  recommends  the  addition  of  saccharate  of 
lime  to  the  milk.  Children  with  this  disease  should  also  be  taken  from  filthy 
and  damp  apartments  to  those  in  which  the  air  is  pure  and  dry,  and  their 
mouths  and  persons  should  be  kept  clean. 

The  remedy  in  common  use  in  the  treatment  of  thrush,  and  which  is 
usually  effectual,  is  borax.  This,  if  applied  sufficiently  often  to  the  affected 
membrane,  not  only  destroys  the  parasitic  growth,  but  prevents  its  reproduc- 
tion. It  is  commonly  employed  with  honey  or  in  a  powder  with  sugar  or 
dissolved  in  water.  The  officinal  mel  boracis,  consisting  of  one  part  of  borax 
to  eight  of  honey,  is  so  much  used  in  families  that  it  may  be  considered 
almost  a  domestic  remedy.  There  is,  however,  an  objection  to  using  any 
application  for  the  removal  of  thrush  which  contains  either  sugar  or  honey. 


128  DISEASES  OF  THE  NEWLY-BORN. 

since  either  substance  remaining  in  the  mouth  would  rather  promote  the 
growth  of  the  parasite.  Still,  it  is  desirable  to  employ  a  wash  of  such  con- 
sistence that  it  will  remain  a  longer  time  in  contact  with  the  buccal  surface 
than  will  a  simple  solution  in  water.  I  know  no  better  vehicle  for  the  borax 
than  glycerin,  which  has  the  advantage  of  consistence,  does  not  undergo  any 
chemical  change,  and  has  no  unpleasant  flavor.  The  borax  may  be  used  dis- 
solved in  glycerin,  with  or  without  some  flavoring  ingredient : 

K.  Sodii  borat.,  3J  ; 

Glycei'ini,  ^ij  ; 

Aquse,  ^j. — Misce. 

This  wash  should  be  applied  four  or  five  times  daily,  and  continued  for  a 
time  after  the  disease  has  disappeared  from  sight,  since  the  roots  of  the  plant 
must  be  destroyed  or  the  branches  are  rapidly  reproduced.  It  should  be 
applied  by  a  camel's-hair  pencil  or  with  a  soft  cloth  upon  the  finger  or  a 
stick.  It  should  be  so  freely  used  in  extensive  and  severe  forms  of  the 
disease  that  the  infant  will  swallow  some,  since  the  entire  oesophagus  may  be 
also  the  seat  of  sprue  in  such  eases.  In  the  intervals  between  the  applica- 
tions of  borax,  if  the  buccal  surface  be  hot,  dry,  and  tender,  so  as  to  increase 
the  fretfulness  of  the  infant,  it  is  well  to  use  mucilaginous  washes,  as  the 
mucilage  of  acacia  or  mallows.  If  the  disease  continue  notwithstanding  the 
use  of  the  borate  of  sodium,  the  aeidum  boricum  may  be  properly  employed 
with  it,  as  in  the  following  formula : 

R .  Sodii  borat. , 

Acidi  borici,  da.  ^j  ; 

Glycerini,  .^^ij ; 

Aquae  anisi,  q.  s.  ad  ^iv. — Misce. 

For  a  mouth-wash,  applied  hourly  or  every  two  hours. 

In  many  cases,  however,  the  treatment  of  thrush  is  of  less  importance 
than  that  of  the  disease  which  the  thrush  complicates.  The  remedial  meas- 
ures which  I  have  mentioned  then  become  subordinate  to  those  employed  for 
the  graver  disease.  When  this  disease  is  relieved  and  the  general  health 
improves,  thrush  is  more  easily  and  permanently  cured  than  during  the  state 
of  feebleness  and  ill-health. 


CHAPTER    III. 

DIAEEHCEA,  CONSTIPATION,  AND  TETANUS  OF  THE  NEW-BOEN. 

Diarrhoea  of  the  Newly-born. 

The  colostrum,  or  the  first  secretion  of  the  mammary  glands  after  partu- 
rition, contains  more  oily  matter  and  sugar  than  occur  in  the  subsequent 
secretion.  In  consequence  of  this  peculiarity  in  its  composition  the  colos- 
trum has  a  laxative  efiiect  by  which  the  meconium  is  expelled.  If  the  mam- 
mary glands  continue  to  secrete  colostrum  after  the  first  week,  diarrhoea  is 
likely  to  result.  A  more  common  cause  of  diarrhoea  of  the  newly-born  is  the 
employment  of  various  sweetened  mixtures  by  mothers  or  nurses  in  the  belief 
that  the  breast-milk  is  inadequate,  or  they  are  employed  for  the  purpose  of 
relieving  the  supposed  colicky  pains  whenever  the  baby  frets.  Cane-sugar 
added  to  the  various  mint  teas  not  only  gives  rise  to  diarrhoea,  but  also  in 
time  to  more  or  less  gastro-intestinal  catarrh  and  stomatitis,  with  the  occur- 
rence of  sprue.  Sprue  is  more  common  in  the  newly-born  than  at  any  other 
period  of  life,  and  it  can  usually,  according  to  my  experience,  be  traced  to 


BIARBHCEA  AND  CONSTIPATION.  129 

the  use  of  improper  sweetened  mixtures.  The  infant  immediately  after  birth 
may  be  given  a  little  sweetened  water  or  a  teaspoonful  of  sweet  oil  to  aid  in 
the  expulsion  of  the  meconium,  but  subsequently,  in  the  great  majority  of 
cases,  no  carminative  or  nutritive  mixtures  are  required.  The  breasts  of  the 
mother  if  she  have  the  usual  health  furnish  all  that  is  needed.  The  neonatus 
requires  almost  no  nutriment  during  the  first  three  days,  and  the  breasts  fur- 
nish but  little  during  this  time,  but  frequent  traction  upon  the  nipple  pro- 
motes the  mammary  secretion,  and  after  the  third  day,  in  ordinary  cases, 
sufiicient  nutriment  is  obtained  from  the  breasts  to  supply  the  wants  of  the 
system  and  promote  a  healthy  growth.  If  what  is  natural  were  left  to  itself, 
and  no  artificial  measures  were  employed,  the  result  in  most  instances  would 
be  good ;  but  the  unfortunate  practice  of  filling  the  infant's  stomach  with 
various  admixtures  disturbs  normal  digestion,  impairs  the  appetite,  causes 
colicky  pains,  vomiting,  and  diarrhoea,  and,  if  persisted  in,  gastro-intestinal 
catarrh.  In  many  cases  green  fermenting  and  unhealthy  stools  cease,  and  a 
more  normal  state  of  the  digestive  apparatus  is  produced  by  forbidding  the 
use  of  superfluous  and  injurious  food  and  drinks  which  had  been  given  to 
supplement  wet-nursing  in  the  mistaken  belief  that  more  food  was  required. 
Food  in  excess,  even  if  it  be  of  the  proper  quality  or  it  be  breast-milk,  usu- 
ally causes  diarrhoea  if  it  be  not  vomited,  since,  not  being  digested,  it  under- 
goes fermentative  changes,  and  acts  as  an  irritant  until  it  is  expelled.  We 
have  treated  of  this  subject  elsewhere. 

Diarrhoea  in  the  newly-born,  whatever  its  cause,  should  be  immediately 
arrested.  After  the  meconium  is  removed  by  the  action  of  the  colostrum, 
three  daily  evacuations  from  the  bowels  are  sufiicient.  A  larger  number  is 
usually  attended  with  loss  of  flesh  and  strength.  The  use  of  sweetened  mix- 
tures, which  nurses  are  in  the  habit  of  administering  when  infants  are  not 
well,  as  catnip,  fennel,  or  aniseed  tea,  we  repeat,  must  be  strictly  forbidden. 
A  mother  with  a  sick  and  fretful  infant  usually  applies  it  to  the  breast  too 
frequently,  even  every  half  hour  during  the  day.  This  should  also  be  strictly 
forbidden.  The  infant,  like  the  adult,  should  take  food  at  stated  intervals, 
so  that  the  digestive  organs  may  have  some  respite  from  the  task  of  diges- 
tion. The  application  of  the  new-born  infant  to  the  breast  twelve  times  in 
twenty-four  hours  is  sufiicient  for  its  nutrition,  and  the  mother's  health  is 
better  preserved  and  her  milk  of  better  quality  than  when  she  is  deprived 
of  the  needed  rest  by  more  frequent  suckling.  If  the  infant  be  unfortunately 
deprived  of  breast-milk  and  be  bottle-fed,  the  utmost  care  is  required  in  the 
selection  and  preparation  of  the  food,  as  well  as  in  determining  the  amount 
of  food  to  be  given  and  the  frequency  of  feeding.  Facts  relating  to  this 
important  subject  have  been  presented  in  preceding  pages. 

If  the  diarrhoea  do  not  cease  by  the  use  of  the  proper  diet  given  in  suit- 
able quantity  at  proper  intervals,  medicinal  treatment  is  needed.  I  have 
found  the  following  prescriptions  very  useful  for  the  diarrhoea  of  infants 
under  the  age  of  one  month,  as  well  as  for  those  that  are  older : 

B .   Bismuthi  subnitrat. ,  .^iij  ; 

Pepsini  pui'i  in  lamellis,  3j. — Misce. 

Give  as  much  as  goes  on  a  ten-cent  piece  before  each  suckling  or  feeding. 

R.   Bismuthi  subnitrat. ,  ^ij  ; 

Wyeth'  s  elixir  of  digestive  ferments,  or  Fairchild'  s 

essence  of  pepsin,  ^^j  ; 

Aquae  destillat.,  5iij. — Misce. 

Shake  bottle.     Give  20  drops  before  each  suckling  or  feeding. 
9 


130  DISEASES  OF  THE  NEWLY-BORN. 

A  clyster  of  bismuthi  subnitrat.,  gr.  v  to  x  ;  resorcini,  gr.  iij  ;  aqusa 
purse,  5J — Misce,  is  also  frequently  useful  for  the  diarrhoea. 

Constipation  of  the  Newly -born. 

In  the  infant  constipation  results  from  several  different  causes.  The  most 
serious  and-  obstinate  form  of  it,  to  which  the  term  obstipation  is  more  appro- 
priately applied,  arises  from  intestinal  malformations.  In  rare  instances  con- 
genital obstruction  occurs  in  the  small  intestines.  It  is  sometimes  produced 
by  cystic  tumors  or  twisting  of  the  intestine.  Congenital  stenosis  occasion- 
ally occurs  at  the  ileo-caecal  orifice.  Thus  in  the  Transactions  of  the  Londori 
Pathological  Society  for  1870  is  the  history  of  a  case  in  which  there  was  such 
narrowing  of  the  ileo-caecal  orifice,  believed  to  be  congenital,  that  a  No.  9 
catheter  could  barely  be  passed  through  it.  The  patient  lived  until  his 
thirty-second  year,  but  throughout  his  life  suffered  from  constipation  and 
colic.  After  his  death  the  ileum  next  to  the  ileo-csecal  valve  was  found  to 
have  a  diameter  of  seven  inches,  while  the  large  intestine  was  much  atrophied 
and  its  entire  lumen  contracted  from  disuse.  Occasionally  the  stenosis  occurs 
a  little  above  the  ileo-caecal  orifice,  and  rarely  in  the  duodenum  at  the  point 
of  union  of  the  pancreatic  or  bile-duct  with  the  intestine.  The  obstacle  in 
some  instances  appears  to  be  hypertrophied  valvulae  conniventes,  the  edges 
of  two  opposite  folds  being  more  or  less  adherent.  Such  congenital  intestinal 
obstructions— whether,  as  is  probable,  produced  by  inflammations  in  the  foetus 
or  from  simple  perverted  nutrition ;  whether  arising  from  the  syphilitic 
cachexia  or  other  cause — of  course  retard  the  evacuations  according  to  their 
location  and  the  amount  of  closure.  The  same  degree  of  stenosis  in  the  colon 
or  rectum  obviously  causes  a  more  constipating  effect  than  in  the  small  intes- 
tines, since  the  latter  have  more  mobility  than  the  former  and  their  contents 
are  more  liquid. 

But  the  most  common  of  the  congenital  obstructions  in  the  intestines 
occur  from  malformations  of  the  rectum.  These  malformations  vary  con- 
siderably in  different  cases.  They  may  be  classified  in  at  least  four  different 
groups:  1st.  The  anus  may  appear  normal,  but  instead  of  the  normal  rectum 
two  cul-de-sacs  are  present,  representing  the  upper  and  lower  ends  of  the 
rectum,  and  connected  by  an  occluded  segment  of  the  rectum  or  by  a  firm 
fibrous  cord.  2d.  The  anus  is  absent,  and  the  rectum  has  a  fistulous  opening 
in  the  perineum,  or  through  the  scrotum  in  the  male  or  vulva  in  the  female. 
In  the  embryonic  development  the  outlet  of  the  rectum  was  formed  too  near 
and  encroached  upon  the  sexual  apparatus.  3d.  The  anus  is  absent  and  there 
is  no  external  fistulous  opening  representing  the  anus,  but  the  rectum  opens 
at  some  point  upon  the  mucous  membrane  of  the  genito-urinary  apparatus. 
4th.  Anus  absent  and  the  entire  lower  part  of  the  rectum  obliterated.  The 
upper  portion  of  the  rectum  terminates  in  a  cul-de-sac  in  the  neighborhood 
of  the  promontory.  Some  of  these  malformations  do  not  prevent  the  dis- 
charge of  fecal  matter,  but  when  there  is  closure  of  the  rectum  and  no  fistu- 
lous opening,  of  course  no  evacuation  of  the  intestines  can  occur  unless  relief 
be  obtained  by  surgical  measures.  In  the  ordinary  form  of  occlusion  a  por- 
tion of  the  rectum  is  represented  by  a  cord,  or  a  firm,  unyielding  septum  shuts 
off  the  lower  part  of  the  rectum  from  that  above,  so  that  defecation  is  impos- 
sible. The  infant  with  this  serious  malformation  takes  the  breast  for  a  time 
like  other  infants,  but  the  intestines  soon  become  distended  with  fecal  matter, 
and  restlessness  from  the  distention  and  vomiting  occur.  The  only  mode  of 
relief  is  by  an  incision  or  puncture  through  the  obstruction ;  but  a  large  pro- 
portion of  infants  with  this  obstructive  malformation  die  whether  operated  on 
or  not.     The  surgical  treatment  of  these  cases  will  be  discussed  elsewhere. 


DIARRHCEA  AND   CONSTIPATION.  131 

The  great  length  of  the  sigmoid  flexure  in  infancy,  and  the  curvatures 
which  occur  in  consequence,  more  in  number  than  in  older  children,  tend  to 
retard  the  descent  of  fecal  matter  and  promote  constipation.  In  the  adult 
numerous  depressions  and  inequalities  in  the  colon  retard  the  downward 
movement  of  the  intestinal  contents,  but  in  infancy  the  surface  of  the  colon 
is  comparatively  smooth  and  even,  and  the  detention,  so  far  as  any  exists, 
occurs  from  the  curvatures  or  loops,  which  are  sometimes  twisted  partially 
on  their  axes.  The  sigmoid  flexure  is  so  long  in  infants  under  the  age  of 
ten,  and  especially  of  six  months,  that  the  curvatures  usually  lie  in  part  to 
the  right  of  the  median  line,  and  even  in  the  right  iliac  fossa.  Those  who 
have  witnessed  the  post-mortem  examinations  of  young  infants  in  the  asylums 
find  no  difiiculty  in  accepting  the  statements  of  certain  writers  that  the  cur- 
vatures or  loops  in  the  sigmoid  flexure,  which  sometimes  extend  as  high  as 
the  umbilicus  and  laterally  to  the  right  iliac  fossa,  cause  habitual  constipa- 
tion in  some  infants. 

Occasionally  in  young  infants,  as  well  as  in  those  who  are  older,  the  intes- 
tines act  sluggishly  from  insufiiciency  of  food.  Thus  the  infant  sometimes 
hangs  an  unusually  long  time  on  the  breast,  and  the  mother  or  wet-nurse 
believes  it  to  be  a  hearty  nurser,  when  there  is  really  a  deficiency  of  milk, 
and  the  stools  are  scanty  and  infrequent  from  lack  of  material :  under  such 
circumstances  the  infant  is  restless  when  away  from  the  breast,  or,  not  being 
fed,  loses  flesh,  and  soon  has  the  appearance  of  one  in  ill-health.  These  symp- 
toms disappear  upon  the  supply  of  a  more  liberal  allowance  of  food  of  proper 
quality. 

Again,  a  constipated  state  of  the  bowels  occasionally  occurs  in  infants 
who  nurse  heartily  and  seem  to  obtain  a  sufiicient  quantity  of  milk  ;  and  the 
cause  of  it  appears  to  be  in  the  state  of  the  digestive  organs,  and  not  in  the 
milk.  We  find  now  and  then  that  breast-milk  has  a  constipating  eff"eet, 
although  we  discover  nothing  in  the  mother's  diet  or  health  to  cause  this 
result.  The  comparison  of  ordinary  breast-milk  with  colostrum  may  furnish 
an  explanation  of  the  constipation  under  such  circumstances.  Colostrum  is 
known  to  be  more  laxative  than  ordinary  milk,  and  it  difi"ers  from  it  chemi- 
cally in  containing  more  butter,  sugar,  and  salts.  Hence  the  theory  seems 
plausible  that  when  breast-milk  is  constipating  these  elements  occur  in  less 
than  the  normal  quantity,  and  we  will  find  that  treatment  suggested  by  this 
theory  tends  to  obviate  the  constipation. 

Constipation  has  also  been  attributed  to  a  deficiency  in  the  intestinal 
secretions  and  to  too  great  viscidity  of  them  from  lack  of  water.  Deficient 
peristalsis,  whether  from  congenital  weakness  or  other  cause,  also  leads  to 
constipation.  The  use  of  starchy  foods  without  sugar  or  with  but  little  sugar 
also  sometimes  has  a  constipating  eff"ect. 

Gautier  of  Geneva,  Switzerland,  states  that  an  anal  fissure  is  a  common 
cause  of  constipation,  whether  in  the  newly-born  or  older  infants.  If  such  a 
fissure  be  present,  pain  in  defecation  might  instinctively  lead  the  infant  to 
resist  the  desire  to  evacuate  the  bowels  and  to  postpone  the  act,  so  as  to  estab- 
lish a  constipated  habit ;  but  if  such  fissures  are  common  in  this  country, 
except  in  the  syphilitic,  they  have  escaped  our  notice. 

Finally,  constipation  has  a  tendency  to  perpetuate  itself,  since  retained 
feculent  matter  becomes  more  consistent  and  firmer,  and  the  contractile  power 
of  the  muscular  tissue  becomes  weakened  by  over-distention. 

Symptoms. — When  there  is  a  mechanical  cause  of  scanty  and  infrequent 
defecation,  the  acuteness  of  the  symptoms  and  the  suff"ering  are  usually  pro- 
portionate to  the  degree  of  obstruction.  In  cases  of  complete  obstruction  of 
the  intestines,  as  in  imperforate  rectum,  fecal  accumulation  occurs  above  the 
obstruction.     Under  such  circumstances  distention  of  the  abdomen,  vomiting, 


132  DISEASES  OF  THE  NEWLY-BORN. 

fretfulness  apparently  from  the  abdominal  pain,  and  progressive  loss  of  flesh 
and  strength,  indicate  the  serious  nature  of  the  disease. 

In  constipation  from  other  causes— that  is,  without  obstruction  except 
such  as  arises  from  fecal  accumulation — the  condition  of  the  infant  may- 
attract  little  attention  at  first ;  but  if  it  do  not  have  proper  evacuations,  it 
soon  begins  to  suff"er  in  its  health.  Fretfulness,  an  unhealthy  physiognomy, 
vomiting,  and  more  or  less  fever  occur  until  the  patient  is  relieved  of  the 
ailment. 

The  TREATMENT  of  coHstipation  in  the  new-born,  as  well  as  in  older  chil- 
dren, we  will  consider  elsewhere. 

Tetanus  Neonatorum. 

Several  years  ago  Humboldt  wrote  that  there  is  no  subject  in  the  whole 
range  of  scientific  investigation  more  obscure  than  the  causation  and  spread 
of  the  acute  infectious  diseases.  Humboldt  did  not  live  long  enough  to 
witness  the  wonderful  discoveries  by  the  microscope  and  the  light  thrown  by 
this  instrument  on  the  obscure  subject  which  puzzled  him  whose  investiga- 
tions embraced  the  whole  universe. 

In  the  decade  commencing  with  1880  the  bacillus  which  causes  tetanus 
was  discovered  by  the  conjoined  labors  of  distinguished  bacteriologists, 
among  the  earliest  and  most  successful  of  whom  was  Mcolaier,  so  that  the 
bacillus  was  at  first  designated  by  his  name.  In  November,  1886,  Eosenbach 
produced  tetanus  in  two  guinea-pigs  by  inserting  under  their  skin  small  por- 
tions of  gangrenous  material  from  the  ulcer  of  an  individual  having  tetanus. 
He  also  demonstrated  the  fact  that  the  bacillus  of  Nicolaier  is  capable  of 
causing  tetanus  in  animals.  These  discoveries  excited  great  interest,  and 
were  soon  followed  by  the  important  chemical  researches  of  Brieger,  by 
which  he  isolated  a  toxine  occurring  in  the  cultures  of  the  bacilli  of  tetanus 
and  generated  by  them.  This  toxine  has  the  formula  Ci3,H3o,Az.,,04,  and 
it  produces  tetanus  when  injected  under  the  skin  of  an  animal  susceptible  to 
this  disease,  while  the  bacilli  deprived  of  this  toxine  by  filtration  are  inert. 
Brieger  also  states  that  he  extracted  from  the  same  cultures  two  other  toxines 
of  great  activity,  which  he  designates  tetanotoxine  and  spasmotoxine.  The 
setting  free  of  these  toxines  was  accomplished,  according  to  Brieger,  with 

the    disengagement    of   sul- 
jTjQ    14  phuretted    hydrogen.     Bac- 

teriologists      describe      the 
*         ^  bacillus   of  tetanus   as  hav- 

a      0^^  iiig    twice     or     thrice     the 

'q       '^  length     of    the     tubercular 

«  ^^  bacillus,    but     thicker    and 

^      V  J  straighter,   and   knobbed   or 

'/*    o    ^       enlarged    at    one    extremity 
J  A  so  as  to  be  designated  pin- 

B  shaped.      Bonome,      among 

The  tetanus  bacillus.  Others,     made     microscopic 

examinations  and  cultures 
of  this  bacillus  obtained  from  the  wounds  or  sores  of  human  beings,  horses, 
and  sheep.  Among  micrococci  and  bacilli  of  various  sizes  and  forms  he 
observed  the  constant  presence  of  the  fine  bristle-shaped,  pin-headed  bacillus 
identical  with  that  described  by  Nicolaier.  Bonome  endeavored  in  vain  to 
obtain  pure  cultures  of  the  bacillus,  and  concluded  that  it  did  not  thrive 
except  in  company  with  the  germs  of  putrefaction. 

The  recent  cultivation  of  the  tetanus  bacillus  in  the  laboratory  of  the 


A 


TETANUS  NEONATORUM. 


133 


Fig.  15. 


chemist  is  a  fact  of  great  interest,  and  one  that  throws  light  on  the  causa- 
tion of  tetanus,  whether  in  the  infant  or  adult.  The  process  is  described  by 
Mr.  R.  T.  Hewlett,  demonstrator  of  bacteriology  in  King's  College,  in  the 
London  Lancet^  July  1-i,  1894,  as  follows :  "  In  order  to  obtain  the  chemical 
products  for  inoculation  and  other  purposes,  the  bacillus  of  tetanus  may  be 
grown  without  the  use  of  any  complicated  apparatus  in  an  atmosphere  of 
hydrogen,  in  the  following  manner ;  Yeast-flasks  of  about  90  c.  c.  capacity 
are  made  use  of,  and  are  filled  three  parts  full  with  a  2  per  cent,  grape- 
sugar  bouillon.  The  neck  is  corked  with  a  perforated  rubber  cork  through 
which  a  glass  tube  passes  to  the  bottom  of  the  flask,  projects  two  inches 
above  the  rubber  cork,  and  is  plugged  near  its  top  with  cotton  wool,  care 
being  taken  that  the  plugs  are  loose  enough  to  allow  air  to  pass  freely.  The 
whole  is  sterilized  and  inoculated  and  allowed  to  remain.  The  glass  tube,  which 
passes  through  the  rubber  cork,  is  then  connected  with  a  Kipp's  or  other 
hydrogen-generating  apparatus  by  means  of  a  rubber  tube,  and  a  current  of 
hydrogen  is  passed  through  the  flask.  The 
hydrogen  bubbles  through  the  bouillon  and 
escapes  by  the  lateral  tube.  After  the  gas 
has  escaped  for  about  an  hour,  a  small 
capsule  containing  mercury  is  applied  to 
the  end  of  the  lateral  branch,  so  that  the 
open  end  just  dips  below  the  surface  of  the 
mercury,  and  the  tube  which  passes  through 
the  rubber  cork  is  sealed  ofi"  in  the  blow- 
pipe flame,  care  being  taken  that  all  the  air 
has  been  expelled  from  the  flask  by  a  free 
current  of  hydrogen.  The  flask,  with  the 
capsule  of  mercury  applied  to  the  end  of 
the  lateral  branch,  can  then  be  placed  in 
the  incubator.  Thus  the  mercury  forms  a 
valve ;  air  cannot  enter,  while  gases  formed 
by  the  growth   of  the   organism   have  free 

exit."  By  this  simple  apparatus  the  bacillus  of  tetanus  is  grown  in  the 
flask  of  the  chemist  in  an  atmosphere  of  hydrogen.  Air  or  oxygen  is 
totally  excluded,  this  microbe  being  anaerobic. 

Prof.  Wm.  H.  "Welch  of  Johns  Hopkins  University,  in  his  address  before 
the  American  Medical  Association  at  Newport,  June  28,  1889,  said  :  "Among 
the  pathogenic  bacteria  which  have  their  natural  home  in  the  soil  the  most 
widely  distributed  are  the  bacilli  of  malignant  oedema  and  those  of  tetanus. 
I  have  found  some  garden-earth  in  Baltimore  extremely  rich  in  tetanus  bacilli, 
so  that  the  inoculation  of  animals  in  the  laboratory  with  small  bits  of  this 
earth  rarely  fails  to  produce  tetanus." 

The  fact,  as  stated  by  Prof.  Welch,  that  the  bacillus  of  tetanus  has  its 
natural  home  in  the  soil,  throws  light  on  many  interesting  observations  which 
have  been  recorded  in  the  literature  of  tetanus.  Several  years  ago  that  large 
part  of  New  York  Island  now  occupied  by  the  Central  Park,  and  between  the 
Central  Park  and  the  Hudson  River,  was  occupied  by  the  laboring  class, 
living  in  shanties  of  the  simplest  construction.  The  streets  were  not  sew- 
ered, and  refuse  matter  from  the  shanties  and  stables,  the  two  being  often 
built  together,  was  dumped  upon  the  open  spaces.  The  stables  were  occupied 
by  horses  and  cows.  As  might  be  expected,  these  simple  and  primitive  domi- 
ciles and  their  surroundings  were  fllthy  as  were  the  habits  of  most  of  the 
families.  Tetanus  neonatorum  was  not  uncommon  in  this  part  of  the  island. 
I  recollect  that  in  one  of  the  shanties  in  this  locality  two  infants  died  of  this 
disease  at  an  interval  of  about  flfteeu  to  eie:hteen  months.     These  observa- 


134  DISEASES  OF  THE  NEWLY-BORN. 

tions  correspond  with  the  fact  that  many  have  stated  that  the  bacilli  of  tetanus 
thrive  best  among  the  germs  of  putrefaction  and  in  a  soil  mixed  with  the 
excreta  of  horses. 

Another  fact,  showing  that  the  soil  is  the  natural  home  of  the  tetanus 
bacillus,  was  observed  some  years  ago  by  surgeons  of  Bellevue  Hospital. 
The  surgical  patients  entering  this  hospital  from  a  certain  part  of  Long 
Island  were  very  liable  to  have  tetanus  at  the  time  of  entering  or  to  manifest 
it  soon  after. 

There  are  or  have  been  localities  in  every  climate  where  tetanus  neona- 
torum was  the  most  prevalent  and  fatal  of  the  infantile  diseases.  The  bleak 
and  barren  islands  of  Hiemacy  and  St.  Kilda  in  the  far  north,  nearly  destitute 
of  vegetation  and  with  guano  for  fuel,  probably  containing  the  tetanus 
bacillus,  the  dirty  negro  cabins  of  the  Southern  States,  Fulda,  Demerara,  and 
Bombay,  may  be  mentioned  among  the  places  where  tetanus  neonatorum  is 
or  has  for  lengthened  periods  been  so  common  as  to  materially  check  the 
increase  of  population,  and  afford  evidence  of  the  correctness  of  the  theory 
that  the  natural  home  of  this  bacillus  is  the  soil. 

Several  cases  have  recently  been  reported  throwing  light  on  the  etiology 
and  pathology  of  tetanus.  Paul  Berger  states  that  he  requested  the  late 
distinguished  surgeon  M.  Nelaton  to  see  a  case  of  tetanus.  Nelaton  sat  on 
the  edge  of  the  bed,  watched  the  undressing  of  the  wound,  and  withdrew 
without  having  touched  the  patient.  A  boy  of  eight  years  had  been  run 
over  by  a  fiacre  and  brought  to  the  hospital,  having  multiple  contused  wounds. 
Nelaton  and  the  associate  surgeon  washed  their  hands  in  a  solution  of  cor- 
rosive sublimate  and  partly  dressed  the  wounds,  an  externe  completing  it. 
Seven  days  subsequently  the  boy  began  to  exhibit  unmistakable  symptoms 
of  tetanus,  such  as  trismus,  lockjaw,  the  sardonic  grin,  and  opisthotonos,  but 
eventually  recovered  {La  France  medicale,  June  21,  1888). 

Dr.  Adam  reports  the  case  of  Chas.  S ,  who  was  admitted  into  the 

Foochow  Native  Hospital  Sept.  28,  1887,  with  a  crushed  toe,  which  was  am- 
putated, being  gangrenous.    On  the  following  evening  tetanus  appeared.    Case 

II. — S.  I ,  aged  thirty-one  years,  was  admitted  into  the  same  hospital  on 

Oct.  8th,  having  internal  bleeding  piles.  These  were  ligated  on  the  10th,  and 
the  improvement  was  so  rapid  that  he  returned  home,  apparently  well,  on  Oct. 
19th.  On  the  following  day  he  returned  to  the  hospital,  complaining  of 
stiffness  of  the  back  and  jaws.  The  disease  was  recognized.  He  became 
despondent,  and  died  on  the  26th.  Tetanus  not  being  common  in  Southern 
China,  the  occurrence  of  the  above  cases  is  strongly  suggestive  of  the  com- 
municability  of  the  disease.  Rdchelot  has  also  narrated  (La  Semaine  med., 
Sept.,  1888)  two  cases,  the  second  of  which  evidently  resulted  from  the  first. 
They  occurred  in  the  laparotomy  ward  of  a  hospital,  and,  as  the  flower-beds 
of  the  hospital  had  recently  been  manured,  it  was  believed  that  the  first  case 
originated  from  the  infected  soil. 

The  fact  familiar  to  army  surgeons  that  after  certain  sanguinary  battles 
the  wounded  who  have  fallen  to  the  ground  have  been  very  liable  to  tetanus 
is  most  satisfactorily  explained  on  the  supposition  that  the  soil  of  the  battle- 
field contains  the  specific  microbe.  Sometimes  tetanus  follows  injuries  which 
are  not  attended  by  any  breach  of  surface  through  which  the  bacillus  could 
enter,  and  in  some  instances  the  intervals  are  so  short  between  the  injury  and 
the  commencement  of  the  tetanus  that  it  seems  very  improbable  that  the 
tetanus  could  be  due  to  the  agency  of  the  bacilli,  but  rather  to  injury  of  the 
peripheral  nerves,  and  consequent  excitation  of  the  reflex  spinal  system. 
Thus  cases  have  been  reported  in  which  only  twenty-four  or  twelve  hours,  or 
even  a  shorter  time,  elapsed  between  the  injury  and  the  tetanus — too  short 
a  time,  it  would  seem,  for  the  development  of  bacilli.     In  studying  the  causa- 


TETANUS  NEONATORUM.  135 

tion  of  tetanus,  whether  of  the  neonati  or  of  older  patients,  we  should  not 
overlook  the  fact  that  there  is  a  form  of  the  disease  designated  puerperal,  of 
which  form  the  late  Sir  James  Y.  Simpson  collated  the  histories  of  over 
twenty  cases.  (See  Simpson's  Ohstetrical  and  Gynsecological  Works^  vol.  i.) 
Puerperal  tetanus  occurs  after  abortion  or  labor  at  term,  or  after  intra-uterine 
operations,  and  is  probably  correctly  attributed  to  decaying  animal  tissue, 
which,  excluded  from  oxygen,  generates  hydrogen  and  other  poisonous  gases. 
Such  cases  have  given  rise  to  the  opinion  held  by  some  that  the  germs  of 
tetanus  are  occasionally  received  into  the  system  by  inhalation,  and  are 
developed  in  the  putrid  substance  with  which  they  come  in  contact.  Another 
theory  held  by  some  distinguished  specialists  in  nervous  diseases  is  that 
exposure  to  cold  is  an  important  cause,  and  is  sufl&cient  in  itself  to  produce 
the  disease.  Hence  Gower -states  that  there  is  a  variety  of  tetanus  which  is 
caused  by  exposure  to  cold,  and  which  he  designates  idiopathic  or  rheumatic. 
By  this  theory  it  is  easy  to  find  an  explanation  for  the  origin  of  cases  of 
tetanus  neonatorum,  several  of  which  have  been  reported,  in  which  the 
umbilicus  and  its  vessels  seemed  normal  and  there  was  no  injury  of  the 
cutaneous  surface.  In  my  opinion  the  time  is  not  far  distant  when  the 
bacillus  of  tetanus  will  be  regarded  as  the  cause  of  endemic,  epidemic,  and 
a  large  proportion  of  single  cases.  Occurring  without  traumatism  or  any 
appreciable  cause,  we  may  accept  the  theory  of  Gower,  that  in  these  cases  of 
obscure  origin  the  cause  is  "  taking  cold."  But  it  seems  to  me  not  unlikely 
that  the  investigations  in  reference  to  the  causation  of  tetanus  may  end  in  a 
similar  way  to  those  in  regard  to  diphtheria ;  that  is,  that  true  tetanus  is 
always  produced  by  the  bacillus  of  Nicolaier,  but  there  is  a  spastic  muscular 
contraction  in  infancy  as  well  as  in  adults  which  is  due  to  a  cause  or  causes 
distinct  from  the  bacillus. 

In  examining  the  literature  of  tetanus  it  is  evident  that  the  tonic  con- 
traction of  the  muscles  in  certain  cases  which  has  been  supposed  to  indicate 
the  presence  of  tetanus  has  been  due  to  spinal  or  cerebro-spinal  meningitis, 
and  not  to  tetanus.  Thus,  Billard  reported  a  case  in  which  tonic  contraction 
of  the  muscles  occurred  in  an  infant  three  days  old,  and  the  anatomical 
characters  observed  after  death  were  those  of  spinal  meningitis.  That  tonic 
muscular  contractions  frequently  occur  in  infancy  and  childhood  in  conse- 
quence of  meningeal  inflammation  is  well  known,  and  in  some  of  the  epi- 
demics reported  as  tetanus  meningitis  was  present,  and  was  doubtless  the 
cause  of  the  muscular  contractions.  Such  an  epidemic  was  observed  by  Prof. 
Cederschjold  in  Stockholm  in  1834.  Within  a  few  months  he  treated  forty- 
two  cases,  and  in  the  bodies  examined  after  death  he  found  a  fibrinous  exuda- 
tion at  the  base  of  the  brain.  I  see  no  reason  to  doubt  that  the  epidemic, 
which  he  describes  as  one  of  tetanus,  was  one  of  cerebro-spinal  fever,  more 
frequently  designated  cerebro-spinal  meningitis. 

Time  of  Commencement  in  Fatal  Cases. 

Case    1.  Male  ;  taken  when  three  days  old  ;  lived  sixty  hours.    Labatt,  Edin.  Med. 

and  Surg.  Journ.,  April,  1819. 
"      2.  Female  ;  taken  when  three  days  old  ;  lived  forty  hours.     Ihid. 
"      3.  Taken  when  five  days  old  :  lived  fifty  hours.     Ihid. 
"      4.  Taken  when  three  days  old  ;  lived  one  day.     Ibid. 
"      5.  Male ;    taken  when  two  days  old ;  lived  two  days.      Billard,  Treatise  on 

Diseases  of  Children,  Stewart's  trans.,  p.  477. 
"      6.  Male  ;  taken  when  three  days  old  ;  lived  two  days.     Romberg. 
*'      7.  Male  ;  taken  when  six  days  old ;    lived  ninety-three  hours.     Dr.  Imlach, 

Month.  Journ.  of  Med.  Sci.,  Aug.,  1850. 
"      8.  Female  ;  taken  at  five  days  ;  lived  four  days.     Caleb  Woodworth,  M.  D., 

Boston  Med.  and  Surg.  Journ.,  Dec.  13,  1831. 


Case 

i    9. 

u 

10. 

11 

11. 

(( 

12. 

li 

13. 

il 

14. 

11 

15. 

a 

16. 

u 

17. 

li 

18. 

u 

19. 

.: 

20. 

u 

21. 

u 

22 

136  DISEASES  OF  THE  XEWLY-BOB^^. 

Negro:  taken  at  seven  days  ;  lived  twenty-four  hours.  P.  C.  Gaillard,  M. 
D.,  South.  Journ.  of  Med.  and  Fhar.,  Sept.,  184:6. 

Male ;  taken  when  seven  days  old ;  lived  one  day.  Augustus  Eberle, 
M.  D.,  Missouri  Med.  and  Surg.  Journ.,  1847. 

Taken  when  seven  days  old.    D.  B.  Nailer,  N'.  0.  Med.  Journ.,  Nov.,  1846. 

Male :  taken  when  three  days  old  ;  lived  one  day.  N.  0.  Med.  and  Surg. 
Journ.,  3Iay,  1853. 

Negro  ;  taken  when  three  days  old  ;  lived  three  days.  Robert  H.  Chinn, 
M.  D.,  N.  O.  Med.  and  Surg.  Journ. 

Taken  when  two  days  old ;  died  in  four  hours  after  the  doctor's  visit. 
Ibid. 

Taken  when  seven  days  old  ;  lived  one  day.  C.  H.  Cleveland,  Keio  Jersey 
Med.  Re}}.,  April,  1852. 

Negro  ;  taken  when  seven  days  old  ;  death  finally.  Greenville  Dowell, 
Amer.  Journ.  of  Med.  Sci.,  Jan.,  1863. 

Takeii  when  twelve  days  old ;  lived  one  day.  Thomas  C.  Boswell,  com- 
municated to  Dr.  Sims,  Amer.  Journ.  of  Med.  Sci.,  1846. 

Taken  when  about  five  days  old  ;  died  at  about  the  age  of  nine  days.  B. 
R.  Jones,  Ibid. 

Taken  at  or  soon  after  birth ;  lived  two  davs.  Dr.  Sims,  Amer.  Journ.  of 
Med.  Sci.,  April,  1846. 

Taken  at  the  age  of  six  days  ;  lived  one  day.     Ibid. 

Taken  when  two  days  old  :  lived  two  days.     Ibid. 

Male :  taken  at  the  age  of  eight  days ;  died  in  three  hours.  Communi- 
cated to  the  writer. 

Taken  at  the  age  of  twelve  hours  ;  lived  two  days.  Communicated  to  the 
writer. 

Female  ;  taken  when  seven  days  old  ;  lived  forty-five  hours.     The  writer. 

Male  taken  at  the  age  of  seven  days;  lived  forty-ei.oht  hours.     Ibid. 

Female  ;  taken  at  the  age  of  eight  days  ;  lived  three  days.     Ibid. 

Female  ;  taken  at  the  age  of  five  days  ;  lived  three  days.     Ibid. 

Female  ;  taken  when  four  days  old  :  lived  two  days.     Ibid. 

Taken  when  six  days  old ;  died  nest  day.     Ibid. 

Taken  when  five  daj's  old  ;  lived  twenty-four  hours.     Ibid. 

Taken  when  eight  days  old  ;  lived  two  days.     Ibid. 

Male  :  taken  when  five  days  old  ;  lived  one  day.     Ibid. 

Favorable  Cases. 

Case  1.  Negro  female  :  taken  when  three  days  old  ;  recovered  in  a  few  days.   Robert 

S.  Baily,  Charleston  Med.  Journ.  and  Bev.,  Nov.,  1848. 
''    2.  Negro ;  taken  at  eleven  days ;  recovered  in  fifteen  days.     W.  B.  Lindsay, 

N.  0.  Med.  Journ.,  Sept.,  1846. 
"    3.  Negro ;   taken  when  ten  days  old ;    recovered  in  thirty-one  days.     P.   C. 

Gaillard,  Charleston  Med.  .lourn.  and  Bev..  Nov.,  1853. 
"    4.  Male ;   taken  at  the  age  of  eight  days ;    recovered  in  twenty-eight  days. 

Ibid. 
"    5.  Negro  ;  taken  at  seven  days ;  recovered  in  fifteen  days.     Augustus  Eberle, 

Missouri  Med.  and  Surg.  Journ.,  1847. 
"    6.  Taken  when  eight  days  old ;  recovered  in  four  weeks.     Furlonge,  Edin. 

Med.  and  Surg.  Journ.,  Jan.,  1830. 
"    7.    Taken  at  the  age  of  one  week ;  recovered  in  two  days.     Dr.  Sims,  Amer. 

Journ.  of  Med.  Sci.,  April,  1846. 
"    8.  Female ;  taken  at  the  age  of  three  days  •,  recovered  in  five  weeks.     The 

writer. 

Period  of  Commexcement. — Finckh,^  who  saw  cases  of  tetanus  of  tlie 
newly-born  in  the  Stuttgart  Hospital,  states  that  it  began  in  1  case  on  the 
second  day  after  birth,  in  8  on  the  fifth,  and  in  7  on  the  seventh. 

Copland  ^  says  that  it  generally  commences  on  the  first  seven  or  nine  days 

^  Seeker's  Annalen,  vol.  iii.  No.  3,  p.  304.  '^  Medical  Dictionary. 


24. 

25. 

26. 

"^T 

-J  i . 

28. 

29. 

30. 

31. 

32. 

TETANUS  NEONATORUM.  137 

after  birtli,  and  rarely  later  than  the  fourteenth.  Romberg  states  that  it 
commences  between  the  fifth  and  ninth  days.  In  200  cases  observed  by 
Reicke  in  Stuttgart  in  the  course  of  forty-two  years  it  was  never  found  to 
commence  before  the  fifth,  rarely  after  the  ninth,  and  never  after  the  eleventh, 
day.  Schneider  says  that  the  disease  occurs  oftenest  between  the  second  and 
seventh,  and  rarely  after  the  ninth,  day.  In  6  cases  reported  by  Dr.  C.  Levy 
of  Copenhagen  it  began  in  2  on  the  third  day,  in  2  on  the  fifth,  and  in  2  on 
the  sixth.  Dr.  Greenville  Dowell,^  who  has  seen  much  of  tetanus  neonatorum 
among  the  negroes  in  Mississippi  and  Texas,  says  it  is  almost  sure  to  come  on 
between  the  fifth  and  twelfth  days  after  birth.  In  the  40  cases  embraced  in 
the  above  table  the  disease  began  as  follows : 

Age.  Cases. 

Under  two  days 2 

Two  days 1 

Three  days 9 

Four  days 2 

Five  days -    ...  6 

Six  days 3 

Seven  days 8 

Eight  days 6 

Ten  days 1 

Eleven  days 1 

Twelve  days 1 

Pathology. — It  is  an  interesting  fact  that  in  the  warm  regions  of  the 
United  States  the  victims  are  chiefly  negro  infants.  L.  S.  Grier,  M.  D.,^  of 
Mississippi  says :  "  The  first  form  of  disease  which  assails  the  negro  among 
us  is  trismus.  The  mortality  from  this  disease  alone  is  very  great.  No  sta- 
tistical record,  we  suppose,  has  ever  been  attempted,. but  from  our  individual 
experience  we  are  almost  willing  to  affirm  that  it  decimates  the  African  race 
upon  our  plantations  within  the  first  week  of  independent  existence.  We 
have  known  more  than  one  instance  in  which,  of  the  births  for  one  year,  one- 
half  became  the  victims  of  this  disease,  and  that,  too,  in  spite  of  the  utmost 
watchfulness  and  care  on  the  part  of  both  planter  and  physician.  Other 
places  are  more  fortunate,  but  all  suffer  more  or  less ;  and  the  planter  who 
escapes  a  year  without  having  to  record  a  case  of  trismus  naseentium  may 
congratulate  himself  on  being  more  favored  than  his  neighbors,  and  prepare 
himself  for  his  own  allotment,  which  is  surely  and  speedily  to  arrive."  Dr. 
Wooten*  says:  "  It  is  a  disease  of  fatal  frequency  on  the  cotton  plantations 
in  this  section  of  Alabama."  He  has,  however,  never  seen  a  white  child 
affected  with  it. 

While  tetanus  infantum  prevails  in  regions  wide  apart  and  presenting 
very  diverse  climatic  conditions,  there  is  a  similarity  as  regards  the  personal 
and  domiciliary  habits  of  the  people  who  suffer  most  from  its  occurrence.  It 
occurs  chiefly  among  those  who  are  filthy  and  degraded  in  their  habits — who 
live,  either  from  choice  or  necessity,  in  neglect  of  sanitary  requirements. 
It  is  now  demonstrated  beyond  all  doubt  that  the  bacillus  of  tetanus,  like 
most  pathogenic  germs,  is  fostered  and  rendered  more  virulent  by  filth,  and 
especially  the  soil  which  has  been  occupied  by  old  stables  and  saturated  by 
the  excreta  of  horses,  is  the  richest  of  all  in  the  development  of  this  microbe. 

That  uncleanliness  and  impure  air  are  causes  of  tetanus  is  as  fully 
demonstrated  as  most  facts  in  the  etiology  of  diseases.  The  attention  of  the 
profession  was  forcibly  directed  to  this  cause  by  Dr.  Joseph  Clarke  in  a  paper 

^  Amer.  Journ.  of  Med.  Sci.,  Jan.,  186.3. 
^iV.  0.  Med.  and  Surg.  Journ.,  May,  1854 
^Ibid.,  May,  1846. 


138  DISEASES  OF  THE  NEWLY-BORN. 

read  before  the  Royal  Irish  Academy  in  1789.  This  physician  was  in  charge 
of  the  Dublin  Lying-in  Asylum,  and  had  rightly  concluded  that  the  mortality 
among  the  new-born  infants  was  due  to  imperfect  ventilation.  Through  his 
advice,  apertures  (twenty-four  inches  by  six)  were  made  in  the  ceiling  of  each 
ward ;  three  holes,  an  inch  in  diameter,  were  bored  in  each  window-frame ; 
the  vipper  parts  of  the  doors  leading  into  the  gallery  were  also  perforated 
with  sixteen  one-inch  apertures,  and  the  number  of  beds  was  reduced.  The 
results  of  these  simple  sanitary  regulations  may  be  seen  from  Dr.  Clarke's 
own  statement.  He  says :  "  At  the  conclusion  of  the  year  1782,  of  17,650 
infants  born  alive  in  the  Lying-in  Hospital  of  this  city,  2944  had  died  within 
the  first  fortnight — that  is,  nearly  every  sixth  child."  The  disease  in  nine- 
teen cases  out  of  twenty  was  tetanus.  After  the  wards  were  better  ventilated 
■ — namely,  from  1782  till  the  time  of  the  preparation  of  Dr.  Clarke's  paper — 
8033  children  were  born  in  the  hospital,  and  only  419  in  all  had  died,  or 
about  one  in  nineteen.  So  impressed  was  Dr.  Evory  Kennedy,  who  at  a 
later  period  had  charge  of  the  same  asylum,  with  the  belief  that  Dr.  Clarke 
had  discovered  the  true  cause,  and  had  been  able  in  great  measure  to  prevent 
it,  that  he  enthusiastically  writes  :  "  If  we  except  Dr.  Jenner,  I  know  of  no 
physician  who  has  so  far  benefited  his  species,  making  the  actual  calculation 
of  human  life  saved,  the  criterion  of  his  improvements."  The  cases  occur- 
ring in  my  own  practice  have  almost  all  been  in  tenement-houses,  where 
habits  of  cleanliness  are  not  observed,  and  I  have  not  yet  seen  in  the  prac- 
tice of  others  nor  heard  of  a  case  which  occurred  in  the  better  class  of  dom- 
iciles. The  statements  of  physicians  in  the  Southern  States,  who  speak  from 
extensive  observation  among  negroes,  are  strongly  corroborative  of  the  belief 
that  the  disease  is  in  great  measure  due  to  uncleanliness  and  lack  of  pure  air. 

Dr.  Greenville  Dowell  of  Texas  states  that  he  has  been  able  to  trace  tetanus 
infantum  to  the  bed-clothes,  saturated  with  excrementitious  matters,  which 
are  found  in  the  negro  cabins.  In  a  paper  published  by  Prof.  John  M.  Wat- 
son '  the  frequency  of  this  disease  among  negroes  is  accounted  for  as  follows : 
"  When  called  to  see  their  children  we  find  their  clothes  wet  around  their  hips, 
and  often  up  to  their  armpits,  with  urine The  child  is  thus  pre- 
sented to  us,  when,  on  examination,  we  find  the  umbilical  dressings  not  only 
wet  with  urine,  but  soiled,  likewise,  with  faeces,  freely  giving  oif  an  offensive 
urinous  and  fecal  odor,  combined  at  times  with  a  gangrenous  fetor  arising 
from  the  decomposition,  not  desiccation,  of  the  cord." 

In  the  bodies  of  the  new-born  who  die  of  tetanus  lesions  are  observed 
which  doubtless  result  from  the  spasms.  Again,  others  are  found  which  from 
their  nature  could  not  be  a  result,  and  which,  being  observed  in  different 
cases,  are  believed  to  have  a  causal  relation.  The  most  frequent  of  such 
lesions  is  inflammation  of  the  umbilicus  or  umbilical  vessels. 

Moschion,  who  lived  in  the  first  century  of  the  Christian  era,  stated,  in 
writings  still  extant,  that  stagnant  blood  in  the  umbilical  vessels  sometimes 
is  associated  with  dangerous  disease  in  the  new-born  infant,  and  it  is  supposed, 
though  this  is  doubtful,  that  he  referred  to  tetanus.  In  modern  times  the 
attention  of  the  profession  has  been  more  particularly  directed  to  tetanus 
neonatorum  by  a  paper  published  by  Dr.  Colles.''  The  observations  contained 
in  this  paper  were  made  in  the  Dublin  Lying-in  Hospital  during  a  period  of 
five  years.  In  each  of  these  years  he  witnessed  from  three  to  five  post-mor- 
tem examinations  in  cases  of  infantile  tetanus,  and  the  lesions,  he  states,  were 
in  all  much  alike,  as  follows :  The  floor  of  the  umbilical  fossa  was  lined  by  a 
membrane  apparently  formed  by  suppurative  inflammation,  and  in  the  centre 
of  this  fossa  was  a  large  papilla.     This  papilla  consisted  of  a  soft  yellow  sub- 

'^Nashville  Journ.  of  Med.  and  Surg.,  June,  1851. 
^Dublin  Hospital  Reports,  vol.  i.,  1818. 


TETANUS  NEONATORUM.  139 

stance,  apparently  the  product  of  inflammation,  and  in  all  the  cases  the  um- 
bilical vessels  were  in  contact  with  this  substance  and  were  pervious.  In  a 
few  instances  superficial  ulcerations  were  found  near  the  mouth  of  the  umbili- 
cal vein,  and  occasionally  the  skin  surrounding  the  umbilicus  was  raised.  The 
peritoneum  covering  the  vein  was  highly  vascular,  often  not  to  a  greater  dis- 
tance than  an  inch  above  the  umbilicus,  but  sometimes  as  far  as  the  fissure 
of  the  liver.  The  peritoneum  in  the  course  of  the  umbilical  arteries  pre- 
sented the  inflammatory  appearance  in  still  greater  degree,  sometimes  as  far 
as  the  bladder.  The  connective  tissue  lying  along  the  arteries  and  urachus 
anteriorly  was  loaded  with  a  yellow  watery  fluid.  The  inner  surface  of  the 
umbilical  vein  was  not  inflamed,  but  its  coats  in  general  were  thickened.  On 
slitting  open  the  arteries  a  thick  yellow  fluid,  resembling  coagulable  lymph, 
was  found  within  their  coats,  and  in  all  cases  these  vessels  were  thickened 
and  hardened  as  far  as  the  fundus  of  the  bladder. 

Dr.  Finckh,  who  observed  25  cases  in  the  Stuttgart  Hospital,  believes  that 
the  most  frequent  pathological  state  was  suppuration  or  ulceration  of  the 
umbilical  cord.  In  10  of  the  25  cases  the  navel  was  dry  and  cicati'ized ;  in 
the  remainder  it  was  either  wet  or  swollen,  with  a  bluish-red  inflamed  edge  at 
the  margin  of  the  navel ;  a  dirty  viscid  pus  covered  the  umbilical  depression. 

Dr.  Levy,  physician  at  the  Foundling  Hospital  in  Copenhagen,  attended 
22  cases  in  that  institution  in  1838  and  1839.  Of  these  20  died,  and  15  were 
examined  carefully  after  death.  In  14  there  were  decided  marks  of  inflam- 
mation of  the  umbilical  arteries,  especially  of  those  portions  lying  along  the 
urinary  bladder ;  in  several  cases  the  peritoneum  over  the  arteries  was  much 
injected,  and  in  3  adherent  either  to  the  omentum  or  intestine  by  coagulable 
lymph  ;  the  coats  of  the  arteries  were  thickened,  their  cavities  dilated  and  con- 
taining dark  reddish-brown  or  greenish  puriform  matter,  always  fetid.  Some- 
times the  arterial  tunica  interna  was  found  ulcerated  and  absent  in  places,  and 
there  was  spongy  thickening  of  the  subjacent  connective  tissue.  In  2  cases 
the  ulcerative  process  had  extended  from  the  tunica  interna  to  the  peritoneum, 
and  there  was  a  deposit  of  thick  ichorous  matter  around  the  ulcer ;  in  1  case 
both  arteries  were  so  softened  that  their  coats  were  scarcely  distinguishable, 
and  in  another  these  vessels  had  become  gangrenous.  The  appearance  of  the 
umbilicus  was  unchanged  in  4  cases  ;  in  10  the  fundus  was  red  and  filled  with 
puriform  fluid,  which  quickly  reappeared  when  removed,  and,  in  general, 
shortly  before  death  the  navel  presented  a  greenish  color. 

According  to  Romberg,  Dr.  Scholler  made  post-mortem  examinations  in 
18  cases  of  tetanus  infantum,  and  in  15  found  inflammation  of  the  umbilical 
arteries.  The  vessels  were  swollen  near  the  bladder,  in  1  case  to  the  diameter 
of  four  lines,  and  were  found  to  contain  pus.  The  lining  membrane  was  eroded 
or  covered  with  an  albuminous  exudation.  Both  arteries  were  not  always 
equally  inflamed,  and  in  3  cases  only  1   was  aff"ected. 

Schneeman'  found  minute  points  of  suppuration  in  the  umbilical  vein  in 
8  cases,  and  pus  throughout  the  course  of  this  vessel  in  1. 

The  observations  mentioned  above  were  made,  for  the  most  part,  in  hos- 
pitals on  the  Continent,  but  similar  observations  have  been  made  in  private 
practice.  M.  Borian^  of  the  Isle  of  Bourbon  says  that  he  has  found  in  every 
case  inflammation  around  the  umbilicus.  Dr.  Ransom  ^  states  in  a  communi- 
cation to  Prof.  John  M.  Watson  that  he  has  never  seen  a  case  of  tetanus  of  the 
new-born  in  which  the  umbilicus  was  healthy.  In  a  case  related  by  Robert 
S.  Bailey*  there  was  a  hard  scab  on  one  side  of  the  umbilicus,  and  this  part 

1  Holscher's  Annalen,  vol.  v.  p.  484,  1840. 

^  Gazette  medieale,  Paris,  July  11,  1841. 

^  Nashville  Journ.  of  Med.  and  Surg.,  June,  1851. 

*  Charleston  Med.  Journ.  and  Rev.,  Nov.,  1848. 


140  DISEASES  OF  THE  NEWLY-BORN. 

was  mucli  distended.  A  discharge  followed  the  removal  of  the  scab,  and  the 
child  recovered.  In  a  favorable  case  related  by  W.  B.  Lindsay '  the  umbilicus 
was  tumid  and  not  disposed  to  heal.  Dr.  H.  0.  Wooten  -  attributes  the  disease 
to  the  condition  of  the  umbilicus  and  umbilical  vessels,  and  states  that  he  has 
found  the  umbilicus  gangrenous.  A  case  has  been  reported  in  which  the 
umbilical  vessels  were  blocked  up  by  purulent  matter.^  At  a  meeting  of  the 
Obstetrical  Society  of  Edinburgh,  held  April  24,  1850,  Dr.  Imlach  related  a 
case  in  which  there  was  a  dark  and  gangrenovis  appearance  on  the  integument 
around  the  umbilicus,  and  the  peritoneum  underneath  was  also  dark,  but  not 
inflamed  ;  umbilical  vein  healthy  ;  a  little  fibrin  in  the  left  iimbilical  artery  ; 
right  umbilical  artery  much  diseased  ;  its  two  inner  coats  apparently  destroyed, 
and  in  their  place  a  yellow  pultaceous  slough  in  which  pus-globules  were  dis- 
covered with  the  microscope. 

It  is  evident  that  the  pathological  state  of  the  umbilicus  and  umbilical 
vessels  described  above,  which  has  been  noticed  by  so  many  observers  in 
different  countries,  cannot  result  from  the  tetanus.  It  is  possible  that  the 
puriform  substance  noticed  in  the  umbilical  vessels  was  disintegrated  fibrin, 
which  had  coagulated  at  the  time  of  ligation  of  the  cord,  and  the  cells  seen 
by  Dr.  Imlach  and  others  may  sometimes  have  been  white  corpuscles  still 
remaining  from  the  stagnated  blood.*  Still,  the  evidences  of  inflammation, 
in  at  least  a  part  of  the  cases  related  above,  were  of  a  positive  character. 

The  belief  that  umbilical  lesions  occasionally  cause  tetanus  infantum  com- 
ports with  the  well-known  traumatic  causation  of  tetanus  in  the  adult.  This 
belief  is  strengthened  by  the  fact  which  will  appear  farther  on  in  our  remarks 
that  tetanus  of  the  new-born,  from  being  frequent  in  certain  localities,  has 
become  infrequent  through  greater  care  in  dressing  and  managing  the  umbili- 
cal cord. 

But  there  are  cases  of  tetanus  infantum  in  which  there  is  no  disease  in 
or  about  the  umbilicus.  Dr.  Finckh  of  Stuttgart  examined  the  umbilical 
vessels  in  eleven  cases  without  discovering  any  pathological  change.  Dr. 
Samuel  B.  Labatt,^  master  of  the  Dublin  Lying-in  Hospital,  published  a 
paper  entitled  "  An  Inquiry  into  the  Alleged  Connection  between  Trismus 
Nascentium  and  Certain  Diseased  Appearances  in  the  Umbilicus."  This 
paper  was  designed  as  a  reply  to  the  essay  of  Dr.  Colles.  Dr.  Labatt  relates 
several  cases  in  which  there  was  no  disease  of  the  umbilicus  and  umbilical 
vessels,  and  others  in  which  the  disease  was  so  slight  that  it  probably  pro- 
duced no  injurious  effect  on  the  health  of  the  child.  Dr.  James  Thompson,^ 
who  spent  considerable  time  in  the  tropical  regions,  says :  "  I  have  myself 
examined  nearly  40  cases  of  infants  that  have  sunk  under  this  complaint. 
In  many  I  have  looked  at  no  other  part  than  the  navel,  and  have  found  it 
in  all  states  —  sometimes  perfectly  healed,  especially  if  the  infants  had 
lived  several  days ;  at  other  times  a  simple  clean  wound.  When  death 
occurred  on  the  fifth  or  sixth  day  the  wound  was  frequently  in  a  raw  state. 
I  never  yet  saw  it  in  a  sphacelated  condition."  The  writer  concludes  from  his 
observations  that  there  are  cases  in  which  the  cause  is  located  elsewhere  than 
in  the  umbilicus  or  umbilical  vessels.  Dr.  John  Breen^  remarks:  "From 
dissections  ....  we  have  never  been  able  to  discover  any  peculiar  morbid 
appearance  which  would  justify  us  in  offering  any  explanation  of  the  pathol- 
ogy of  the  disease."  In  my  own  eases  there  was  no  evidence  of  disease  of 
the  umbilicus  or  umbilical  vessels,  so  far  as  could  be  ascertained  by  external 

1  N.  0.  Med.  and  Surg.  Journ.,  Sept.,  1846.  '  Bid.,  May,  1846. 

3  Ibid.,  May  1,  1853.  *  Virchoio's  Cellul.  Pathol. 

^  Edin.  Med.  and  Surg.  Journ.,  April,  1819.  *  Ibid.,  Jan.,  1822. 

''Dub.  journ.  of  Med.  and  Chem.  Sci.,  January,  1836. 


TETANUS  NEONATORUM.  141 

examination,  and  in  one  (No.  32)  a  careful  post-mortem  examination  dis- 
closed no  lesion  of  these  parts. 

Other  observations  might  be  related  showing  that  the  bacillus  of  tetanus 
does  in  most  instances  enter  the  system  of  the  newly-born  through  the 
umbilicus  and  umbilical  vessels,  but  a  lacerated  or  wounded  surface  may  be 
the  gateway  of  infection  whatever  the  age. 

Symptoms. — In  many  cases  premonitory  symptoms  are  absent  or  are  so 
slight  as  to  escape  notice.  In  some  patients  fretfulness  precedes  the  attack, 
but  no  more  than  is  often  observed  in  those  who  continue  in  good  health. 
The  first  symptom  which  alarms  the  parents  and  shows  the  grave  nature  of 
the  commencing  disease  is  inability  to  nurse  or  evident  pain  and  hesitation  in 
nursing.  Commencing  with  rigidity  of  the  masseters,  the  disease  gradually 
extends  to  the  other  voluntary  muscles,  and  in  the  course  of  a  few  hours  the 
muscles  of  the  limbs  as  well  as  of  the  trunk  are  involved.  Persistent  mus- 
cular contraction,  which  is  the  pathognomonic  feature  of  infantile  tetanus,  is 
developed  not  fully  in  the  beginning,  but  by  degrees  in  each  affected  muscle, 
so  that  it  is  not  till  after  the  lapse  of  several  hours,  perhaps  even  a  day,  that 
the  greatest  amount  of  rigidity  is  attained.  Therefore  in  the  commence- 
ment of  the  disease  the  limbs  can  be  flexed  and  the  jaw  pressed  open 
more  readily  than  at  a  subsequent  stage,  though  with  manifest  pain  to  the 
infant. 

During  the  period  of  maximum  rigidity  the  jaws  are  fixed  almost  immov- 
ably, often  with  a  little  interspace  between  them,  against  which  the  tongue 
presses  and  in  which  frothy  saliva  collects.  The  head  is  thrown  backward 
and  held  in  a  fixed  position  by  the  stifi"ness  of  the  cervical  muscles.  The  fore- 
arms are  flexed ;  the  thumbs  are  thrown  across  the  palms  of  the  hands,  and 
are  firmly  clenched  by  the  fingers ;  the  thighs  are  drawn  toward  the  trunk ; 
the  great  toes  are  adducted  and  the  other  toes  flexed.  Occasionally  opisthot- 
onos results  from  the  extreme  contraction  of  the  dorsal  and  posterior  cervical 
muscles.  The  infant  can  sometimes  be  raised  without  any  yielding  of  the 
jnuscles  by  the  one  hand  under  the  occiput  and  the  other  under  the  heels. 

The  rigidity  is  liable  to  variation  in  its  intensity  even  after  the  full  devel- 
opment of  the  disease.  If  the  infant  be  quiet,  especially  if  asleep,  the  mus- 
cles are  partially  relaxed  to  such  an  extent  sometimes,  in  the  first  stages  of 
the  complaint,  that  the  features  have  a  placid  and  natural  expression,  though 
only  for  a  short  time.  Frequent  exacerbations  occur  in  the  muscular  con- 
traction, sometimes  without  any  apparent  cause,  and  sometimes  produced 
by  anything  which  excites  or  disturbs  the  child.  Attempts  to  open  the 
lips  or  jaws  or  eyelids  or  to  bend  the  limbs,  blowing  on  the  face,  and  even 
the  crawling  of  a  fly  upon  it,  occasion  the  paroxysms. 

During  the  paroxysm  the  eyelids  are  forcibly  compressed,  as  well  as  the 
lips,  which  are  either  drawn  in  or  are  pouting ;  the  forehead  and  cheeks  are 
thrown  into  wrinkles  and  the  physiognomy  is  indicative  of  great  sufiering. 
The  unnatural  positions  of  the  trunk  and  limbs  which  result  from  muscular 
contraction  are  increased  for  the  moment ;  the  head  is  more  forcibly  thrown 
back  and  the  limbs  more  strongly  flexed.  The  muscular  movements  which 
occur  during  the  paroxysms  are  sometimes  described  as  clonic  spasms.  There 
is  indeed  occasionally  some  quivering  of  the  limbs,  and  yet,  as  I  have  on  differ- 
ent occasions  noticed,  so  far  from  the  muscular  action  being  a  clonic  spasm, 
it  is  clearly  tonic  and  is  intensified  during  the  paroxysm.  In  fatal  cases  the 
paroxysms  occur  more  and  more  frequently  until  the  period  of  collapse. 

The  crying  of  the  child  aff"ected  by  tetanus  is  never  loud,  however  great 
the  suff"ering.  It  is  variou.sly  described  by  writers  as  "  whimpering "  or 
"  whining."  It  is  of  this  suppressed  character  in  consequence  of  the  rigid 
state  of  the  respiratory  muscles  and  their  imperfect  movement. 


142  DISEASES  OF  THE  NEWLY-EOBN. 

During  the  exacerbation  respiration  is  suspended,  or  so  imperfect  and  the 
circulation  so  retarded  that  the  surface  becomes  of  a  deep-red,  ahnost  livid, 
color.  Sometimes  epistaxis  occurs,  affording  partial  relief  to  the  congestion, 
and  sometimes,  though  less  frequently,  the  blood  forces  itself  from  the  con- 
gested liver  along  the  umbilical  vein  and  escapes  from  the  umbilicus.  The 
intense  passive  congestion  consequent  on  the  tetanic  spasm  is  general  through- 
out the  system,  but  extravasation  of  blood  appears  to  be  more  common  around 
the  brain  and  spinal  cord  than  elsewhere. 

The  frequency  of  the  pulse  and  respiration  varies  in  different  cases  and 
at  different  stages  of  the  same  case.  They  are  often  somewhat  accelerated, 
but  at  other  times  are  natural,  or  are  even  slower  than  in  health. 

While  the  appetite  of  the  infant,  to  appearance,  is  not  diminished,  the 
pain  which  it  experiences  in  nursing  is  such  that  alimentation  is  necessarily 
deficient.  It  can  be  fed  with  a  spoon  for  a  time  after  it  ceases  to  take  food 
in  the  natural  way,  but  artificial  feeding  soon  fails.  The  milk  placed  in  its 
mouth  is  in  great  part  pressed  back  through  the  violence  of  the  spasm  which 
is  induced  by  the  attempt  to  feed  it. 

In  consequence  of  imperfect  nutrition  the  infant  rapidly  wastes  away. 
There  is  no  other  disease,  except  the  diarrhoeal  affections,  in  which  the  ema- 
ciation is  so  rapid.  In  a  case  related  by  Dr.  W.  B.  Lindsay  ^  the  record  states 
that  "  the  infant  was  fat  three  days  before,  but  was  now  emaciated."  Rom- 
berg, who  saw  tetanus  neonatorum  in  European  hospitals,  and  Robert  H. 
Chinn  ^  of  Texas,  both  speak  of  the  rapid  emaciation.  The  trunk  and  extrem- 
ities lose  their  fulness  and  the  features  become  pinched.  Several  observers 
have  noticed  the  appearance  of  miliaria  in  this  reduced  state  of  system, 
especially  around  the  shoulders,  and  sometimes  a  decidedly  icteric  hue 
appears  on  the  skin. 

The  condition  of  the  intestines  is  not  uniform.  They  may  be  relaxed, 
particularly  if  the  disease  be  due  to  some  irritation  in  them  ;  in  other  cases 
the  stools  are  natural  or  constipated. 

It  is  often  difficult  to  ascertain  the  state  of  the  eyes,  since  attempts  to 
open  the  eyelids  bring  on  spasms  and  cause  firm  compression  of  the  lids 
against  each  other.  According  to  Sir  Henry  Holland,  one  of  the  first  symp- 
toms which  occurred  in  cases  on  the  island  of  Heimacy  was  strabismus,  with 
rolling  of  the  eyes.  But  this  statement  must  be  received  with  caution,  since 
these  cases  were  not  seen  by  any  physician  and  the  information  was  obtained 
from  the  parents  and  priests.  If  true,  the  proximate  cause  of  the  disease  in 
Heimacy  would  seem  to  be  located  in  the  cerebro-spinal  axis.  Contraction 
of  the  pupils  commonly  occurs  in  the  stage  of  collapse. 

Mode  of  Death. — Death  in  infantile  tetanus  may  occur  from  apnoea  in 
the  paroxysms,  from  extreme  congestion  of  the  cerebral  vessels,  or  apoplexy ; 
and,  lastly,  it  may  occur  from  exhaustion.  The  last  mode  is  probably  the 
most  frequent. 

Prognosis. — All  writers  till  recently  agree  that  tetanus  of  the  infant 
rarely  terminates  favorably.  Cullen  attributes  the  ignorance  of  physicians 
in  regard  to  this  disease  to  the  fact  that  it  is  so  little  amenable  to  treatment 
that  they  are  not  usually  summoned  to  attend  those  affected  with  it.  In  the 
island  of  Heimacy,  of  185  cases  occurring  during  a  series  of  years  about  the 
commencement  of  the  present  century,  not  one  survived;  and  in  the  same 
locality,  at  Westmannoe,  a  small  islet,  64  per  cent,  of  all  the  infants  born 
died  of  trismus  (report  of  Dr.  Schleisner).  Similar  statements  in  regard  to 
the  mortality  of  tetanus  infantum  are  given  by  physicians  in  the  Southern 
States.     Dr.   H.   0.  Wooten  ^  of  Alabama  says  that  he  has  "  never   seen  a 

^N.  0.  Med.  Journ.,  Sept.,  1846.  "" M  0.  Med.  and  Surg.  Journ.,  Sept.,  1854. 

^K  0.  Med.  Journ.,  May,  1846. 


TETANUS  NEONATORUM.  143 

decided  case  of  tetanus  nascentium  that  did  not  prove  fatal.  ....  and  that 
it  is  very  generally  deemed  useless  to  call  in  medical  aid  after  the  initiatory 
symptoms  are  well  declared."  Mr.  Maxwell/  speaking  in  reference  to  the 
West  Indies,  says  :  •'  From  observations  which  I  have  made  for  a  series  of 
years,  ....  I  found  that  the  depopulating  influence  of  trismus  nascentium 
was  not  less  than  25  per  cent.  It  scarcely  has  a  parallel  within  the  bills  of 
mortality,"  Dr.  D.  B.  Nailer  -  says  :  '•  About  two-thirds  of  the  deaths  among 
the  negro  children  are  from  this  disease,  and  so  uniformly  fatal  is  it  that  a 
physician  is  never  sent  for." 

Yet  death  does  not  always  result :  eight  of  the  forty  cases  in  my  collection 
recovered  ;  but  a  correct  opinion  cannot  be  formed  from  this  of  the  actual 
ratio  of  favorable  to  unfavorable  cases,  since  favorable  cases  are  much  more 
likely  to  be  published.  In  the  history  of  these  8  cases  two  interesting  facts 
are  noticed,  which  when  present  may  serve  as  a  ground  for  hope  of  a  success- 
ful termination.  These  were,  the  age  at  which  the  disease  began  and  the 
fluctuations  of  the  symptoms.  With  two  exceptions,  the  infants  who  recov- 
ered were  about  a  week  old  when  the  initiatory  symptoms  appeared,  and  there 
were  fluctuations  in  the  gravity  of  the  sj^mptoms';  whereas  fatal  cases  ordi- 
narily grow  progressively  worse.  Yet  in  favorable  cases  the  symptoms  are 
never  so  severe  as  they  become  in  a  few  hours  in  those  who  succumb. 

Duration  in  Fatal  Cases. — Of  18  cases  observed  by  Finckh  in  the 
Stuttgart  Hospital,  15  died  in  two  days,  2  in  five  days,  and  1  in  seven  days. 
During  the  epidemic  in  the  Stockholm  hospitals  in  18.34,  where  42  cases  were 
treated,  the  disease  seldom  lasted  more  than  two  days.  Romberg  says  :  "  It 
generally  lasts  from  two  to  four  days,  but  its  duration  is  at  times  limited  at 
from  eight  to  twenty-four  hours,  and  occasionally,  though  rarely,  it  extends 
from  five  to  nine  days." 

In   31  fatal   cases  in  my  collection,  in  which  the  duration  is  mentioned^ 

1  lived 3  hours. 

11  others  lived 1  day  or  less. 

12  lived 2  days. 

4  lived 3     " 

3  lived 4     " 

Both  Underwood,  who  published  a  treatise  on  diseases  of  children  in 
1789,  and  Dr.  Elsasser  at  a  more  recent  date,  recorded  fatal  cases  which  were 
unusually  protracted.  The  one  described  by  Underwood  was  treated  in  the 
British  Lying-in  Hospital,  and,  although  all  the  others  treated  in  this  institu- 
tion died  by  the  third  day,  this  lived  six  weeks  ;  but  it  is  suggested  by  the 
author  that  death  was  due  in  part  to  some  other  afi"ection.  The  child  treated 
by  Elsasser  lived  thirty-one  days. 

Duration  in  Favorable  Cases. — In  the  8  favorable  cases  in  my  col- 
lection the  duration  of  the  disease,  reckoned  from  the  time  when  the  infant 
ceased  nursing  till  it  began  again,  was  as  follows:  In  1  case,  two  days;  in 
1,  a  few  days;  in  1,  fourteen  days;  in  2,  fifteen  days;  in  1,  twenty-eight 
days  ;  in  1,  twenty-one  days  ;  and  in  the  remaining  case,  about  five  weeks. 

Diagnosis. — To  one  who  has  seen  this  disease  in  the  new-born  or  is 
familiar  with  its  symptoms  diagnosis  is  easy.  The  symptoms  which  possess 
diagnostic  value  are  more  manifest  and  reliable  than  in  most  other  infantile 
maladies.  Permanent  rigidity  of  the  voluntary  muscles,  with  temporary 
exacerbations,  such  as  have  been  described  above,  which  are  induced  by  any 
cause  which  disturbs  the  infant,  as  attempts  to  open  the  mouth  or  eyelids,  is 
pathognomonic. 

'^Jamaica  Phys.  Journ.,  copied  into  the  London  Lancet,  April  11,  1835. 
^JY.  0.  Med.  Journ.,  November,  1846. 


144  DISEASES  OF  THE  NEWLY-BORN. 

Let  us  stop  for  a  moment  and  consider  the  facts  related  above  wMcli  have 
a  bearing  on  therapeutics  : 

(1)  With  possibly  a  few  exceptions  tetanus,  whether  occurring  in  man 
or  animals,  whether  in  the  infant  or  adult,  is  the  same  disease,  and  is  caused 
b}^  the  entrance  into  the  system  of  a  rod-shaped  microbe  two  or  three  times 
the  length  of  the  tubercular  bacillus.  One  end  of  the  bacillus  is  somewhat 
rounded,  so  as  to  give  it  a  pin-shape,  and  is  enlarged  by  the  presence  of  a 
spore. 

(2)  The  tetanus  bacillus,  as  stated  above,  thrives  most  luxuriantly,  and 
probably  is  most  virulent,  where  dirt  and  filth  abound.  We  have  said  also 
that  its  natural  home  is  the  soil,  and  not  so  much  the  virgin  soil  as  soil 
which  is  rendered  impure  by  the  proximity  and  drainage  of  barnyards,  and 
especially  horse-stables. 

(3)  Of  the  domestic  animals,  the  horse  and,  to  a  less  degree  the  sheep,  are 
liable  to  tetanus,  and  hence  those  who  are  exposed  by  their  occupations  to 
these  animals  or  to  the  soil  infected  by  their  excretions  are  more  liable  to 
tetanus  fi'om  injuries,  even  from  slight  bruises  or  wounds,  than  are  those 
whose  occupations  do  not  bring  them  into  constant  contact  with  these  animals 
or  with  infected  soil. 

(4)  We  have  stated  that  the  bacillus  of  tetanus  is  widespread,  so  that 
this  disease  occurs  in  every  climate  from  the  Arctic  regions  to  Demerara  or 
Bombay.  But  this  bacillus,  like  that  of  diphtheria,  has  remarkable  vitality 
and  power  for  propagation,  so  that  it  has  continued  for  an  indefinite  time  to 
survive  and  multiply  in  certain  localities,  as  in  parts  of  Long  Island,  not- 
withstanding constant  tillage. 

(5)  As  regards  tetanus  neonatorum,  the  observations  which  I  have  related 
show  beyond  doubt  that  in  most  instances  the  specific  bacillus  obtains  entrance 
into  the  system  through  the  umbilical  blood-vessels  and  lymphatics,  and 
within  these  vessels  the  toxine  described  and  analyzed  by  Brieger  and  others, 
and  which  is  so  fatal,  is  produced. 

Preyextiye  Treatment. — While  tetanus  neonatorum,  if  fully  developed, 
is  ordinarily  fatal  in  spite  of  any  remedial  measures  heretofore  used,  there  is 
no  doubt  of  the  efficacy  and  value  of  preventive  measures  when  properly 
employed.  This  was  shown  by  the  great  reduction  in  mortality  in  the  Dub- 
lin Lying-in  Hospital  through  the  thorough  ventilation  introduced  by  Dr. 
Clarke.  Dr.  Meriwether^  of  Montgomery,  Ala.,  says:  "When  the  disease 
appears  endemically  on  a  plantation  it  may  be  arrested  by  having  the  negro 
houses  whitewashed  with  lime  inside  and  out ;  by  raising  the  floors  above  the 
ground ;  by  removing  all  filth  from  under  and  about  the  houses ;  by  par- 
ticular attention  to  cleanliness  in  the  bedding  and  clothing  of  the  mother 
and  in  the  dressing  of  the  child,  so  as  to  prevent  any  of  the  matter  from  the 
umbilicus  lying  long  in  contact  with  the  skin."  Many  physicians,  especially 
in  the  Southern  States,  speak  confidently  of  care  in  dressing  the  cord  and 
attention  to  the  umbilicus  as  a  means  of  prevention.  Graften  ^  says  that  he 
has  "  never  known  the  disease  to  occur  in  any  child  whose  navel  had  the  tur- 
pentine dressing."  He  uses  turpentine  as  follows  :  "  At  the  first  time  a  few 
drops  of  undiluted  turpentine  are  applied  immediately  to  the  umbilicus  around 
the  cord,  and  it  is  anointed  at  every  succeeding  dressing,  the  turpentine  being 
diluted  one-half  or  two-thirds  with  olive  oil,  lard,  or  fresh  butter."  This  use 
of  turpentine  has  also  been  recommended  by  other  practitioners  in  warm 
regions. 

Dr.  John  Furlonge^  of  St.  John's,  Antigua,  believes  that  no  case  would 

^  Amer.  Journ.  of  Med.  Sci.,  April,  1854. 
^  jV.  0.  Med.  and  Surg.  Journ.,  July,  1853. 
^  Edin.  Med.  and  Surg.  Journ.,  January,  1830. 


TETAyUS  yEOXATORUM.  145 

occur  with  the  following  treatment :  "  The  cord,  when  divided,  should  be 
wrapped  in  clean  linen.  Every  night  for  two  weeks  one  or  two  drops  of 
tinct.  opii  and  spts.  vini,  equal  parts,  should  be  given,  and  castor  oil,  with  a 
little  magnesia,  every  morning.  The  child  must  be  washed  in  tepid  water 
every  morning  and  the  funis  dressed."  If  this  treatment  be  attended  by  the 
success  which  is  claimed  for  it  by  Dr.  Furlonge,  so  great  care  in  dressing  the 
cord  is  certainly  well  repaid  in  localities,  as  at  Antigua,  where  a  large  pro- 
portion of  the  infants  die  of  tetanus.  But  since  it  is  now  known  that  tetanus 
neonatorum,  like  that  at  a  more  advanced  age,  usually  has  a  microbie  origin, 
an  antiseptic  and  germicide  dressing  of  the  cord  is  evidently  preferable,  as  by 
filling  the  umbilicus  and  dusting  the  cord  with  aristol. 

Some  experienced  observers  go  so  far  as  to  assort  that  it  is  pos.sible  to 
ward  oif  tetanus  neonatorum  after  the  occurrence  of  premonitory  symptoms. 
Dr.  Dowell  ^  says :  "  Some  with  slight  twitchings  of  the  muscles  have  recov- 
ered without  any  trouble  by  being  put  into  a  mustard-bath,  washed  clean,  and 
put  in  a  clean  and  well-ventilated  cabin." 

Treatment. — In  considering  the  effect  of  medicinal  agents  which  have 
been  employed  in  the  treatment  of  infantile  tetanus,  the  great  difficulty  which 
the  child  experiences  in  swallowing  should  be  borne  in  mind.  "Without  care 
a  considerable  part  of  the  dose  is  lost  by  the  spasm  of  the  muscles  of  degluti- 
tion, which  ordinarily  occurs  when  the  spoon  is  placed  in  the  moiith,  so  that, 
unless  special  attention  be  given  to  this  matter,  it  is  uncertain  whether  the 
prescribed  dose  is  fully  administered. 

The  treatment  employed  by  different  physicians  has  been  very  diverse. 
Antiphlogistic  remedies  were  prescribed  by  Finckh,  but  every  case  so  treated 
was  fatal.  He  states  that  whenever  blood  was  abstracted,  even  in  small  quan- 
tities, the  symptoms  were  aggravated.  The  same  result  has  followed  depletory 
measures  in  the  practice  of  other  physicians. 

The  internal  remedies  which  have  been  most  frequently  prescribed  are 
opiates  and  antispasmodics.  Furlonge  in  a  favorable  case  gave  laudanum  in 
doses  of  one  drop  every  three  hours  alternately  with  two  grains  of  Dover's 
powder.  Woodworth  also  gave  one-drop  doses  of  laudanum  ;  Eberle,  one- 
sixth  of  a  drop  hourly.  The  opiate  has  generally  been  given  in  combination 
with  an  antispasmodic.  The  Dover's  powder  given  every  three  hours  by 
Furlonge  was  combined  with  five  grains  of  sulphate  of  zinc.  The  hourly 
doses  of  laudanum  by  Eberle  were  combined  with  six  drops  of  tincture  of 
asafoetida. 

When  anaesthetics  began  to  be  employed  in  the  treatment  of  diseases  it 
was  believed  that  they  would  be  especially  useful  in  cases  of  tetanus.  Accord- 
ingly, chloroform  has  been  used  in  tetanus  in  the  infant,  with  the  effect  of 
controlling  the  spasm  during  the  time  of  its  use,  but  without  curing  the  dis- 
ease. In  Case  7  in  our  first  table  it  was  employed  several  times,  but  appar- 
ently without  delaying  the  fatal  result.  The  editor  of  the  Nev:  OrJexms 
Medical  and  Surgical  Journcd  states,  in  the  May  issue  of  that  periodical  for 
1853,  that  he  has  u.sed  chloroform  in  tetanus  neonatorum,  with  the  effect,  he 
believes,  of  prolonging  life.  Ansesthetics  certainly  relieve  the  suffering  of 
the  infant,  and  on  this  account,  even  if  they  do  not  prolong  life,  their  judi- 
cious employment  seems  proper. 

The  remedy  which  has  been  more  efficient  than  those  mentioned  above 
has  been  the  hydrate  of  chloral,  given  with  or  without  one  of  the  bromides. 
Since  the  introduction  of  this  agent  into  therapeutics  it  has  been  employed 
by  several  physicians  in  the  treatment  of  this  disease  with  so  good  a  result 
that  it  will  probably  supersede  all  other  medicines  for  this  purpose.  Dr. 
Widerhofer  of  Vienna  states  that  he  has  saved  six  out  of  ten  or  twelve  by 
'^  Amer.  Journ.  of  the  Med.  Sci.,  January,  1863. 
10 


146  DISEASES  OF  THE  NEWLY-BORN. 

the  use  of  chloral.  He  prescribes  it  in  doses  of  one  to  two  grains  by  the 
mouth,  or,  if  there  be  great  difficulty  in  swallowing,  two  or  four  grains  by 
the  i-ectum.  Dr.  F.  Auchenthales  relates  a  case  in  which  he  gave  even  six- 
grain  doses,  and  in  nine  days  the  disease  had  entirely  disappeared.  I  have 
recently  employed  hydrate  of  chloral  in  a  ease  of  tetanus,  giving  it  in  half- 
grain  or  one-grain  doses  every  two  hours,  except  when  there  was  profound 
sleep.  The  disease  was  fully  developed  and  the  symptoms  severe  when  I  was 
called.  I  did  not  believe  that  the  infant  with  the  old  remedies  would  live 
more  than  two  days,  but  by  the  use  of  chloral  life  was  prolonged  nearly  one 
week.  Moreover,  by  the  use  of  chloral  the  suffering  of  the  infant  is  greatly 
diminished.  The  frequent  inhalation  of  sulphuric  ether  also  aids  materially 
in  controlling  the  spasms. 

The  administration  of  alcoholic  stimulants  is  required  at  short  intervals 
on  account  of  the  rapid  emaciation  and  great  prostration. 

Local  treatment  directed  to  the  umbilicus  in  those  cases  in  which  there 
is  evidence  of  inflammation  of  the  umbilicus  or  umbilical  vessels  should  not 
be  neglected.  The  application  of  an  emollient  poultice  to  the  umbilicus  has 
been  followed  by  apparent  improvement,  if  we  may  believe  the  statement  of 
some  physicians  who  have  made  use  of  this  treatment.  Dr.  Meriwether  of 
Alabama  says  if  there  be  no  improvement  from  the  medicine  which  he  orders 
he  applies  a  blister,  larger  than  a  dollar,  to  the  umbilicus,  and  with  this  treat- 
ment the  child  generally  improves — a  remarkable  statement  since  so  few 
improve  at  all. 

No  one  can  fail  to  observe  the  need  of  early  and  continuous  antiseptic 
treatment  of  the  umbilicus,  as  in  septicaemia.  Aristol,  iodoform,  boracic  or 
salicylic  acid  should  be  constantly  and  as  deeply  applied  in  the  umbilical 
fossa  as  possible,  mixed  with  a  liquid,  perhaps  glycerin,  to  make  it  penetrate 
more  deeply. 

A  warm  foot-bath,  repeated  at  intervals  of  a  few  hours,  and  stimulating 
embrocations  along  the  spine,  are  proper  adjuvants  to  the  treatment. 

The  apparent  encouraging  results  of  the  treatment  of  diphtheria  by  the 
subcutaneous  injection  of  the  serum  of  an  animal  rendered  immune  to  this 
disease  by  repeated  inoculations  led  to  observations  and  experimentation  to 
determine  whether  a  similar  treatment  might  be  useful  in  tetanus.  We  have 
seen  how  the  bacillus  of  tetanus  can  be  propagated  and  obtained  in  the  flask 
of  the  chemist,  and  it  is  easily  communicated  to  the  horse  by  inoculation. 
Tizzoni  and  Cattani,  followed  by  others,  have  employed  the  antitoxine  treat- 
ment of  tetanus.  It  is  obviously  best,  in  order  to  determine  its  efficiency,  to 
learn  the  results  of  its  use  whatever  the  age,  for  it  is  the  same  disease  in 
infancy,  childhood,  and  adult  life. 

Escherich  reports  (  Wien.  klin.  Woch.,  Aug.  10,  1893)  four  cases  of  tetanus  neona- 
torum treated  by  Tizzoni' s  antitoxine.  The  following  are  the  statistics  of  these  cases  : 
In  the  four  cases  the  umbilical  cord  was  detached  on  the  sixth,  third,  fourth,  and 
fourth  days ;  the  incubation  was  two,  nine,  one,  and  seven  days  ;  the  duration,  two, 
five,  two,  and  twelve  days.  The  fourth  or  last  case  only  recovered.  In  all  who 
died  septic  inflammation  of  the  umbilical  cord  was  present,  and  all  exhibited  septic 
symptoms.  A  little  of  the  tissue  at  the  umbilicus,  taken  from  the  bodies  of  the  first 
and  third  cases  and  inoculated  in  mice,  caused  tetanus  in  them.  In  Case  1  (fatal) 
only  0.015  by  2.0  of  antitoxic  serum  was  injected ;  in  Case  2  (fatal)  the  injections 
of  0.25  were  discontinued  on  account  of  the  occurrence  of  septic  pneumonia ;  in 
Case  3  (fatal)  the  tetanus  was  exceptionally  severe,  so  that  a  good  result  could  not 
be  expected.  In  the  case  that  recovered  an  injection  (0.3)  was  given  on  the  third 
and  twice  on  the  fourth  day. 

Lesi  (Rif.  Med.,  Aug.  18,  1893)  :  A  man  wounded  his  foot  with  a  piece  of  glass 
while  walking  over  a  heap  of  stable  manure.  Six  days  later  tetanic  phenomena 
appeared,  which  rapidly  involved  the  muscles  of  the  legs,  neck,  and  back,  and 


TETANUS  NEONATORUM.  147 

caused  marked  trismus  and  dysphagia.  On  the  afternoon  of  the  second  day  after 
the  appearance  of  the  symptoms  the  patient  received  a  hypodermic  injection  of  50 
cc.  of  serum  obtained  from  one  of  Tizzoni's  immunized  horses,  1  gramme  of  which 
serum  had  been  found  sufficient  to  protect  10,000,000  grammes.  After  this  injec- 
tion there  was  no  further  spread  of  the  tetanic  symptoms,  which  remained  confined 
to  the  parts  already  affected.  In  these  parts,  indeed,  the  spasms  became  somewhat 
more  pronounced  during  the  first  and  second  days  of  treatment.  During  the  even- 
ing of  the  second  day  a  further  injection  of  20  cc.  was  given,  after  which  the  patient 
had  a  fair  night's  rest.  The  next  day  another  injection  of  10  cc.  was  given.  The 
patient  was  almost  free  from  pain,  except  for  the  trismus  and  difficulty  m  swallow- 
ing. On  the  fourth  day  a  last  injection  of  20  cc.  was  given,  after  which  the  patient 
rapidly  convalesced  and  was  able  to  leave  the  bed  six  days  after  the  admission. 

In  the  British  Med.  Journ.,  January  19,  1895,  the  case  of  a  man  is  related  who 
was  injured  by  a  catapult,  and  six  days  afterward  began  to  have  tetanic  symptoms. 
The  wound  was  half  an  inch  below  the  symphysis  of  the  lower  jaw,  and  gave  rise 
to  a  foul  discharge  containing  shreds  of  string  and  shoemaker's  wax.  Trismus, 
inability  to  open  the  mouth,  prominence  and  rigidity  of  the  muscles  of  the  neck 
and  back  followed.  The  symptoms  gradually  increased,  and  on  the  third  day  of 
the  tetanus  2.5  grammes  of  Tizzoni's  antitoxine  in  sterilized  distilled  water  were 
introduced  by  punctures  in  the  abdominal  walls.  Each  puncture  was  painful  and 
was  attended  by  strong  opisthotonic  spasms.  On  the  following  day,  October  7,  or 
fourth  day  of  the  tetanus,  1  gramme  (15  grains)  was  injected.  On  each  of  the  fol- 
lowing days,  October  8,  9,  10,  11,  12,  and  13,  either  one-half  or  one  gramme  (7J  or 
15  grains)  was  injected,  but  none  was  used  on  the  15th.  On  October  16  his  tongue 
was  caught  between  the  teeth,  and  could  not  be  released  by  the  attendants.  Violent 
and  almost  continuous  spasms  followed,  with  laceration  of  the  tongue  and  great 
dyspnoea.  When  the  patient  appeared  to  be  dying,  grain  ^^  of  physostigmine  and 
grain  i  of  morphine  were  injected,  and  in  less  than  a  minute  the  masseters  were  so 
relaxed  that  the  lacerated  tongue  was  released  and  the  lividity,  dyspnoea  and  violent 
opisthotonic  spasms  ceased.  On  this  eventful  day  the  antitoxine  was  not  employed, 
so  that  forty-eight  hours  elapsed  without  its  use.  On  October  17th,  18th,  and  19th 
one  gramme  each  day  was  administered,  and  on  October  20th  half  a  gramme.  From 
this  time  the  patient  steadily  improved. 

Mr.  Marriott,  who  reported  the  above  case,  summarizes  the  treatment  as 
follows :  "Antitoxine,  with  the  exception  of  the  three  injections  of  the  phy- 
sostigmine and  morphine,  was  the  only  remedy  used  in  this  case,  as,  though 
chloral  was  at  first  prescribed,  only  a  very  small  quantity  was  swallowed. 
The  patient  certainly  seemed  much  relieved  by  the  treatment,  and  it  is  to  be 
remarked  that  the  severe  and  nearly  fatal  relapse  occurred  after  the  diminu- 
tion of  the  dose  on  October  14th  and  its  suspension  on  October  15th.  He 
states  also  that  the  two  injections  of  physostogmine  and  morphine  when 
given  together  had  a  most  salutary  eifect  in  diminishing  the  spasms." 

In  the  same  number  of  the  British  Med.  Journal  a  case  is  related  better 
adapted  to  our  purpose,  for  it  is  one  of  tetanus  neonatorum  treated  with 
tetanus  antitoxine,  reported  by  Mr.  Firth.  The  infant  was  born  on  Septem- 
ber 18,  189-4,  and  after  ligation  of  the  cord  the  navel  was  dressed  with  a 
clean  piece  of  linen.  On  the  sixth  day  it  was  dressed  with  a  scorched  piece 
of  linen  soaked  in  castor  oil.  On  the  eighth  day  the  infant  was  fretful  and 
took  the  breast  with  difficulty.  On  the  eleventh  day  after  birth  or  fourth 
of  the  disease  it  was  admitted  into  the  Bristol  General  Hospital,  and  on  the 
fifth  day  of  the  disease  it  was  more  carefully  examined.  It  was  icteric  ;  its 
eyelids  tightly  closed,  the  conjunctivae  could  not  be  seen ;  the  face  was 
wrinkled;  no  risus  sardonicus ;  masseters  hard;  lower  jaw  rigidly  fixed; 
head  slightly  retracted ;  neck  and  spine  very  rigid ;  arms  and  forearms 
addueted  and  rigid ;  fingers  firmly  flexed  into  the  palm,  and  thumbs  firmly 
flexed  over  them  ;  it  swallowed  with  great  difficulty,  and  became  cyanotic 
when  a  little  milk  was  placed  in  the  mouth ;  spasms,  lasting  three  or  four 
minutes  and  beginning  and  ending  gradually  occurred ;  temperature  normal 


148  DISEASES  OF  THE  NEWLY-BOBN. 

or  sliglitly  subnormal ;   pulse  128,  resp.  36 ;  chloral  hydrate  gr.  '.  and  potas. 
bromtde,  'gr.  1  to  2,  were  administered  every  four  hours. 

On  the  sixth,  seventh,  and  eighth  days  no  improvement  occurred,  but 
spasms  of  tonic  muscular  contractions  severe  and  attended  by  cessation  of 
respiration  and  very  frequent,  weak,  or  inappreciable  pulse  were  present.  At 
one  time  it  was  thought  to  be  dead.  On  the  eighth  day  of  the  disease  the 
tetanus  antitoxine  was  employed,  six  grains  being  injected  under  the  skin  of 
the  abdomen  in  five  places.  On  the  ninth  day  a  similar  injection  was  made 
at  4  P.  M.,  and  the  third  at  8.30  p.  M.  On  the  tenth  day  the  patient  had 
eight  of  the  spasmodic  attacks  of  muscular  rigidity  lasting  from  five  to 
fifteen  minutes,  and  the  longest  su.spension  of  respiration  in  the  attacks  was 
seven  minutes.  A  last  injection  of  twelve  grains  of  tetanus  antitoxine  was 
made  at  1  P.  M.,  and  death  occurred  at  8  P.  M. 

It  will  be  seen  that  the  infant  had  four  injections  of  the  antitoxine,  two 
grammes  or  thirty  grains  in  all,  without  any  appreciable  contx'olling  effect  on 
the  tetanus.  No  post-mortem  examination  was  allowed,  and  nothing  in  the 
external  appearance  indicated  that  the  navel  or  umbilical  vessels  sustained 
any  causal  relation  to  the  tetanus. 

From  the  above  cases,  and  from  others  of  a  similar  nature  which  have 
been  published,  it  appears  that  the  tetanus  antitoxine  in  order  to  be  efficient 
must  be  used  early,  and  more  observations  are  required  in  order  to  ascertain 
what  power  it  possesses  in  the  treatment  of  tetanus  even  at  an  early  stage. 
The  tetanus  antitoxine,  like  that  of  diphtheria,  is  still  on  trial,  and  many  more 
observations  will  be  required  before  its  efficiency  is  determined.  ^Yith  or  with- 
out this  new  remedy  it  is  evident  that  the  hydrate  of  chloral,  with  perhaps 
one  of  the  bromides,  should  still  be  employed. 

The  method  of  preparing  and  using  the  antitoxic  serum  is  as  follows : 
The  toxine  employed  for  immunizing  the  horse  is  prepared  in  a  flask  contain- 
ing grape-sugar  bouillon  and  hydrogen,  in  the  manner  described  by  Mr.  Hew- 
lett.'^which  I  have  already  related.  The  toxine  of  tetanus  prepared  in  this 
manner  in  the  flask  of  the  chemist  is  such  a  powerful  poison  that  in  employ- 
ing it  to  immunize  the  horse  by  subcutaneous  injections  it  is  first  diluted  by 
admixture  with  an  equal  Cjuantity  of  G-ram's  iodine  solution.  Hewlett  in 
immunizing  the  horse  employed  three  injections  weekly,  beginning  with  .5 
c.cm.,  and  gradually  increasing  to  8  com.  or  10  c.cm.  from  May  2d  to  June 
22d,  after  which  Mr.  Hewlett  gradually  diminished  the  diluent  until  the  pure 
toxine  was  employed  on  and  after  July  2d.  but  sometimes  with  dangerous 
symptoms.  '^  On  July  25th,  4  c.cm.  were  injected  into  the  jugular  vein,  fol- 
lowed by  rather  alarming  symptoms  half  an  hour  after,  the  animal  falling 
prostrate  with  legs  extended,  labored  respiration,  and  rapid  small  pulse." 
The  animal  recovered  in  ten  minutes.  As  in  preparing  the  diphtheritic  anti- 
toxine, the  horse  should  receive  these  injections  about  three  times  weekly  for 
three  to  six  months,  but  before  immunized  serum  is  placed  in  the  hands  of 
the  physician  or  pharmacist  it  should  be  tested  upon  animals. 

Mr.  Hewlett  writes  in  reference  to  the  antitoxic  serum  of  the  horse  prop- 
erly prepared  as  follows :  "  Experimentally,  the  effects  of  the  antitoxine  are 
little  short  of  marvellous.  Minute  doses  injected  into  animals  will  completely 
neutralize  fatal  doses  of  the  tetanus  toxine  injected  eight  or  twelve  hours 
afterward.  Thus,  0.0005  c.cm.  of  the  antitoxic  serum  was  found  to  be  suffi- 
cient to  protect  a  guinea-pig  weighing  400  to  500  grammes  from  the  minimum 
fatal  dose  of  the  tetanus  toxine,  which  in  the  present  instance  was  about  0.01 
c.cm.  Mixtures  of  the  toxine  with  the  antitoxic  serum  in  the  propoition  of 
forty  or  fifty  parts  of  the  former  to  one  of  the  latter  are  completely  inert,  and 
2  cubic  centimetres  of  such  a  mixture,  containing  nearly  2  c.cm.  of  the  deadly 
toxine,  may  be  injected  into  a  guinea-pig  without  producing  any  effect.     The 


SCLEREMA   NEONATORUM.  149 

antitoxine  also  possesses  considerable  curative  power,  but  much  larger  doses 
are  necessary  when  the  disease  has  declared  itself  than  when  used  as  an 
immunizing  agent." 

■'  The  antitoxine  treatment  of  tetanus  would  seem  to  be  the  one  which  gives 
the  best  hope  of  cure.  ...  I  have  been  able  to  collect  records  of  42  cases 
of  tetanus  treated  with  antitoxine,  nearly  all  traumatic,  and  of  these  15  died 
and  27  recovered,  giving  a  mortality  of  about  36  per  cent.  .  .  .  The  anti- 
toxine must  be  administered  by  subcutaneous  injection.  It  is  difficult  to 
state  what  the  dose  should  be,  for  this  has  varied  enormously  in  recorded 
cases, — from  10  c.cm.  to  165  c.cm.  Probably  20  c.cm.  to  40  c.cm  for  the 
first  dose,  followed  by  10  c.cm.  every  six  to  twelve  hours,  would  be  found 
most  suitable." 

Sclerema  Neonatorum. 

This  is  a  rare  disease,  and  most  of  the  cases  which  have  been  observed 
have  occurred  in  foundling  asylums  or  maternity  wards.  It  is  characterized 
by  induration  of  the  skin  and  subcutaneous  tissue  over  a  greater  or  less 
extent  of  the  system.  The  sensation  communicated  to  the  finger  pressed 
upon  the  affected  surface  is  not  unlike  that  produced  by  the  cadaver.  Those 
having  the  disease  are  feeble,  poorly  nourished,  and  a  considerable  proportion 
are  prematurely  born.     Their  temperature  is  below  normal. 

Sclerema  of  the  newly-born  was  first  described  by  Underwood  in  the 
eighteenth  century,  and  following  him,  in  1781,  Andry  applied  this  term  to 
oedema  occurring  in  the  first  days  after  birth,  and  which  should  not  be  con- 
founded with  sclerema.  Sclerema  neonatorum  occurs  in  emaciated  or  atrophic 
infants,  but  the  skin  over  the  aff"ected  part,  instead  of  lying  in  wrinkles 
or  folds,  as  is  usual  in  a  state  of  great  emaciation  or  atrophy,  becomes 
smooth  and  is  firmly  adherent  to  the  subjacent  parts,  from  which  it  cannot 
be  raised.  The  induration  usually  first  appears  in  the  lower  extremities,  and 
it  passes  upward  along  the  hips  and  lumbar  region,  and  it  ma}^  occur  not  only 
upon  the  trunk  and  upper  extremities,  but  even  upon  the  face.  The  limbs 
are  extended  and  immobile,  and  the  soft  parts,  firm  and  resisting,  do  not  pit 
on  pressure.  The  skin  has  a  dusky-yellow  color  and  is  perhaps  slightly 
cyanotic.  The  respiration  is  feeble  and  slow.  The  rigidity  when  extensive 
resembles  that  in  tetanus.  Nursing  from  the  breast  is  imperfectly  performed, 
and  when  the  muscles  of  the  face  and  lips  are  involved  is  impossible.  The 
causes  of  sclerema  appear  to  be  prematurity,  atrophy  or  poor  nutrition,  and 
great  heart  failure. 

This  disease,  so  long  as  the  patient  is  able  to  take  nutriment,  may  con- 
tinue for  weeks  before  the  fatal  ending,  with  a  constant  abnormally  low  tem- 
perature. 

Parrot  made  post-mortem  examinations,  and  found  hardening  and  atrophy 
of  the  skin  and  rete  Malpighii,  the  cells  pertaining  to  which  being  indistinct 
and  forming  a  firm  mass.  In  the  adipose  tissue  underlying  the  skin  the  fat 
had  disappeared  to  a  considerable  degree,  the  fat-cells  being  atrophied,  but 
having  distinct  nuclei.  The  fibres  of  the  connective  tissue  were  apparently 
increased  in  number  and  thickness.  The  blood-vessels,  particularly  in  the 
papilla,  were  shrunken  or  narrowed  to  such  an  extent  that  their  lumina  were 
not  visible.  Henoch  made  a  post-mortem  examination  of  the  brain  and  spi- 
nal cord  in  two  cases  which  had  lain  for  weeks  in  his  ward  in  a  rigid  state, 
and  found  them  normal. 

A  clear  idea  of  the  symptoms  and  anatomical  characters  of  sclerema  can 
be  obtained  by  the  narration  of  a  typical  case  that  occurred  in  the  New  York 
Foundling  Asylum.  The  curator  gave  a  full  and  graphic  description  of 
this  case  at  the  first  session  of  the  American  Pasdiatric  Society  :  The  patient, 


150  DISEASES  OF  THE  NEWLY-BORN. 

a  female,  was  brought  to  the  asylum  as  a  foundling  at  age  of  five  days.  It 
was  jaundiced,  had  sprue,  and  a  rectal  temperature  of  965°  F.  The  efforts 
to  increase  its  temperature  were  unavailing,  and  two  days  later  it  was  care- 
fully examined.  Its  face  was  cold  and  rigid,  and  the  coldness  and  rigidity 
had  extended  over  not  only  the  features,  but  the  scalp,  shoulders,  arms, 
hands,  hips,  thighs,  legs,  and  feet.  The  extremities  were  so  stiff  that  pres- 
sure upon  them  or  attempts  to  move  them  communicated  the  sensation  of  a 
cadaver  or  half-frozen  tissue.  Its  eyes  were  closed ;  its  surface  had  a  dirty, 
yellowish-brown  color.  When  handled  it  uttered  a  feeble  whimpering  cry, 
but  was  otherwise  motionless  and  quiet ;  no  pulse ;  rectal  temperature  below 
the  lowest  figure  on  the  thermometer ;  respiration  feeble  and  shallow.  Death 
occurred  two  days  later,  at  the  age  of  nine  days. 

At  the  autopsy  the  sclerema  was  found  to  be  less  in  the  abdominal  walls 
than  elsewhere.  On  incising  the  hardened  tissues  no  blood  or  serum  escaped 
from  the  cut  surface.  The  lungs  had  been  fully  inflated,  no  collapse  being 
present,  and  they  contained  dark  hemorrhagic  points  or  spots.  Nothing 
unusual  was  observed  in  the  skull,  brain,  heart,  and  great  vessels,  the 
stomach,  intestines,  liver,  and  kidneys,  except  the  urates  in  the  tubuli 
uriniferae.  The  hemorrhagic  extravasations  in  the  lungs  were  found  to  con- 
sist of  fresh  blood  in  the  alveoli  and  connective  tissue.  Dr.  Northrup  made 
microscopic  examinations  of  the  skin  and  subcutaneous  tissues,  and  found 
that  they  took  injections  well,  showing  normal  vascular  network.  The 
microscopic  slides  have  been  examined  by  expert  microscopists  and  derma- 
tologists, and  they  can  discover  nothing  abnormal  that  throws  light  on  the 
cause  or  pathology  of  the  sclerema. 

Sclerema  bears  considerable  resemblance  to  oedema  of  the  newly-born.  In 
oedema  the  temperature  is  low  and  the  oedematous  tissues  may  present  con- 
siderable firmness,  but  the  surface  usually  pits  on  pressure,  unlike  that  in 
sclerema.  Of  the  different  opinions  expressed  by  observers  in  reference  to 
the  cause  and  pathology  of  sclerema,  that  expressed  by  Ludwig  Langer  in 
1881  (^Wiener  Sitzungshericht,  1881)  is  the  most  plausible.  It  is  as  follows: 
In  the  adult  oleic  acid  is  the  chief  constituent  of  the  adipose  tissue,  but  in 
the  newly-born  the  fat  contains  a  large  proportion  of  palmitin  and  stearin, 
which  solidify  when  the  heat  of  the  body  undergoes  a  moderate  reduction 
below  the  normal. 

Infants  having  sclerema  after  lingering  for  days  or  weeks  die  in  a  state  of 
extreme  weakness.  I  am  not  aware  that  recovery  has  occurred  in  any  case 
of  genuine  sclerema  of  the  new-born.  Still,  it  is  proper  to  increase  the  tem- 
perature by  warm  applications  to  the  body  and  limbs  and  to  endeavor  to 
improve  the  nutrition  in  every  possible  way.  Perhaps  a  more  abundant 
breast-milk  or  breast-milk  of  a  better  quality  can  be  obtained,  and  a  few 
drops  of  Tokay  or  other  good  wine  or  of  brandy  may  be  given  every  sec- 
ond hour. 

(Edema  Neonatorum. 

In  this  disease  thickening  of  the  integument  occurs  and  the  subcutaneous 
connective  tissue  is  infiltrated  with  serum.  The  oedema  in  most  cases  is  at 
first  in  the  legs,  from  which  it  extends  along  the  thighs  to  the  genitals.  It 
may  extend  over  the  trunk,  upper  extremities,  and  cheeks,  but  in  some  cases 
it  appears  only  in  the  hands  and  feet,  producing  tumefaction  of  the  palms  of 
the  one  and  soles  of  the  other.  If  the  amount  of  serous  infiltration  be  great, 
the  tissues  may  be  firm  and  resisting,  communicating  to  the  touch  a  sensation 
similar  to  that  in  sclerema ;  but  when  the  infiltration  is  less  in  degree  the  tis- 
sues are  soft  and  doughy.  The  skin  has  a  dusky  or  yellowish  color,  and 
sometimes,  when  much  distended,  it  has  a  shiny  appearance.     In  cases  of 


PEMPHIGUS  NEONATORUM.  151 

great  oedema  tlie  movement  of  the  affected  part  is  diminished,  but  not  to  the 
same  extent  as  in  sclerema.  As  in  sclerema,  the  temperature  is  below  the  normal. 
In  fatal  cases  the  adipose  tissue  is  found  of  a  brownish,  yellowish,  or 
reddish -yellow  color,  from  which  a  yellowish  serum  exudes.  (Edema  of  the 
newly-born  does  not  appear  to  result  from  the  same  cause  in  all  instances. 
Occurring  in  feeble,  ill-nourished  infants,  it  apparently  results,  in  most  in- 
stances, from  extreme  heart-weakness.  The  feeble  circulation  leads  to  venous 
congestion  and  consequent  serous  transudation.  Pulmonary  atelectasis,  occur- 
ring as  it  usually  does  in  ill-nourished  and  feeble  infants,  is  also  an  occasional 
factor  in  producing  venous  stasis  and  transudation  of  serum.  Elsasser  has 
shown  that  occasionally  in  the  newly-born  the  oedema  results  from  nephritis, 
as  it  frequently  does  in  the  adult.  Henoch  relates  the  case  of  an  infant  of 
four  weeks  who  had  '•  marked  oedema  of  face  and  limbs,"  with  serous  effu- 
sion in  the  pleural,  pericardial,  and  peritoneal  cavities,  and  compression  of  the 
left  lower  lobe,  resulting  from  parenchymatous  nephritis.  Another  occasional 
cause  of  the  oedema  is  erysipelas.  This  cause  is  revealed  by  the  dark-red 
color  of  the  skin  characteristic  of  erysipelatous  inflammation. 

Recently  Prof.  Dumas  in  an  elaborate  paper  on  oedema  of  the  new-born  arrives 
at  the  following  conclusions  :  "1.  (Edema  of  the  new-born  is  only  one  of  the  symp- 
toms of  a  phlegmasia  alba  dolens  which  is  developed  during  the  first  days  after 
birth.  2.  Its  causes  are  of  the  same  nature  as  in  the  adult,  and  may  be  divided 
into  predisposing  and  determining  varieties.  Among  the  latter,  the  principal  one 
consists  in  the  incomplete  establishment  of  respiration  or  in  the  pathological  or 
other  causes  which  this  function  encounters.  3.  The  symptoms  of  phlegmasia  in 
the  new-born  are  the  same  as  in  the  adult,  excepting  certain  modifications  with 
respect  to  the  special  physiology  of  the  first  days  following  birth.  4.  The  pathological 
anatomy  is  also  about  the  same,  but  the  venous  thrombosis  in  the  new-born  is  more 
frequently  located  in  the  inferior  vena  cava  than  it  is  in  the  same  disease  in  the 
adult."'  It  does  not  seem  improbable  that  Prof.  Dumas"s  explanation  is  applicable 
to  a  considerable  proportion  of  cases,  the  formation  of  clots  in  the  veins  producing 
such  obstruction  and  venous  congestion  that  serum  transudes  as  a  consequence. 
Dumas  recommends,  in  order  to  prevent  this  disease,  "  suitable  care  to  effect  respi- 
ration in  the  new-born  at  the  moment  of  birth,  and  not  too  hasty  ligation  of  the 
cord."' 

(Edema,  like  sclerema,  is  ordinarily  fatal,  but  occasionally,  as  when  it 
results  from  erysipelas,  recovery  is  possible.  The  treatment  should  be  largely 
hygienic  and  dietetic.  An  abundant  supply  of  good  breast-milk  should  be 
obtained,  or  if  this  be  impossible  peptonized  cow's  milk.  As  in  sclerema, 
artificial  warmth  and  moderate  alcoholic  stimulation  are  required. 

Pemphigus  Neonatorum. 

Pemphigus  occurs  in  two  distinct  forms  in  the  newly-born,  which  may  be 
properly  designated  pemphigus  simplex  and  pempliigus  cachecticus. 

Pemphigus  Simplex  commonly  occurs  between  the  ages  of  two  and  twelve 
days.  The  vesicles,  which  vary  in  size  from  that  of  a  pea  to  a  hazel-nut, 
appear  in  some  cases  nearly  simultaneously,  but  in  other  instances  in  suc- 
cessive crops.  When  fully  developed,  they  ordinarily  have  a  transparent 
yellowish  color,  and  they  may  appear  upon  almost  any  part  of  the  surface 
except  the  palms  of  the  hands  and  soles  of  the  feet.  When  the  eruption  is 
nearly  general  upon  the  surface,  as  it  occasionally  is,  one  or  two  blebs  may 
even  appear  upon  these  parts,  but  as  a  rule  in  pemphigus  simplex  the  palms 
of  the  hands  and  soles  of  the  feet  are  not  affected. 

In  investigating  the  causes  of  this  form  of  pemphigus  we  are  struck  with 
the  fact  that  in  a  considerable  proportion  of  the  recorded  cases  those  affected 
with  it  appear  to  be  otherwise  in  perfect  health.  Occasionally  in  maternity 
hospitals  it  occurs  as  an  epidemic.     Thus,  Ahlfeld  observed  twenty-five  cases 


152  DISEASES  OF  THE  NEWLY-BORN. 

during  two  months  in  an  institution  in  Leipzig.  The  mothers  of  these  infants 
were  apparently  healthy,  and  the  pemphigus  commenced  in  all  between  the 
second  and  fourteenth  days  after  birth.  The  palmar  surfaces  of  the  hands 
and  plantar  surfaces  of  the  feet  were  not  affected  in  any  of  these  cases, 
though  vesicles  appeared  on  the  fingers  in  some  of  them.  Ahlfeld,  from  these 
observations,  believed  that  the  disease  was  infectious  or  of  a  miasmatic  nature. 
Koch  states  that  thirty-one  cases  occurred  in  the  practice  of  a  certain  midwife, 
while  in  the  practice  of  other  midwives  no  case  occurred.  Weyl  of  Berlin, 
aware  of  facts  like  the  above,  states  that  the  disease  is  undoubtedly  conta- 
gious. Bohn,  on  the  other  hand,  regards  cutaneous  irritants  as  a  cause,  and 
he  states  that  the  repeated  occurrence  of  pemphigus  in  the  practice  of  a  cer- 
tain midwife  was  traced  to  the  fact  that  she  habitually  used  water  too  hot  in 
bathing  the  infants.  But  there  is  now  a  sufficient  number  of  observations  to 
render  highly  probable,  if  they  do  not  demonstrate,  the  contagious  nature  of 
pemphigus  in  certain  cases.  Roeser  always  found  micrococci  in  the  serum 
of  the  vesicles.  Gibier  found  chain  bacteria,  single  bacteria,  and  also  bacteria 
in  zooglea  in  the  vesicles.  Scharlau  met  the  disease  in  different  members  of  a 
family,  and  succeeded  in  inoculating  himself  from  the  vesicular  contents.  We 
may  conclude,  therefore,  that  pemphigus  of  the  newly-born  is  probably  in  cer- 
tain cases  microbic  and  inoculable,  though  the  microbe  which  causes  the  disease 
has  not  been  fully  identified.  But  in  some  instances  it  is  not  improbable  that 
the  disease  is  produced  by  causes  not  microbic,  as  from  cutaneous  irritants. 
Further  investigations  in  regard  to  the  etiology  of  pemphigus  simplex  are 
required  before  positive  statements  can  be  made. 

Pemphigus  simplex  is  usually  attended  by  little  constitutional  disturbance, 
but  sometimes,  it  is  said,  a  slight  fever  attends  the  eruption  of  the  vesicles. 
The  skin  adjacent  to  the  vesicles  may  have  the  normal  or  a  slightly  congested 
or  vascular  appearance.  The  vesicular  contents  escape  in  a  few  days  by 
rupture  of  the  vesicle,  or  disappear  by  absorption,  and  the  detached  cuticle 
forms  a  thin  scale  which  is  soon  thrown  off,  and  in  a  few  days  replaced  by  a 
new  growth  of  cuticle. 

Pemphigus  Cachecticus. — This  form  of  pemphigus  occurs  in  infants  who 
have  a  profound  cachexia,  and  this  cachexia  is  in  a  large  proportion  of  cases 
due  to  inherited  syphilis.  Unlike  pemphigus  simplex,  it  attacks  by  preference 
the  palms  of  the  hands  and  soles  of  the  feet.  It  also  occurs  upon  thin  por- 
tions of  the  skin,  as  the  groin,  axilla,  and  neck.  The  surface  upon  which  the 
vesicles  are  situated  presents  a  reddish  or  livid  appearance,  and  the  vesicles 
are  only  partially  filled.  The  exuded  liquid  is  not  so  clear  as  in  pemphigus 
simplex,  and  it  is  often  turbid  or  even  bloody.  The  vesicles  or  remains  of 
vesicles  are  sometimes  observed  at  birth,  and  are  then  believed  to  have  a 
syphilitic  origin.  When  the  cause  is  syphilis  other  manifestations  of  this 
disease  may  also  be  present. 

Pemphigus  cachecticus  may  be  prolonged  several  weeks,  if  the  patient 
live,  by  the  occurrence  of  new  vesicles.  It  is  important,  as  regards  the 
selection  of  remedies,  to  bear  in  -mind  the  fact  that  the  profound  dyscrasia 
which  underlies  and  gives  rise  to  an  attack  of  pemphigus  cachecticus  may 
occur  from  other  causes  than  syphilis,  as  perhaps  struma.  The  evils  which 
attend  a  family  subjected  to  a  life  of  poverty  in  a  great  city,  as  overwork, 
scanty  and  poor  diet,  overcrowding,  and  foul  air,  may  be  the  cause  of  the 
dyscrasia  in  the  infant  born  under  such  circumstances,  even  when  the  parents 
are  actuated  by  the  best  motives  and  endeavor  to  lead  a  correct  life. 

Anatomy. — The  vesicles  occur  in  the  epidermis  between  the  layers  of  the 
stratum  granulosum  and  stratum  lucidum  (Weyl).  The  contents  of  the  vesi- 
cles consist  largely  of  serum,  but  sometimes  also  of  other  substances,  as  pus- 
cells,  epithelial  cells,  etc. 


OSTEOGENESIS  IMPERFECTA. 


153 


Treatment. — This  is  simple,  consisting  of  cleanliness,  the  use  of  abundant 
pure  breast-milk,  and  frequent  dusting  of  the  surface  with  a  powder  consisting 
of  bismuth  and  lycopodium.  In  the  cachectic  form  of  pemphigus,  especially 
if  the  vesicles  have  an  unhealthy  appearance,  they  should  be  broken,  and 
their  surface  may  be  dusted  with  a  powder  of  one  part  of  iodoform  and  ten 
of  bismuth.  In  syphilitic  cases  Henoch  recommends  the  addition  of  1  gramme 
(15  grains)  of  corrosive  sublimate  to  the  bath  employed.  The  use  of  a  few 
drops  of  Tokay  wine  or  other  alcoholic  stimulant  at  each  nursing  is  also 
required  in  the  cachectic  cases. 

Osteogenesis  Imperfecta. 

Cases  have  been  reported  in  which  bony  substance  was  very  deficient 
in  the  foetal  development,  so  as  to  cause  curvatures  and  deformities  in  the 

Fig.  16. 


N«^ 


skeleton.     It  has  commonly  been  supposed  that  these  cases  are  rachitic,  and 
from  them  has  arisen  the  belief  that  I'achitis  occasionally  occurs  in  the  foetus. 


154 


DISEASES  OF  THE  NEWLY-BORN. 


But  recent  microscopic  examinations  have  shown  that  in  at  least  some  of 
the  cases  of  supposed  foetal  rachitis,  rachitis  has  not  been  present.  Stilling 
published  such  a  case  in  Virchow's  Archiv.  It  is  represented  in  Fig.  16  from 
Sajous'  Annual,  vol.  ii.,  1890.  The  skeleton,  which  was  that  of  a  female  born 
at  the  eighth  month,  was  very  deficient  in  bone-substance,  but  without  the 
characters  of  rachitis.  Stilling  suggests  that  the  cause  of  this  deficiency 
and  malformation  may  have  been  syphilis. 

In    the   Wood    Museum   of   Bellevue    Hospital    is    a   skeleton   which   is 
probably  similar  to  those  in  the  Prague  and  Wurzburg  museums.     It  shows 
in  a  striking  manner  the  deform- 
ities   of    this    congenital    disease.  Fig.  18. 
The  case  occurred  in  my  practice,                               . 
and  the  dissection  was   made  by 
Prof.  Francis  Delafield.     The  in- 
fant,  born   at   term,   died    a    few 
hours  after  birth  from  atelectasis, 
apparently  produced  by  the  con- 
tracted state  of  the  thoracic  walls. 
The    parents    were    hard-working 
English  people.     They  were  free 
from  syphilitic  taint.    The  accom- 
panying wood-cut  (Fig.  1*7)  repre- 
sents this  skeleton. 

Fig.  17. 


Skeleton  of  an  infant  which  died  a 
few  hours  after  birth  (from  the  Wood 
Museum). 


Showing  foetal  deformity  of  skeleton  ^\  ithout 
rickets. 


The  following  case  (Figs.  18,  19)  occurred  in  my  service  in  the  New  York 
Infant  Asylum.  The  child  lived  five  hours,  being  kept  alive  by  artificial  res- 
piration. Its  mother  seemed  healthy,  but  its  father  was  unknown  to  the  phy- 
sicians of  the  Asylum.  The  longitudinal  section  of  the  lower  extremities, 
as  is  seen  in  the  illustration  and  was  proven  by  microscopic  examination, 
made  by  Prof.  Prudden,  did  not  exhibit  any  of  the  characters  of  rachitis. 


OSTEOGENESIS  IMPERFECTA. 


155 


Fig.  19. 


Longitudinal  sections  of  the  bones  of  the  lower  extremities. 


PABT    III. 
CONSTITUTIONAL  DISEASES. 


SEOTIOI^  I. 

DIATHETIC   DISEASES. 


CHAPTEE     I 

RACHITIS. 


Eachitis  is  a  constitutional  disease,  but  its  most  conspicuous  anatomical 
characters  pertain  to  the  osseous  system.  The  gross  nutritive  changes  which 
it  produces  in  the  bones  and  cartilages,  causing  deformities,  are  well  known 
to  physicians  and  the  laity.  In  addition  to  these  anatomical  changes  in  the 
skeleton,  typical  cases  exhibit  a  lack  of  tonicity  with  stretching  of  the  liga- 
ments, causing  the  knock -knee  and  flat-foot ;  weakness  of  the  muscles,  resem- 
bling paralysis  are  .sometimes  mistaken  for  it  in  severe  cases ;  reflex  irrita- 
bility, rendering  rachitic  patients  liable  to  laryngismus  and  tetany ;  undue 
perspiration  ;  anasmia  and  proneness  to  catarrhal  inflammation ;  and  certain 
anatomical  changes  in  the  spleen  and  liver  in  aggravated  forms  of  the  disease. 
These  many  and  divers  anatomical  and  functional  characters  indicate  the 
constitutional  or  general  nature  of  rachitis.  Therefore  theories  which 
restrict  rachitis  to  the  osseous  system  are  inadequate  and  erroneous. 

Rachitis  is  probably  an  ancient  disease.  It  is  said  that  an  old  statue  of 
^sop,  who  was  thrown  from  a  precipice  by  the  indignant  Delphians  564  years 
before  Christ,  exhibited  rachitic  deformities  ;  and  Hippocrates,  born  460  years 
before  Christ,  is  believed  to  have  alluded  to  it  in  his  treatise  on  the  Articu- 
lations. 

Occasionally  expressions  in  the  works  of  Celsus  and  Galen  in  the  second 
century  of  the  Christian  era  have  led  writers  on  rickets  to  believe  that  they 
also  had  observed  the  deformities  produced  by  this  disease.  But  rickets  was 
first  investigated  in  a  scientific  manner  by  Whistler,  Glisson,  and  their  con- 
temporaries in  the  middle  of  the  seventeenth  century.  During  the  last  few 
years  many  excellent  monographs  have  been  written  on  this  malady,  and  its 
causation,  pathology,  and  treatment  are  better  understood  than  formerly. 

Frequency. — Rachitis  is  a  widespread  disease,  but  it  is  comparatively 
infrequent  in  rural  localities,  where  families  enjoy  the  hygienic  requirements 
of  pure  air,  sunlight,  and  a  plentiful  diet  of  good  quality.  It  is  most  common 
in  crowded  and  badly-fed  families  in  city  tenement-houses,  where  antihygienic 
conditions  prevail. 

Mild  cases  of  rickets,  not  manifested  by  any  prominent  signs  or  symp- 
156 


RACHITIS.  157 

toms  are  often  overlooked,  so  that  the  physician  is  not  summoned,  or,  if  he 
be  summoned  and  have  not  given  particular  attention  to  this  disease,  he,  in 
not  a  few  instances,  does  not  detect  its  presence.  In  the  absence  of  deform- 
ity, which  occurs  later,  the  fretfulness,  tenderness  of  surface,  and  perspira- 
tions are  likely  to  be  attributed  to  other  causes  than  the  correct  one.  Hence, 
according  to  my  observations,  rachitis  is  more  common  in  its  milder  forms  in 
the  asylums  and  dispensaries  and  in  the  tenement-houses  of  New  York,  and 
probably  in  other  American  cities,  than  is  commonly  believed  by  the  laity, 
and  even  by  physicians  who  have  given  little  attention  to  the  disease.  A  few 
years  since  in  one  of  the  New  York  asylums  my  attention  was  directed  to  a 
rachitic  child  in  whom  the  anatomical  characters  of  rachitis  had  become  so 
pronounced  that  they  attracted  the  attention  of  the  nurses.  Prompted  by 
the  occurrence  of  this  case,  which  had  developed  during  my  attendance  in  the 
asylum,  I  made  an  examination  of  all  the  infants,  and  found,  what  I  had 
previously  not  suspected,  that  about  one  in  nine  presented  unmistakable  signs 
of  rachitis,  though  in  a  mild  form  and  for  the  most  part  in  its  commencement. 
The  late  Dr.  John  S.  Parry  of  Philadelphia  stated  that  at  least  28  per  cent, 
of  the  children  between  the  ages  of  one  mouth  and  five  years  who  came 
under  his  observation  in  the  Philadelphia  Hospital,  during  the  three  years 
preceding  the  publication  of  his  paper  in  1872,  were  rachitic.  According  to 
Dr.  Gee,  whose  observations  were,  however,  made  as  far  back  as  1867  and 
1868,  of  the  patients  under  the  age  of  two  years  in  the  London  Hospital  for 
Sick  Children,  30.3  per  cent,  were  rachitic  ;  and  Hitter  von  Rittershain,  whose 
observations  were  also  made  several  years  ago,  stated  that  of  1623  out-door 
patients  under  the  age  of  five  years  brought  to  the  Clinique  at  Prague.  504, 
or  31.1  per  cent.,  manifested  this  disease.  Recently  Prof.  Henoch  of  the 
University  of  Berlin  has  stated  that  he  had  seen  many  thousand  cases  of 
rachitis,  and  he  adds  that  its  spread  in  the  large  cities  of  Northern  and  Mid- 
dle Europe  is  enormous.  He  states  that  his  observations  in  regard  to  the 
frequency  of  rachitis  in  dispensary  practice  correspond  with  those  of  Von 
Kittershain,  as  many  as  31  per  cent,  being  rachitic.  In  Manchester  also, 
with  its  large  number  of  operatives,  Ritchie's  statistics  show  that  of  728  out- 
door patients  219.  were  rachitic.  The  late  curator  of  the  New  York  Foundling 
Asylum,  who  served  ten  years,  informs  me  that  he  believes,  without  the  accu- 
racy of  statistics,  that  as  many  as  20  per  cent,  of  the  cadavers  examined  by 
him  in  the  dead-house  presented  the  anatomical  characters  of  rachitis,  usually 
in  a  mild  form. 

The  recent  large  emigration  from  Europe  of  destitute  families,  living  from 
choice  or  necessity  in  filth  and  degradation,  who  for  the  most  part  remain  in 
the  cities,  occupy  small,  dark,  and  dirty  apartments,  and  whose  food  is  of  the 
poorest  quality  and  often  insufficient,  greatly  increases  the  number  of  rachitic 
children  in  New  York  and  probably  in  other  American  cities.  In  the  out- 
door department  of  Bellevue,  to  which  many  thousand  immigrants  from  the 
lowest  class  of  European  society  carry  their  sick  children  for  treatment, 
rachitis  is  not  infrequent ;  and  the  fact  has  been  observed  in  this  institution 
that  a  larger  proportion  of  severe  cases  attended  by  marked  deformities  occur 
in  the  Italian  families  than  in  those  from  other  parts  of  Europe.  In  families 
of  American  parentage  it  is  generally  admitted  that  rachitis  is  more  prevalent 
in  the  negro  than  in  the  white  race. 

Although  this  disease  occurs  most  frequently  in  the  families  of  the  desti- 
tute and  poorly  fed,  nevertheless  children  of  well-to-do  families  occasionally 
sufi"er  from  it,  even  in  an  aggravated  form,  in  consequence,  I  think,  usually 
of  ignorance  on  the  part  of  parents  in  regard  to  the  dietetic  requirements  of 
young  children.  Merei,  in  his  treatise  on  the  Disorders  of  Infantile  Develop- 
ment (London,  1850),  states  that  in  Manchester,  where  his  observations  were 


158 


CONS  TIT  UTIONA  L  DISEA  SES. 


made,  one  child  in  every  five  in  comfortable  circumstances  presented  rachitic 
symptoms.  In  the  United  States  rachitis  is  rare  in  well-to-do  families,  who 
provide  sufficient  and  suitable  diet  for  their  children  and  have  a  proper  regard 
for  sanitary  requirements.  When  it  does  occur  in  such,  it  is  due  usually, 
I  think,  to  improper  feeding.  But  this  cause  will  be  discussed  in  another 
place. 

Diagnosis. — In  preparing  statistics  relating  to  rachitis  it  is  obviously 
important  that  the  diagnosis  of  mild  and  incipient  cases  should  be  clear  and 
unmistakable.     What  symptoms  and  anatomical  characters  indicate  rachitis? 

The  fact  that  an  infant  has  reached  its  ninth  month  without  a  tooth  is 
regarded  by  Sir  William  Jenner  as  a  reliable  sign  of  rachitis.  In  order  to 
determine  to  what  extent  dentition  is  retarded  by  rachitis — and  retarded 
dentition  may  be  considered  a  sign  of  rachitis — Dr.  H.  R.  Purdy,  physician 
to  the  Out-door  Department  of  Bellevue  Hospital,  made  the  following  obser- 
vations : 


Showing  at  what  Age  200  Infants  exhibiting  no  signs  of  Rachitis 
cut  the  First  Tootli — cases  consecutive. 


Table  I.—;. 

3  cut  firs 

14    "     " 

16    ''     " 

20    "     " 

24    "     " 

37    "     " 

28  cut  first  tooth  at   8  months. 

20    "      "       "      "    9      " 

24     "        a         li        "  1Q        a 

15    "      "       "      "  11      " 
1    "      "       "      "  13      " 


Of  these,  132  were  wet-nursed,  68  bottle-fed. 


Table  II. — Showing  at  what  Age  50  Infants  exhibiting  one  or  more  Rachitic 
Symptoms  cut  the  First  Tooth — cases  consecutive  (18  wet-nursed,  32  bottle- 
fed). 
2  cut  first  tooth  at  4  months.  7  cut  first  tooth  at  11  months. 


2    "     "       " 

'  5 

3     «       u          a 

'  6 

2    "     "       " 

'  7 

5    "     "       " 

'  8 

6    "     "       " 

'  9 

12 
13 
14 
16 
18 


Table  III. —  Thirty  Infants  loith  Teeth,  hit  loith  j)ronounced  Rachitic  Symj)- 
toms.  In  all  these  cases  the  rachitic  rosary,  enlarged  subcutaneous  veins, 
profuse  pei'spirations,  abdominal  distention,  and  enlarged  joints  were  pres- 
ent.   Bottle-fed,  21 ;  wet-nursed,  9.    Age  at  which  they  cut  the  first  tooth. 

7  months.  3  at  12  months. 

2  "  13  " 
2  "  14  " 
1  "  15       " 


6  at 

7 

10  " 

8 

1  " 

9 

1  " 

10 

4  " 

11 

It  is  evident  from  these  interesting  statistics  that  dentition  delayed  until 
the  ninth,  or  even  the  tenth  or  eleventli  month,  is  not  a  certain  sign  of  rachi- 
tis, but  slow  teething  is  common  in  the  rachitic,  and  therefore  it  aids  in  the 
diagnosis.     It  is  one  of  the  diagnostic  signs. 

In  order  to  determine  whether  rachitis  incipient  or  of  a  mild  form  be 
present,  all  the  signs  which  characterize  it  should  be  considered — the  fretful- 
ness,  free  perspiration  upon  the  head,  neck,  face  and  chest,  the  tenderness  of 
surface,  anaemia  and  general  deterioration  of  health,  delayed  dentition,  swell- 
ing of  the  joints,  craniotabes,  bending  of  the  long  bones,  rachitic  rosary,  mis- 


RACHITIS.  159 

shapen  head,  prominent  frontal  and  parietal  bones,  deformity  of  the  thorax 
with  depression  of  the  ribs,  projecting  or  misshapen  sternum  and  prominent 
abdomen,  with  Harrison's  groove.  All  these  signs  and  symptoms  must  be 
considered  before  making  a  diagnosis  in  incipient  or  mild  rachitis.  In  order 
to  determine  the  diagnostic  value  of  enlargement  of  the  costo-chondral  articu- 
lations, "  the  rachitic  rosary,"  I  have  examined  these  joints  in  children  sup- 
posed to  be  healthy  or  suffering  from  other  ailments  than  rachitis  in  three  of 
the  New  York  institutions.  In  many  young  children  believed  to  be  healthy 
who  were  examined,  these  joints  were  not  appreciable  on  palpation.  In  others 
a  slight  prominence  could  be  felt  in  one  or  more  joints.  In  order  that  the 
beading  of  these  articulations  be  sufficient  to  indicate  rachitis,  it  should,  I 
think,  be  plainly  detected  by  the  fingers  in  most  of  the  costo-chrondral  articula- 
tions.   Less  than  this  I  would  not  regard  as  sufficient  evidence  of  this  disease. 

Age  of  Occurrence. — Deficiencies  and  curvatures  in  the  bones  of  the  newly- 
born  have  until  recently  been  supposed  to  result  from  foetal  rachitis.  But 
microscopic  examination  of  some  of  these  cases  has  demonstrated  beyond 
doubt  that  the  disease  present  was  not  the  result  of  rachitis,  but  an  osteo- 
genesis of  unknown  origin.    This  disease  is  described  in  the  preceding  chapter. 

Enlargement  of  the  costo-chondral  articulations,  known  as  the  rachitic 
rosary,  has  been  observed,  though  rarely,  in  infants  only  a  few  weeks  old. 
Dr.  Parry  saw  it  as  early  as  the  sixth  week  after  birth,  and  Dr.  Lee  at  the 
third  or  fourth  week.  The  significance  of  this  enlargement  as  a  sign  of  rachi- 
tis we  have  treated  of  elsewhere.  We  have  stated  that  with  few  exceptions 
rachitis  begins  before  the  close  of  the  third  year.  Though  first  detected  and 
diagnosticated  at  a  later  date,  it  will  ordinarily  be  ascertained,  on  inquiry,  that 
its  symptoms  had  an  earlier  beginning.  Still,  according  to  certain  observers, 
it  may  have  a  considerably  later  commencement.  Glisson,  Portal,  and  Tripier 
state  that  they  have  seen  it  commence  in  children  who  were  well  on  toward 
the  age  of  pulDerty.  Sir  William  Jenner  says  that  he  has  seen  children  of 
seven  and  eight  years  who  were  only  beginning  to  suffer  from  rachitis. 

The  following  are  the  aggregate  statistics  of  Bruennische,  Von  Bitters- 
hain,  and  Bitsche  relating  to  the  age  at  which  rachitis  occurs : 

No.  of  Cases. 

During  the  first  half  year 99 

"        "    second  half  of  first  year 259 

"        "         "      year      .        ." 342 

"        "    third  year 134 

"        "    fourth  year 31 

"        "    fifth  year      17 

Between  the  fifth  and  ninth  years 21 

Aggregate  .......  903 

^tioIjOQY.— Inheritance. — Some  patients  with  rachitis  appear  to  have 
inherited  a  predisposition  to  it.  Feeble  digestion  and  defective  assimilation 
in  the  infant— which  are,  as  we  will  see,  important  factors  in  producing  the 
rachitic  state — are  often  traceable  to  disease  or  cachexia  of  one  or  both 
parents.  Among  the  parental  causes  may  be  mentioned  poverty,  hardships, 
and  defective  nutrition  of  either  parent ;  age  of  father  and  exhausting  dis- 
charges of  the  mother,  such  as  purulent,  hsemorrhoidal,  or  uterine  fluxes. 
The  offspring  of  a  tubercular,  syphilitic,  or  otherwise  enfeebled  parent  is  more 
likely  to  become  rachitic  than  is  one  of  healthy  and  robust  ancestry.  We 
will  especially  emphasize  the  syphilitic  dyscrasia  in  either  parent  as  a  potent 
cause,  but  M.  T.  Parrot,  in  his  thesis  published  in  1872,  evidently  went  too 
far  in  attempting  to  show  that  congenital  syphilis  is  the  common  cause  of 
rachitis.     Most  rachitic  cases  are  entirely  free  from  the  syphilitic  taint,  and 


160  CONSTITUTIONAL  DISEASES. 

a  large  proportion  of  the  children  who  have  inherited  the  syphilitic  dyscrasia 
do  not  exhibit  any  signs  of  rachitis. 

Antihygienic  Conditions. — In  the  damp,  dark,  filthy,  and  overcrowded 
tenement-houses  of  the  city,  rickets  occurs  most  frequently  and  in  its  sever- 
est forms.  There  can  be  no  doubt  that  general  mal-hygiene  is  a  potent 
factor  in  causing  this  disease,  and  that  it  sometimes  produces  it  in  those  who 
have  inherited  good  constitutions.  On  the  other  hand,  many  children  with 
healthy  parentage  and  vigorous  at  birth,  i-educed  by  poverty  to  a  life  of 
squalor  and  privation,  do  not  become  rachitic. 

Food. — Of  the  antihygienic  conditions  which  give  rise  to  rachitis,  the 
most  common  and  potent  appears  to  be  the  use  of  food  not  sufficiently  nutri- 
tious, or,  if  nutritious,  not  suited  to  the  age  and  digestive  powers  of  the  child. 
The  use  of  thin  and  poor  breast-milk  and  artificial  food  of  poor  quality  or  not 
suitable  for  the  stage  of  growth  and  development  is  a  common  cause  of 
rachitis.  Those  children  who  have  been  prematurely  weaned,  and  who  have 
been  given  food  which  is  not  a  proper  substitute  for  the  natural  aliment,  and 
those  too  long  wet-nursed  by  scantily-fed  and  poorly-nourished  mothers,  and 
not  allowed  the  additional  aliment  which  they  require,  are  especially  liable  to 
this  disease.  Those  children  whose  digestive  power  is  feeble,  from  whatever 
cause,  are  more  likely  to  become  rachitic  than  those  who  in  a  state  of  robust 
health  have  a  hearty  digestion.  Hence  we  meet  with  rickets  as  a  sequel  of 
various  protracted  and  exhausting  maladies  during  infancy. 

I  might  relate  cases  of  rachitis  occurring  during  the  use  of  certain  of  the 
popular  proprietary  or  commercial  foods.  I  have  examined  the  analyses  of 
these  foods  made  by  Prof.  Leeds  in  order  to  determine  what  ingredient  is 
lacking,  and  they  are  found  to  contain  a  considerably  smaller  percentage  of 
fat  than  occurs  in  human  milk.  Too  little  fat  in  the  food  may,  as  Cheadle 
observes,  be  one  of  the  chief  dietetic  causes  of  rachitis.  Infants  suckled  by 
healthy  mothers  or  wet-nurses  who  have  an  abundance  of  milk,  of  good 
quality,  do  not  become  rachitic  as  long  as  their  nutriment  is  derived  from 
this  source.  But  those  prematurely  weaned  and  given  a  diet  deficient  in 
nutritive  properties,  and  those  who  are  allowed  the  promiscuous  food  of  the 
table  or  have  largely  a  farinaceous  diet  during  the  first  and  second  years, 
when  the  food  should  be  chiefly  milk,  are  especially  liable  to  become  rachitic. 

It  is  an  interesting  fact,  and  one  that  throws  light  on  the  dietetic  cause 
of  rachitis,  that  it  does  not  occur  in  Japan.  Physicians  who  have  had 
abundant  opportunities  to  observe  the  diseases  of  the  Japanese  state  that 
they  have  never  seen  or  heard  of  a  case  among  them.  M.  Remy,  in  his  Notes 
Medicales  siw  le  Japon,  says  that  the  Japanese  women  have  a  remarkable 
abundance  of  milk,  and  that  they  suckle  their  young  until  the  age  of  five  or 
six  years,  but  their  children  are  also  given  artificial  food  after  the  first  year. 
Remy's  explanation  of  the  immunity  of  the  Japanese  from  rachitis  is  as  fol- 
lows :  "  The  Japanese  have  always  eaten  plentifully  of  fats  and  oil  of  fishes, 

the  blubber  of  the  whale,  the  eel  and  loach  especially The  universal 

use  of  the  food  under  notice  from  the  time  of  ancient  Buddhist  flesh-prohibi- 
tion, but  especially  the  consumption  of  fish  by  the  lactating  women,  together 
with  the  fish  given  to  the  children  as  supplementary  feeding,  which  at  that 
time  is  allowed  them  by  Japanese  tradition,  are,  in  my  opinion,  main  causes 
of  the  non-existence  of  rachitis  in  Japan." 

Observations  on  the  feeding  of  animals  have  also  aided  in  the  elucidation 
of  the  causation  of  rachitis.  Guerin  gave  certain  puppies  a  diet  of  meat  four 
or  five  months,  and  they  became  markedly  rachitic,  while  other  puppies  of  the 
same  litter,  suckled  by  their  mother,  remained  well.  At  a  meeting  of  the 
section  of  Diseases  of  Children  of  the  British  Medical  Association,  held  in 
August,  1888,  Dr.  W.  B.  Cheadle  read  an  instructive  paper  on  rachitis,  in 


RACHITIS.  161 

which  he  said  that  the  results  of  feeding  young  animals  in  the  Zoological 
Gardens  strongly  support  the  view  that  a  deficiency  of  animal  fats  and  earthy 
salts  are  the  most  efficient  agents  in  producing  rickets.  He  states  that  in  the 
Zoological  Gardens  the  young  monkeys  taken  from  their  mothers  and  fed 
with  a  vegetable  diet,  chiefly  fruits,  become  rachitic.  Such  diet  is  destitute 
of  animal  fat,  and  is  deficient  in  proteids  and  earthy  salts.  Two  young  bears 
were  fed  with  rice  biscuits,  and  occasionally  with  lean  meat,  which  they 
licked  but  rarely  ate.  Fat,  proteids.  and  lime  salts  were  practically  excluded 
from  their  food.  The  bears  died  of  extreme  rickets  while  still  young.  Cheadle 
also  states  that  more  than  twenty  litters  of  lions  had  died  successively  of 
rachitis,  and  the  next  brood  were  fed  with  cod-liver  oil,  pulverized  bones,  and 
milk.  In  three  months  all  signs  of  rickets  had  disappeared.  The  addition 
of  fat  and  bone-salts  caused  the  change,  and  after  eighteen  months,  when  the 
last  observations  were  made,  the  brood  of  young  lions  were  strong  and 
healthy.  They  had  received  in  every  respect  the  same  treatment  as  the 
litters  that  had  perished,  except  as  regards  the  diet.  The  latter  had  been 
fed  with  the  carcasses  of  old  horses,  which  are  destitute  of  fat  and  whose 
bones  resisted  the  lions'  teeth. 

The  theory  that  lactic  acid  is  the  causal  agent  in  rachitis  has  been  strongly 
advocated  by  Dr.  C.  Heitzmann,  formerly  of  Vienna,  but  now  of  New  York. 
He  administered  lactic  acid  by  mouth  and  subcutaneous  injection  to  five  dogs, 
seven  cats,  two  rabbits,  and  one  squirrel.  The  lactic  acid  administered  to  the 
dogs  and  cats,  with  "  restricted  administration  of  calcareous  food,"  produced 
the  characteristic  enlargement  of  the  epiphyses,  and  finally  the  "  curvatures 
of  the  bones  of  the  extremities."  After  four  or  five  months  of  administration 
of  lactic  acid  the  long  bones  were  very  flexible,  and  repeated  inflammations 
of  the  conjunctiva,  bronchi,  stomach,  and  intestines  had  occurred. 

But  in  man}^  cases  of  rachitis  there  is  no  evidence  of  an  excess  of  lactic 
acid,  and  an  objection  to  the  lactic-acid  theory  apparently  valid  is  that  lactic 
acid,  produced  by  imperfect  digestion,  would  unite  with  a  base,  either  the 
soda  or  potash  in  the  blood,  which  is  always  alkaline,  before  it  reached  the 
osseous  system.  The  more  the  causation  of  rachitis  is  elucidated  by  observa- 
tions on  man  and  experiments  on  animals,  the  stronger  is  the  evidence  that 
its  chief  cause  is  dietetic — that  there  is  a  failure  to  receive  or  to  digest  and 
assimilate  certain  important  substances  in  the  food,  particularly  the  fat,  phos- 
phate of  lime,  and  proteids.  The  deprivation  of  these  alimentary  substances 
produces  the  rachitic  dyscrasia,  which  is  manifested  by  malnutrition  in  many 
tissues.  Of  course  general  antihygienic  conditions,  which  lower  the  vitality, 
may,  as  we  have  stated  elsewhere,  be  a  factor  in  causing  rachitis. 

Pathology. — Distinguished  pathologists  and  clinical  observers  who  have 
investigated  rachitis,  and  whose  investigations  have  been  chiefly,  if  not 
entirely,  restricted  to  the  osseous  system,  have  regarded  this  disease  as  an 
inflammation  afiecting  the  bones  and  cartilages.  Among  those  who  have  ex- 
pressed this  opinion  may  be  mentioned  Yirchow  and  Niemeyer.  Memeyer 
says  :  "  It  seems  to  me  that  the  most  probable  hypothesis  regarding  the  cause 
of  rachitis  is  that  which  refers  it  to  inflammation  of  the  epiphyseal  cartilages 
and  periosteum."  The  increased  vascularity  of  the  periosteum,  the  prolifera- 
tion of  periosteum  and  cartilage,  the  tenderness  and  pain  on  motion,  and  the 
elevation  of  temperature  in  acute  forms  of  the  disease,  indicate  inflammation 
rather  than  any  other  recognized  pathological  state.  If  the  rachitic  disease 
of  the  osseous  system  be  regarded  as  an  inflammation,  it  obviously  presents 
a  subacute  or  chronic  character,  like  cirrhosis  and  certain  forms  of  chronic 
nephritis,  in  which  proliferation  of  connective  tissue  and  sclerosis  occur.  The 
eburnation,  instead  of  normal  ossification,  which  terminates  the  rachitic  pro- 
cess, might  be  considered  an  osteosclerosis.  Moreover,  the  thickening,  hyper- 
11 


162  CONSTITUTIONAL  DISEASES. 

aemia,  and  infiltration  of  the  periosteum,  exudation  and  formation  of  new 
vessels  in  the  periosteum  and  underlying  cartilaginous  and  osseous  tissues, 
are  conformable  with  the  theory  of  the  inflammatory  nature  of  rachitis.  On 
the  other  hand,  some  of  the  structural  changes  in  the  soft  tissues  in  rachitis 
which  are  described  in  this  paper  are  not  such  as  ordinarily  result  from 
inflammatory  processes.  Billroth,  seeing  the  difiiculties  in  the  way  of  the 
inflammatory  theory,  wrote  of  rachitis  that  it  "  cannot  be  exactly  classed 
among  the  chronic  inflammations,  although  nearest  related  to  this  process." 
If  seems  most  in  consonance  with  the  facts  to  regard  rachitis  as  a  constitu- 
tional or  general  disease,  a  dyscrasia  afi'ecting  the  nutrition  of  various  tissues 
of  the  body,  and  producing  disease  in  the  osseous  system  which  is  either 
inflammatory  or  closely  allied  to  inflammation. 

Changes  in  the  Soft  Tissues. — We  have  stated  that  although  the  con- 
spicuous lesions  of  rachitis  pertain  to  the  skeleton,  the  soft  tissues  are  also 
more  or  less  implicated,  as  might  be  expected,  since  the  disease  is  systemic  in 
its  nature.  The  skin  in  milder  cases  is  but  little  involved,  but  as  a  rule  the 
perspiration  of  the  rachitic  is  excessive  from  the  head,  face,  neck,  and  chest. 
This  may  occur  before  changes  are  observed  in  the  skeleton.  Pyrexia  is  in 
some  patients  absent  or  slight,  but  catarrhs  of  the  mucous  surfaces  are  com- 
mon, and  these  are  likely  to  give  rise  to  some  elevation  of  temperature.  The 
fever  that  frequently  accompanies  severe  eases  may  sometimes  result  from 
the  disease  of  the  skeleton.  In  protracted  and  severe  cases  the  patients 
become  markedly  anaemic,  but  in  recent  and  mild  cases  the  pallor  may  be  so 
slight  as  not  to  attract  attention.  Emaciation  is  not  pronounced,  as  a  rule, 
in  the  rachitic,  but  in  certain  patients  the  muscles  throughout  the  system 
become  shrunken  and  flabby,  partly  perhaps  in  consequence  of  the  gastro- 
intestinal disorder,  indigestion,  and  malnutrition,  partly  perhaps  from  want 
of  use,  for  the  rachitic  are  likely  to  be  passive. 

Mucous  Membranes. — Rachitis,  as  we  have  stated  above,  increases  the 
liability  to  catarrh  of  the  mucous  surfaces.  Writers  on  this  disease  have 
remarked  the  frequent  occurrence  of  bronchitis,  broncho-pneumonia,  entero- 
colitis, and  conjunctivitis. 

Ligaments. — The  ligaments  become  relaxed  and  flabby,  giving  unusual 
mobility  to  the  joints  and  unsteadiness  to  the  movements.  The  fibrous  bands 
which  unite  the  vertebrae,  as  well  as  the  ligaments  of  the  extremities,  partici- 
pate in  the  relaxation.  Talipes  valgus  and  knock-knee  are  especially  likely 
to  occur  in  rickets  as  a  result  of  the  relaxation  of  ligaments,  even  when  the 
bones  are  but  slightly  involved.  Kyphosis,  lordosis,  and  scoliosis — backward, 
forward,  and  lateral  curvatures  of  the  spine — also  result  from  relaxation  of 
the  ligaments,  aided  by  the  softening  and  change  in  shape  of  vertebrae  and 
of  the  intervertebral  cartilages. 

The  Spleen  and  Liver. — The  spleen  is  sometimes  enlarged,  as  ascertained 
by  palpation  and  percussion.  Ritter  von  Rittershain  found  this  organ  de- 
cidedly enlarged  in  10  out  of  35  cases  which  he  examined  after  death.  The 
enlargement  is  the  result  of  cellular  proliferation,  common  in  diseases  which 
are  attended  by  a  dyscrasia.  In  a  recent  very  anaemic  and  fatal  case  of 
rachitis  in  the  New  York  Foundling  Asylum  the  spleen  extended  below  the 
level  of  the  umbilicus.  But  in  many  cases  of  rachitis,  even  when  profound, 
splenic  enlargement  is  slight  or  is  not  appreciable. 

The  liver  in  many  patients  undergoes  no  perceptible  change,  except  that 
it  is  carried  downward  by  the  lateral  depression  of  the  ribs.  It  is  occasion- 
ally enlarged  from  fatty  infiltration,  but  no  special  significance  attaches  to 
this,  for  fatty  liver  is  common  in  various  forms  of  disease  attended  by  innu- 
trition and  wasting.  It  is  common  in  tuberculosis  and  in  protracted  intestinal 
catarrh,  and  its  pathological   significance  appears  to   be  the  same  in  these 


RACHITIS.  163 

various  diseases.  There  can  be  no  doubt  that  Sir  William  Jenner  errs  when 
he  states  that  albuminoid  infiltration  of  the  liver  is  common  in  rachitis. 
Parry,  Gee,  Dickinson,  and  Senator  agree  that  it  is  rare,  and  that  when  it 
does  occur  it  is  a  coincidence. 

In  the  discussion  of  rickets  at  the  meeting  of  the  British  Medical  Asso- 
ciation in  August,  1888,  Dr.  Ranke  of  Munich  said  that,  according  to  the 
records  of  34  post-mortem  examinations  of  rachitic  cases  in  Virchow's  Patho- 
logical Institute  between  1872  and  1880,  13  exhibited  changes  in  the  liver, 
mostly  parenchymatous  fatty  infiltration  with  increase  of  volume.  In  the  34 
cases  the  spleen  was  recorded  enlarged  in  9  and  small  in  2.  In  the  remaining 
23  cases  the  size  and  appearance  of  the  spleen  were  probably  normal,  or  some 
mention  would  have  been  made  of  it.  Dr.  Ranke  also  consulted  the  records 
of  the  Munich  Pathological  Institute  under  Prof.  Bollinger,  and  in  9  of  25 
post-mortem  examinations  of  rachitic  cases  more  or  less  enlargement  of  the 
liver  was  recorded.  We  may  therefore  infer  from  these  carefully  conducted 
examinations  that  enlargement  and  structural  changes  of  the  liver  and  spleen 
only  occasionally  occur  in  rachitis — that  in  the  majority  of  cases  this  disease 
runs  its  course  without  any  notable  alteration  in  these  organs.  My  own 
observations  lead  me  to  believe  that  hypertrophy  of  the  spleen,  and  probably 
also  of  the  liver,  occurs  chiefly  in  decidedly  anaemic  subjects. 

The  abdomen  is  protuberant  from  various  causes.  The  lateral  depression 
of  the  thoracic  walls  causes  the  liver  and  spleen  to  descend  a  little  lower  in 
the  abdominal  cavity  than  natural,  producing  at  the  base  of  the  chest  ante- 
riorly Harrison's  groove,  which  is  transverse  and  corresponds  with  the  inser- 
tion of  the  diaphragm.  The  enlargement  of  the  liver  and  spleen,  the  feeble 
tonicity  of  the  intestinal  muscular  fibres,  and  consequent  distention  of  the 
intestines  with  gas,  and  the  rachitic  shortening  of  the  spinal  column,  which 
causes  approximation  of  the  ribs  and  pelvis,  necessarily  produce  abdominal 
protuberance. 

The  Kidneys  and  Urine. — Observations  thus  far  have  not  detected  any 
structural  change  or  disease  of  the  kidneys  attributable  to  rachitis,  except 
that  this  organ  is  enlarged  in  some  cases.  Moreover,  the  records  of  the  urine 
are  so  conflicting  that  more  exact  and  more  numerous  examinations  of  this 
excretion  are  required  before  any  positive  statement  can  be  made  in  reference 
to  its  composition.  Dr.  C.  H.  Flagge  has  seen  two  eases  in  which  there  were 
large  quantities  of  uric  acid  in  the  urine.  Ephraim  also  mentions  an  increased 
elimination  of  uric  acid  up  to  18  per  cent.  Ephraim  likewise,  as  well  as  Mar- 
chand  and  Lehmann,  state  that  there  is  an  increase  of  phosphate  of  lime  and 
the  occurrence  of  lactic  acid  in  the  urine. 

Brain  and  Spinal  Cord. — It  is  not  improbable  that  the  symptoms  of 
rachitis  which  are  referable  to  the  nervous  system,  such  as  laryngismus 
stridulus,  tetany,  convulsions,  and  weakness  or  paralysis  of  the  extremities, 
may  be  largely  due  to  the  pressure  exerted  in  places  upon  the  cerebro- 
spinal axis  by  its  bony  covering.  Hence  we  will  postpone  their  considera- 
tion until  we  have  described  the  changes  produced  by  rachitis  in  the  osseous 
system. 

Changes  in  the  Osseous  System. — A  knowledge  of  the  normal  anatomy 
and  normal  development  of  the  osseous  system  will  enable  us  to  better  under- 
stand the  changes  which  occur  in  this  system  in  disease,  and  especially,  which 
concerns  us  at  present,  in  rachitis.  Hence  we  will  give  a  brief  resume  of  the 
anatomy  of  the  skeleton  in  health  before  we  consider  the  changes  produced 
in  it  by  rachitis. 

Osseous  System  in  Health. — In  health  and  when  fully  developed,  bone  con- 
sists of  animal  matter  (chiefly  gelatin)  and  earthy  salts,  in  the  proportion,  by 
weight,  of  about  one  part  of  the  former  to  two  of  the  latter.     The  following 


164  CONSTITUTIONAL  DISEASES. 

is  the  analysis,  which  may  be  regarded  as  approximately  correct,  of  healthy 
human  bone  of  the  adult : 

Animal  matter 33.30 

f  Tribasic  phosphate  of  calcium     .    :    .51.04 

Carbonate  of  calcium 11.30 

Earthy  salts.  -    Fluoride  of  calcium 2.00 

Phosphate  of  magnesium 1.16 

Soda  and  chloride  of  sodium  .    .    .    .    1.20 

100.00 

In  childhood  the  bones  are  softer,  more  elastic,  and  less  likely  to  fracture  than 
in  the  adult.  Of  the  earthy  salts  in  bone,  it  is  seen  that  the  phosphate  of 
calcium  is  the  most  abundant,  and  it  is  the  most  important.  Hence  it  is 
termed  "  bone  earth."  The  phosphate  of  calcium,  combined  with  animal 
matter,  produces  a  hard  compound.  The  enaiuel  of  the  tooth  consists  chiefly 
of  phosphate  of  calcium  (88 J  per  cent.),  while  the  softer  egg-shell  consists 
chiefly  of  the  carbonate  of  calcium.  The  strength  of  bone  is  remarkable, 
being,  according  to  Holden,  when  compared  with  wood,  nearly  three  times 
that  of  the  elm  or  ash,  and  double  that  of  the  oak.  It  is  elastic  on  account 
of  the  animal  matter  which  it  contains.  If  a  long  bone  be  placed  at  right 
angles  upon  a  hard  substance,  and  the  projecting  end  receive  a  blow  from  a 
hammer,  the  latter  will  rebound.  The  Arab  children  are  said  to  make  bows 
of  the  camel's  ribs. 

If  a  longitudinal  section  be  made  through  a  long  bone,  we  observe  a  hard 
or  compact  outer  part,  and  in  the  interior  the  medullary  canal,  containing 
marrow.  In  birds  of  flight  the  hollow  of  the  bones  contains  air  instead  of 
marrow,  and  this  air  communicates  with  the  lungs. 

The  hard  or  compact  portion  of  bone,  though  solid  like  a  stone,  consists 
of  layers  in  close  apposition,  so  that  there  is  no  interval  between  them.  On 
approaching  the  joints  the  internal  layers  of  the  compact  structure  separate 
from  each  other,  forming  the  cancellous  tissue,  so  that  the  compact  wall 
becomes  thinner.  If  the  earthy  salts  be  removed  by  an  acid,  the  animal 
matter  remaining  is  found  to  consist  of  layers,  which  can  be  separated  from 
each  other.  In  inflammation  the  afflux  of  blood  and  the  exudation  cause 
separation  of  the  layers  and  enlargement  of  the  bone. 

The  cancellous  tissue  occupies  the  interior  of  the  bone,  and  is  most  abun- 
dant in  its  articular  ends.  The  bony  layers  in  the  cancellous  structure  are 
separated  from  each  other,  so  as  to  form  cavities,  which  are  strengthened  by 
cross-plates  like  latticework.  In  the  adult  the  marrow  in  the  interior  of  the 
shafts  of  the  long  bones  is  yellow,  consisting  of  96  per  cent,  of  fat,  but  in 
the  articular  ends  of  the  long  bones,  in  the  ribs,  cranial  bones,  and  short 
bones,  the  marrow  has  a  reddish  tinge,  and  it  consists  of  about  75  per  cent, 
of  water  and  about  25  per  cent,  of  albumin,  without  fat  or  only  a  trace  of  it. 
This  kind  of  marrow  occurs  in  all  the  bones  of  the  foetus  and  the  infant,  and 
it  contains  cells  with  many  nuclei,  designated  "  myeloid  cells."  Holden  says 
that  bones  are  as  minutely  provided  with  blood-vessels  and  nerves  as  are  the 
soft  tissues.  Near  the  extremities  of  the  long  bones  are  numerous  minute 
openings  through  which  blood  is  conveyed  to  and  from  the  cancellous  tissue. 
On  the  shafts  of  the  long  bones  are  slight  grooves  parallel  with  the  shafts, 
at  the  bottom  of  which  are  minute  holes,  scarcely  visible,  through  which 
blood  is  conveyed  to  and  from  the  compact  tissue.  The  blood  which  supplies 
the  osseous  tissue  is  conveyed  through  these  holes  by  minute  arteries  from 
the  vessels  of  the  periosteum,  and  is  returned  by  veins  to  the  periosteum. 
Near  the  middle  of  the  shaft  of  the  long  bone  is  a  distinct  canal  passing 
obliquely  through  the  shaft.     This  canal  contains  the  nutrient  artery  of  the 


RACHITIS.  165 

medulla,  dividing,  after  entering  the  medullary  cavity,  into  two  branches,  one 
passing  upward  and  the  other  downward.  The  blood-vessels  supplying  the 
different  parts  of  the  bone  from  these  various  sources  intercommunicate. 
Other  bones  than  the  long  bones  are  supplied  with  blood  in  a  similar  man- 
ner, and  the  nutrient  vessels  are  accompanied  by  nerves,  as  in  other  parts 
of  the  system. 

The  microscope  is  required  in  order  to  reveal  the  minute  anatomy  of  bone. 
It  is  found  to  consist  of  canals,  termed  the  Haversian,  and  around  each  canal 
the  bone  is  arranged  in  concentric  layers,  like  the  concentric  rings  of  a  tree. 
Between  the  rings  are  dark  spots,  designated  lacunae,  arranged  concentrically, 
now  known  to  be  minute  reservoirs  containing  blood.  Minute  lines  are  seen 
connecting  the  reservoirs  with  each  other  and  with  the  adjacent  Haversian 
canal.  The  lines  are  minute  blood-vessels,  and  through  them  the  blood  is 
conveyed  to  every  part  of  the  bone.  They  are  designated  canaliculi.  They 
connect  externally  with  the  vessels  of  the  periosteum,  and  internally  with  the 
vessels  of  the  medullary  membrane  or  endosteum.  In  the  interspaces  between 
£he  lacunae  and  canaliculi,  in  the  animal  matter,  an  infinite  number  of  osseous 
granules  is  deposited,  consisting  mainly  of  phosphate  and  carbonate  of  lime. 

Alterations  in  the  Osseous  System  in  Rachitis. — For  convenience  of  descrip- 
tion the  course  of  rachitis  as  regards  the  osseous  system  is  divided  into  three 
periods  :  (1)  That  of  proliferation  and  altered  nutrition  of  cartilage  and  perios- 
teum ;   (2)  That  of  curvature  and  deformity  ;   (3)  That  of  reconstruction. 

1.  Anatomical  Characters  in  the  Stage  of  Proliferation  and  Altered 
Nutrition. — The  long  bones  in  normal  growth  increase  in  length  by  the  form- 
ation of  bone  in  the  cartilage  between  the  diaphysis  and  epiphysis,  and  in 
thickness  by  the  development  of  bone  from  the  vascular  and  cellular  under- 
surface  of  the  periosteum.  As  regards  the  flat  and  short  bones,  growth  in 
the  thickness  occurs  from  the  periosteum,  and  growth  in  breadth  occurs  from 
the  development  and  ossification  of  the  cartilaginous  borders  and  edges,  which 
correspond  with  the  epiphyseal  cartilage  of  the  long  bones. 

If  we  examine  the  epiphyseal  cartilage  of  a  long  bone  during  normal 
ossification,  we  observe,  beginning  at  the  distal  end,  a  white  zone,  consisting 
of  the  hyaline  matrix,  in  which  are  the  usual  cartilage-cells.  This  consti- 
tutes most  of  the  cartilage.  Underneath  this,  and  nearer  the  bone,  is  the 
zone  of  proliferation,  the  cartilage  in  which  is  softer  and  more  yielding  than 
that  of  the  distal  zone,  in  consequence  of  cell-formation  and  absorption  of 
the  matrix  to  make  way  for  cell-groups.  Each  cell  in  the  proliferating  zone 
has  divided  into  two  cells,  and  each  of  these  cells  into  two  other  cells  ;  and 
the  division  has  been  repeated,  so  that  eight  cells  instead  of  one  are  observed, 
surrounded  by  a  common  capsule.  The  capsule  becomes  distended  by  the 
cell-multiplication  and  swelling  of  each  cell,  the  size  of  which  is  considerably 
greater  than  that  of  the  parent  cell.  Near  the  bone,  along  the  extremity  of 
the  diaphysis,  the  cell-groups,  enclosed  in  their  capsules,  nearly  touch  each 
other,  the  matrix  having  been  for  the  most  part  absorbed.  The  end  of  the 
diaphysis  is  covered  with  a  layer  of  these  cell-groups  about  to  undergo  ossifi- 
cation, with  almost  no  intervening  matrix.  The  proliferating  zone  has  very 
little  depth.  It  appears  to  the  naked  eye  as  a  very  thin,  scarcely  perceptible 
layer  of  a  reddish-gray  color  upon  the  end  of  the  shaft.  It  is  so  thin  that  it 
but  slightly  increases  the  thickness  of  the  cartilage. 

In  rachitis  the  state  is  different.  The  zone  of  proliferation,  instead  of 
being  confined  to  a  single  or  at  most  double  layer  of  cell-groups,  consists  of 
many  layers,  involving  nearly  the  whole  epiphyseal  cartilage.  The  cells,  still 
enclosed  in  their  capsules,  undergo  a  more  frequent  division  than  in  health, 
so  that,  instead  of  groups  of  eight  cells,  as  in  the  normal  state,  each  group 
consists  of  thirty  or  forty  cells  enclosed  in  the  distended  capsule.     Therefore 


166 


CONSTITUTIONAL  DISEASES. 


in  rachitis  the  proliferating  cartilaginous  zone  is  a  broad  cushion,  very  soft, 
of  a  grayish  translucent  appearance,  causing  the  characteristic  swelling 
observed  around  the  joint.  Over  the  distal  end  of  the  proliferating  carti- 
lage there  may  still  be  a  zone,  though  perhaps  of  little  depth,  of  normal 
cartilage  like  that  in  health. 

While  the  changes  described  above  occur  in  the  cartilages,  the  ossifying 
process  is  arrested  or  rendered  abnormal.  We  indeed  perceive  an  effort  in  the 
direction  of  bone-formation.  The  Haversian  canals,  surrounded  by  capillary 
loops,  extend  from  the  bone  into  the  proliferating  zone  of  cartilage.  Their 
extension  is  effected  by  absorption  of  the  matrix  and  appropriation  of  cell- 
groups  which  lie  in  their  way.  The  cells  in  these  groups,  as  they  enter  the 
Haversian  system,  become  much  smaller  by  rapid  segraentation,  forming 
medullary  cells.  We  also  find,  as  further  evidence  of  the  attempt  at  bone- 
formation,  granules  and  masses  of  lime  scattered  through  the  cartilage,  and 


Fig.  21. 


Fig.  20. 


-«h       ^»»» 


4 


here  and  then'  spiculee  and  nodules  of  true  bone  .springing  up  from  the  bony 
substance  of  the  shaft.  Some  of  the  canals  are  prolonged  far  into  the  carti- 
lage— nearly,  indeed,  to  its  free  surface — but  most  of  them  terminate  in  its 
lowest  portions. 


RACHITIS. 


167 


We  have  stated  that  the  growth  of  bone  in  thickness  occurs  from  the 
under  surface  of  the  periosteum.  In  health  a  soft,  vascular  germinal  tissue 
springs  from  the  periosteal  surface,  rapidly  receives  lime  salts,  and  is  trans- 
formed into  bone.  This  germinal  tissue,  consisting  largely  of  capillaries 
rising  from  the  fibrous  tissue  of  the  pei'iosteum,  is  a  very  thin  substance, 
barely  visible,  transient,  and  constantly  changing  from  its  conversion  into 
bone. 

In  rachitis  this  vascular  subperiosteal  tissue,  not  undergoing,  or  under- 
going slowly  and  imperfectly,  the  osseous  transformation,  and  at  the  same 
time  increasing  more  rapidly  than  in  health  under  the  irritating  influence 
of  the  rachitic  disease,  becomes  a  thick  layer.  Its  color  and  appearance 
are  like  spleen-pulp,  so  that  the  older  observers  supposed  that  there  was 
hemorrhagic  extravasation  between  the  periosteum  and  the  bone.  There  is, 
however,  no  extravasation  of  blood,  unless  it  accidentally  occurs  from  the 
numerous  delicate  capillaries.  The  resemblance  to  extravasated  blood  or 
spleen-pulp  is  due  to  the  abundant  growth  of  large  and  thin-walled  capil- 
laries from  the  under  surface  of  the  periosteum,  as  shown  by  the  microscope. 
This  vascular  outgrowth  is,  for  the  most  part,  quite  uniform  over  the  shafts 

Fig.  22. 


of  the  long  bones,  while  upon  the  cranial  bones  its  thickness  is  much  greater 
in  one  locality  than  in  another.     The  attempt  at  ossification  also  appears  in 


168 


CONSTITUTIONAL  DISEASES. 


this  tissue.  Lime  salts  are  scantily  and  loosely  deposited  through  it,  forming 
osteophytes,  vascular  and  fragile,  rather  than  true  bone.  The  question 
naturally  arises,  How  does  rachitis  affect  bone  which  is  already  formed  when 
the  rachitic  state  begins  ?  Virchow's  answer  is  the  following :  "  Rachitis 
has  by  more  accurate  investigation  been  shown  to  consist,  not  in  a  process  of 
softening  in  the  old  bone,  as  it  has  previously  been  considered  to  be,  but  in  a 
non-consolidation  of  the  fresh  layers  as  they  form  :  the  old  layers  being  con- 

FiG.  23. 


sumed  by  the  normally  progressive  formation  of  medullary  cavities,  and  the 
new  remaining  soft,  the  bone  becomes  brittle." 

We  have  seen  that  in  healthy  bone  the  earthy  salts  are  in  excess  of 
organic  matter  nearly  in  the  proportion  of  two  to  one,  but  in  rachitis  the 
proportion  is  reversed,  the  organic  matter  being  much  in  excess.     The  follow- 


RACHITIS.  169 

ing  table  gives  analysis  of  rachitic  bones  by  Marchancl,  Davy,  Boettger,  and 
Friedleben  : 

Femur.  Radius.  Vertebra. 

Inorganic.  Organic.      Inorganic.    Organic.      Inorganic.    Organic. 

Case  1 20.60         74.40  21.24         78.76  18.68         81.32 

Case  II 37.80         62.20  20.00         80.00  32.29         67.71 

Case  III 20.89         79.11 

Case  IV 52.85         47.15 

As  might  be  expected,  the  relative  proportion  of  the  inorganic  matter  (the 
earthy  salts)  and  the  organic  matter  varies  greatly  in  different  cases.  In 
severe  rachitis  many  bones  are  affected.  It  is  stated  that  there  is  no  bone  in 
the  entire  skeleton  that  may  not  suffer,  but  in  mild  cases  only  a  few  are 
involved,  at  least  to  such  an  extent  as  to  produce  structural  changes  appre- 
ciable to  touch  or  sight. 

Rachitic  bone,  when  the  disease  is  still  in  its  active  period,  presents  a 
bluish  or  dusky-red  appearance  from  its  increased  vascularity.  After  a  vari- 
able time — weeks  or  months  according  to  the  severity  of  the  disease — deform- 
ities begin  to  appear. 

2.  Anatomical  Characters  of  the  Rachitic  Child.— In  typical  rachitis 
the  bone  seldom  retains  its  normal  form  or  shape :  its  projecting  points  are 
rounded,  and  as  soon  as  it  softens  it  begins  to  yield  to  pressure  exerted  upon  it. 
Hence  the  curvatures  so  common  and  characteristic.  The  portion  of  a  long 
bone  which  is  formed  after  rachitis  commences  contains  so  little  earthy  matter 
that  it  bends  readily  in  its  fresh  state  either  by  muscular  action  or  by  the 
weight  of  the  trunk,  ■•  in  the  manner,"  says  Vogel,  "  of  a  quill  or  willow 
stick."  The  interior  of  the  bone,  which  was  formed  before  rachitis  began, 
and  which  contains  nearly  or  quite  the  normal  proportion  of  lime,  is  likely 
to  break  instead  of  bend,  but,  as  it  is  surrounded  on  all  sides  by  the  soft 
tissue,  the  fragments  are  not  displaced,  and  probably  do  not  crepitate.  So 
scanty  is  the  calcareous  deposition  in  typical  cases  that,  says  Trousseau, 
"  the  bones  ....  can  be  cut  with  a  knife  with  as  much  ease  as  a  carrot  or 
other  soft  root,"  and  the  dried  specimen  weighs  from  one-sixth  to  one-eighth 
of  the  weight  of  normal  bone.  One  writer  states  that  the  dried  rachitic  bone 
is  sometimes  so  porous  from  the  small  amount  of  lime  which  it  contains  that 
it  is  possible  to  respire  through  it  as  through  a  sponge. 

In  ordinary  cases  the  bones  which  exhibit  most  strikingly  the  rachitic 
change,  and  which,  therefore,  should  be  examined  carefully  in  making  the 
diagnosis,  are  the  cranial  bones,  the  ribs,  and  the  radius — the  sternal  ends  of 
the  ribs  and  the  lower  end  of  the  radius.  It  is  seldom  that  these  bones  do 
not  give  evidence  of  the  disease  if  it  be  present,  and  in  greater  degree  than 
other  bones.  They  are  the  first  to  be  affected  to  an  extent  that  is  appreciable 
to  the  observer. 

Changes  in  the  Cranial  Bones. — In  these  bones  interesting  and  important 
alterations  occur.  Their  edges  which  correspond  with  the  epiphyseal  carti- 
lages of  long  bones,  undergo  proliferation,  and  become  thickened  like  the 
latter.  This  thickening  and  the  delayed  union  of  the  sutures  produce  grooves 
which  can  be  traced  by  the  fingers  between  the  bones,  and  which  are  some- 
times appreciable  to  the  sight.  Rachitis  causes  enlargement  of  the  cranium, 
but  the  enlargement  seems  greater  than  it  really  is,  on  account  of  the  retarded 
growth  of  the  facial  bones.  In  a  discussion  on  rachitis  in  the  London  Patho- 
logical Society,  reported  in  the  London  Lancet  (1888,  ii.  1017),  it  was  stated 
that  in  seventeen  rachitic  children  with  an  average  age  of  4.72  years,  the 
average  circumference  of  the  head  was  21.22  inches,  while  in  the  same  num- 
ber who  were  non-rachitic,  and  whose  average  age  was  6.05  years,  the  aver- 


170  CONSTITUTIONAL  DISEASES. 

age  circumference  was  19.95  inches.  The  retarded  ossification  is  manifested 
not  only  in  the  open  sutures,  but  also  in  the  large  size  and  patency  of  the 
fontanelles,  which  are  not  closed  until  long  after  the  usual  time.  The  ante- 
rior fontanelle  in  the  healthy  infant  is  closed  at  about  the  fifteenth  or  six- 
teenth month,  but  in  the  rachitic  it  remains  membranous  a  longer  time :  in 
some  cases  it  is  still  membranous  as  late  as  the  third  or  fourth  year.  Since 
examination  of  the  anterior  fontanelle  aids  in  determining  whether  or  not 
rachitis  be  present,  it  should  be  borne  in  mind  that  in  the  normal  state  this 
space  increases  in  size  till  the  seventh  month,  when  it  is  at  its  maximum, 
and  that  after  the  ninth  month  it  becomes  progressively  smaller.  Ossifica- 
tion in  severe  rachitis  is  retarded  for  a  longer  period  than  is  stated  above,  for 
Gerhard  relates  a  case  in  which  the  anterior  fontanelle  had  not  entirely  closed 
at  the  ninth  year. 

The  shape  of  the  rachitic  head  varies.  In  general,  instead  of  its  normal 
rounded  form  it  approaches  a  square  shape.  Another  type  is  sometimes 
observed  in  which  there  is  no  marked  angularity,  but  in  which  the  antero- 
posterior diameter  is  enlarged.  In  the  square  head  the  forehead  projects, 
and  both  the  frontal  and  parietal  protuberances  are  unusually  prominent. 
The  sutures  are  depressed  to  a  certain  extent,  as  has  already  been  mentioned,^ 
and  the  anterior,  lateral,  superior,  and  posterior  surfaces  are  more  flattened 
than  in  health.  The  undue  prominence  of  the  frontal  and  parietal  eminencea 
is  largely  due  to  the  exaggerated  proliferation  of  the  periosteum  and  to  the 
vascularity  and  infiltration  underneath.  Enlarged  veins  are  seen  ramifying 
in  the  scalp,  which  in  marked  rachitis  supports  a  scanty  growth  of  hair. 
The  free  perspiration  from  the  scalp,  and  in  some  cases  the  activity  of  its 
sebaceous  follicles,  will  be  mentioned  elsewhere. 

Craniotahes. — Thinning  of  the  cranial  bones  in  places,  so  that  the  brain 
lacked  proper  protection,  had  long  been  noticed  in  the  examination  of  rachitic 
heads,  but  the  injury  that  resulted  to  the  infant  was  overlooked  until  pointed 
out  by  Elsasser.  Craniotabes  occurs  for  the  most  part  in  infants  under  the 
age  of  one  year,  and  a  large  proportion  are  under  eight  months.  Its  occur- 
rence in  the  foetus,  as  shown  by  a  case  published  in  the  New  York  Ohstetrical 
Journal  in  1870.  and  by  Heitzmann's  case,  has  already  been  alluded  to.  The 
factors  in  producing  this  thinning  are  rachitic  softening  of  the  bones  and 
pressure  from  the  brain  within  and  from  the  pillow  without.  Consequently, 
the  portions  of  the  cranium  in  which  the  thinning  is  most  pronounced  are  the 
posterior  and  lateral,  the  occipital  bone  and  the  posterior  half  of  the  parietal. 
If  the  infant  lie  in  its  crib  chiefly  on  one  side,  on  this  side  the  craniotabes 
occurs,  while  those  portions  of  the  cranium  which  are  not  pressed  upon 
exhibit  no  thinning  or  a  less  degree  of  it.  The  soft  spots  in  the  cranium 
are  yielding  when  pressed  upon,  and  in  the  cadaver  they  are  seen  to  be  trans- 
lucent when  the  bone  is  held  to  the  light.  There  are  in  some  instances  simple 
depressions  like  erosions  in  the  bone,  a  continuous  but  thin  bony  layer  remain- 
ing. In  other  cases,  such  as  have  been  particularly  examined  and  studied  by 
physicians,  the  bony  absorption  has  been  complete  over  areas  of  greater  or 
less  extent.  On  examining  a  child  for  craniotabes  it  should  be  borne  in  mind 
that  the  margins  of  the  cranial  bones,  even  when  there  is  no  thinning,  but 
thickening  from  the  cartilaginous  proliferation,  are  flexible  in  the  rachitic. 
The  pressure  must  be  made  in  a  direction  away  from  the  sutures  to  ascertain 
whether  craniotabes  has  occurred.  The  pressure  should  at  first  be  made 
lightly  and  cautiously  with  the  fingers,  for  if  there  be  total  absence,  unless 
of  very  little  extent,  deep  and  forcible  pressure  might  injure  the  brain, 
since  so  soft  and  delicate  an  organ,  covered  only  by  scalp  and  dura  mater, 
badly  tolerates  pressure.  If  the  first  examination  detect  no  soft  place,  the 
fingers  may  be  pressed  more  firmly  against  the  scalp,  when,  if  the  bone  be 


RACHITIS. 


171 


much  thinned,  so  that  there  is  only  a  small  layer  of  lime  salts  underneath,  it 
will  be  found  to  yield.  The  sensation  communicated  to  the  fingers  when 
there  is  an  open  space  in  the  cranium,  and  the  dura  mater  and  scalp  are  in 


Fig.  24. 


Head  of  a  rachitic  child  in  the  New  York  Infant  Asylum, 
laryngismus  stridulus. 


This  child  also  had 


contact,  has  been  likened  to  that  experienced  when  pressing  upon  a  fully-dis- 
tended bladder.  At  a  meeting  of  the  London  Pathological  Society,  reported 
in  the  Lancet  for  November,  1880,  Dr.  Lees  presented  statistics  to  show  that 
craniotabes  is  one  of  the  lesions  of  inherited  syphilis  ;  but  whether  it  does 
sometimes  result  from  inherited  syphilis  or  not,  the  evidence  that  there  is  a 
cranial  softening  which  is  strictly  rachitic,  and  which  occurs  in  those  who 
have  not  inherited  syphilis,  appears  from  reported  observations  to  be  con- 
clusive. 

Changes  in  the  Vertebrse,  etc. — The  short  bones  which  participate  in  the 
rachitic  disease  become  softer  and  more  yielding,  and  their  cancelli  are  filled 
with  a  reddish  pulpy  substance.  In  many  rachitic  cases  the  vertebrae  are  but 
slightly  involved,  so  that  no  deformity  of  the  spinal  column  results  ;  but  occa- 
sionally, when  many  bones  are  aiFected,  the  vertebrae  and  intervertebral  carti- 
lages soften,  and  spinal  curvatures  result.  The  curvatures  are  due  to  the 
weight  of  the  shoulders  and  head  on  the  spinal  column.  They  are,  with  some 
deviations,  an  exaggeration  of  those  present  in  the  normal  state.  Rachitic 
curvatures  of  the  spinal  column  are  therefore  mainly  antero-posterior,  often 
with  more  or  less  lateral  deflection.  When  there  is  much  curvature  the  ver- 
tebrae become  wedge-shaped,  narrowed  upon  the  concavity  and  thickened 
upon  the  convexity.  The  intervertebral  cartilages  are  also  more  or  less 
changed  by  the  pressure,  being  thinned  where  the  vertebrae  approximate  to 
each  other  on  the  concave  aspect  of  the  curvature,  and  of  normal  thickness 
or  thicker  than  normal  upon  the  convexity.  The  accompanying  wood-cut 
exhibits  the  appearance  and  nature  of  rachitic  spinal  curvature  continuing 
into  adult  life.  Rachitis,  having  occurred  at  the  usual  age,  resulted  in  the 
permanent  deformity  here  illustrated. 

In  extreme  cases,  fortunately  rare,  the  functions  of  important  organs  may 
be  seriously  impaired  by  the  curvature  and  consequent  compression,  as  they 
are   in   Pott's   disease.     Thus,   according   to   Miller,  the  aorta   has   been   so 


172 


CONSTITUTIONAL  DISEASES. 


FtG.  25. 


doubled  upon  itself  as  to  materially  diminisli  the  flow  of  blood  to  the  lower 
extremities,  so  that  their  nutrition  was  sensibly  impaired.  The  effect  of  so 
great  curvature  upon  the  heart  and  lungs  must  ob- 
viously be  detrimental.  At  first  the  spinal  curva- 
tures disappear  when  the  child  reclines  or  is  lifted 
by  the  axillae  so  as  to  raise  the  head  and  shoulders 
from  the  spine ;  but  when  the  deformity  has  con- 
tinued so  long  that  the  vertebrae  and  cartilages 
have  become  wedge-shaped,  it  remains  for  life  or 
can  only  be  rectified  slowly  and  with  difficulty  by 
mechanical  appliances.  As  seen  in  the  wood-cut, 
the  common  curvature  in  the  dorsal  region  is  back- 
ward (kyphosis),  while  to  compensate  the  patient 
instinctively  carries  the  neck  forward  with  the 
head  thrown  back,  causing  cervical  lordosis,  a  sim- 
ilar anterior  curvature  being  common  in  the  lum- 
bar region.  Lateral  curvature  (scoliosis)  may  or 
may  not  be  present  even  when  there  is  consider- 
able antero-posterior  flexure.  Scoliosis  is  some- 
times produced  by  the  nurse  in  carrying  the  infant 
habitually  over  one  arm. 

Changes  in  the  Maxillse. — Fleischmann  has 
investigated  the  changes  which  rachitis  produces 
in  the  maxillary  bones.  Stunted  growth  of  the 
facial  bones,  generally,  has  long  been  known,  and 
has  been  remarked  upon  by  various  writers  ;  but, 
according  to  Fleischmann,  other  interesting  changes 
occur  in  the  jaw-bones  which  affect  the  direction 
and  position  of  the  teeth.  According  to  this  ob- 
server, the  arched  shape  of  the  lower  jaw  becomes  polygonal,  and  the  direc- 
tion of  its  alveoli  also  changes,  so  that  they  incline  inward.  This  devia- 
tion in  the  arch  and  in  the  alveolar  border  of  the  lower  jaw,  which  begins 
in  the  region  of  the  canine  teeth,  necessarily  causes  softening  of  the  jaw. 
Commencing  soon  after,  a  change  is  observed  in  the  upper  jaw-bone  from  the 
zygomatic  arch  forward,  so  as  to  cause  lengthening  of  this  bone,  changing 
the  shape  of  the  arch  and  the  position  of  the  teeth.  The  external  incisors, 
instead  of  being  in  front,  have  a  lateral  position,  and  when  the  jaws  are  closed 
the  superior  incisors  and  molars  overlap  the  corresponding  teeth  of  the  lower 
jaw  in  front  and  upon  the  sides — a  condition  opposite  to  that  seen  in  the  jaws 
of  old  people.  Fleischmann  attributes  these  changes  in  the  lower  jaw  to  the 
action  of  the  masseter  and  the  mylo-hyoid  muscles,  and  perhaps  the  genio- 
glossus,  and  to  pressure  of  the  lip,  the  deficiency  of  earthy  salts  in  the 
bone  rendering  it  more  easily  acted  on  by  the  muscles.  The  change  in  the 
upper  jaw-bone  he  attributes  largely  to  lateral  pressure  of  the  zygomatic 
arches. 

Changes  in  the  Ribs. — The  ribs  are  easily  affected  in  rachitis.  The  swell- 
ing of  their  anterior  ends,  where  they  unite  with  the  costal  cartilages,  pro- 
ducing the  "  rachitic  rosary,"  has  been  already  alluded  to  as  one  of  the  first 
and  most  conspicuous  signs  of  rachitis.  The  costochondral  articulations  are 
enlarged  in  all  directions,  appearing  as  nodules  under  the  skin.  If  at  an 
autopsy  an  opportunity  of  inspecting  the  pleural  surface  of  the  articulation 
occur,  the  nodular  prominence  is  seen  to  be  even  greater  and  more  distinct 
than  under  the  skin  (Fig.  26). 

The  deformity  of  the  thorax,  consequent  upon  softening  of  the  ribs,  is 
interesting.     Commencing  with  the  spine,  the  ribs  extend  nearly  directly  out- 


Rachitic  spinal  curvature  in 
an  adult  (from  a  specimen 
in  the  Wood  Museum,  Belle- 
vue  Hospital). 


RACHITIS. 


173 


ward  :  at  the  union  of  tlie  dorsal  and  lateral  portions  they  make  a  short  curve 

Fig.  26. 


Rachitic  child  with  cliaracteristic  deformity  of  head  and  ribs.    (From  a  patient  in  the 
New  York  Foundling  Hospital.) 

forward  and  then   turn  inward,  also  with  a  short  curve,  toward  the  sternum 
(Fig.  22).    This  abrupt  bending  of  the  ribs,  which  in  their  softened  state  has 

Fig.  27. 


Deformity  of  chest  in  rachitis. 


been   caused  by  atmospheric  pressure  during  respiration,  produces  a  depres- 
sion in  the  thoracic  wall  at  about  the  point  where  the  ribs  and  their  cartilages 


174  CONSTITUTIONAL  DISEASES. 

unite.  A  groove  extends  on  the  antero-lateral  aspect  of  the  thorax  from  the 
second  or  third  rib  downward  and  a  little  outward.  In  some  cases  the  costo- 
chondral  articulations  are  in  the  line  of  greatest  depression  in  the  thoracic 
walls  ;  in  other  cases  they  are  a  little  inside  or  outside  of  the  deepest  part  of 
the  groove.  The  transverse  diameter,  therefore,  of  the  anterior  half  of  the 
thorax  is  less  than  that  in  the  normal  rotund  form  of  health.  This  neces- 
sarily diminishes  the  antero-lateral  expansion  of  the  lungs  in  inspiration  and 
causes  unusual  prominence  of  the  sternum.  Hence  the  expressions  '•  pigeon- 
breasted,"  "  resemblance  to  the  prow  of  a  ship,"  etc.  applied  to  this  deformity. 
The  presence  of  the  heart  renders  the  depression  or  groove  less  on  the  left 
side  between  the  fourth  and  sixth  ribs  than  on  the  opposite  side,  since  this 
organ  affords  partial  support  to  the  chest-wall.  That  portion  of  the  pericar- 
dial surface  of  the  heart  upon  which  the  pressure  is  greatest  becomes 
thickened  and  whitish  from  the  rubbing  or  attrition.  On  the  other  hand, 
the  depression  on  the  right  side  below  the  sixth  or  seventh  rib  is,  on 
account  of  the  support  given  by  the  liver,  less  than  on  the  left  side.  But 
on  the  left  side,  as  well  as  on  the  right,  the  lower  part  of  the  thorax,  that 
below  the  eight  or  ninth  ribs,  widens,  being  pressed  outward  and  supported 
by  the  abdominal  viscera.  This  gives  rise  to  an  antero-lateral  furrow  or 
groove  near  the  base  of  the  chest,  sometimes  designated  Harrison's  groove, 
the  site  of  which  is  supposed  to  correspond  with  that  of  the  insertion  of 
the  diaphragm. 

The  ribs  with  their  attached  muscles  are  important  agents  in  respiration, 
but  their  soft  and  yielding  nature  in  the  rachitic  retards,  and  to  a  great 
extent  prevents,  the  lateral  expansion  of  the  thorax  which  is  necessary  for 
normal  and  full  inspiration.  The  action  of  the  respiratory  muscles  and  the 
pressure  of  the  air  from  within  descending  along  the  air-passages  is  not  suffi- 
cient to  fully  overcome  the  external  atmospheric  pressure  in  the  absence  of  the 
proper  resiliency  of  the  ribs.  Consequently  with  each  inspiration  we  observe 
more  or  less  sinking  of  the  thorax  on  each  side,  just  as  when  a  moderate 
obstruction  to  the  entrance  of  air  exists  in  the  larynx  or  trachea.  As  the 
ribs  become  firmer  from  the  deposit  of  lime  salts,  respiration  is  more  regular 
and  normal. 

Changes  in  Bones  of  Upper  Extremities. — Although  swelling  of  the 
lower  end  of  the  radius  is  one  of  the  earliest  signs  of  rachitis,  the  bones  of 
the  upper  extremities  are  less  frequently  curved  and  distorted  than  those 
,of  the  lower  extremities.  The  clavicle  sometimes  softens  and  bends,  pro- 
ducing two  curvatures — one  backward  near  the  scapula,  and  another,  of  larger 
radius,  nearer  the  sternum,  directed  forward  and  a  little  upward.  Careful 
examination  shows,  in  some  rachitic  patients,  thickening  of  the  margins  of 
the  scapulae  like  that  of  the  cranial  bones.  The  humerus  is  occasionally 
bent,  and  usually  at  the  insertion  of  the  deltoid  in  consequence  of  the  power- 
ful action  of  this  muscle  in  raising  and  supporting  the  arm.  The  radius  and 
ulna  are  bent  outward  and  twisted.  This  deformity  is  attributed  by  Sir 
"William  Jenner  to  the  fact  that  rickety  children  support  themselves  while  in 
the  sitting  posture  upon  the  palms  of  the  hands  pressed  upon  the  floor  or 
couch.  Supporting  the  weight  of  the  body  in  this  manner  not  only,  in  his 
opinion,  causes  bending  of  the  ulna  and  radius,  but  also  aids  in  producing 
the  deformities  of  the  humerus  and  clavicle. 

Changes  in  the  Bones  of  the  Pelvis. — The  deformities  of  the  pelvic  bones 
resulting  from  rachitic  softening  are  very  important  in  the  female  infant, 
since  pelvic  deformities  during  the  procreative  period  are  the  common  cause 
of  tedious  or  instrumental  labor  and  stillbirth.  These  deformities,  which 
elongate  some  and  contract  other  axes  of  the  pelvis,  necessarily  occur  when 
the  rachitic  child  is  in  the  erect  position,  since  the  pelvic  bones  support  the 


RACHITIS. 


175 


weight  of  the  trunk,  head,  and  shoulders.  A  common  deformity  produced 
in  this  manner  is  the  cai'rying  forward  of  the  promontory  of  the  sacrum, 
which  sustains  the  weight  of  the  spine.  There  is,  moreover,  twofold  pres- 
sure from  below — that  caused  by  the  heads  of  the  thigh-bones  in  standing, 


Fig.  28. 


Fig.  29. 


Fig.  30. 


Rachitic  deformities  of  the  pelvis  (from  specimens  m  Wood's  Museum). 


and  that  exercised  by  the  tuberosities  of  the  ischia  in  sitting.  Both  these 
forms  of  pressure  have  a  tendency  to  narrow  the  outlet  of  the  pelvis. 
Hence  the  marriage  of  the  female  who  has  been  rachitic  in  infancy  may 
involve  serious  consequences. 

Many  of  the  tedious  instrumental  labors  in  the  families  of  the  city  poor, 
which  severely  tax  the  patience  and  endurance  of  young  practitioners,  are 
attributable  to  rickets  in  early  life. 

Changes  in  the  Bones  of  the  Lower  Extremities. — The  curvature  of  the 
femur  is  usually  forward  or  forward  and  outward.  The  neck  of  the  femur 
sometimes  bends  by  the  weight  of  the  body  or  by  use  of  the  legs,  so  that  the 

Fig.  31. 


Rachitic  deformities  of  the  femur  (Wood's  Museum). 


angle  which  it  forms  with  the  shaft  is  changed.  The  accompanying  wood-cuts 
show  the  rachitic  bend  of  this  bone  in  an  adult,  years  after  rachitis  had  ceased 
and  when  the  bone  had  become  consolidated  by  the  new  deposition  of  lime 
salts.     (Figs.  31  and  32.) 


176 


CONSTITUTIONAL  DISEASES. 


Fig.  33. 


Fig.  34. 


The  curvature  of  the  tibia  and  fibula  varies  in  different  cases.  In  those 
under  the  age  of  one  year  it  is  likely  to  be  outward,  so  that  the  knees  are 
separated  from  each  other.  In  those  old  enough 
to  stand,  the  weight  of  the  body  usually  determines 
a  forward  bending  of  these  bones.  In  one  case 
in  my  practice  an  anterior  curvature,  so  abrupt 
that  an  angle  of  about  70°  was  formed,  existed 
about  five  inches  above  each  ankle.  This  patient, 
although  old  enough  to  walk,  almost  constantly 
sat  during  the  day  with  the  feet  extended  beyond 
the  sofa,  so  that  the  edge  of  the  latter  corresponded 
with  the  abrupt  curvature  or  angle  of  the  legs.  It 
seemed  that  the  weight  of  the  feet,  unsupported 
beyond  the  edge  of  the  sofa,  had  caused  these  cur- 
vatures, especially  as  the  case  was  one  of  very 
marked  rachitic  softening  of  the  different  bones. 

Still,  tibial  and  fibular  bending  at  this  point 
has  been  noticed  by  different  observers,  who  have 
attributed  it  to  the  weight  of  the  body  in  walking. 
Various  other  curvatures  besides  those  mentioned 
occur  in  the  bones  of  the  lower  extremities,  the  di- 
rection in  which  the  limbs  bend  being  determined 
by  the  particular  circumstance  of  the  case.  In 
mild  cases  of  rickets  most  of  the  deformities  de- 
scribed above  may  be  lacking,  but  in  typical  cases 
certain  of  them  stand  out  prominently,  so  as  to  be 
readily  detected  by  one  familiar  with  the  disease. 
In  all  such  cases  the  nature  of  the  malady  is  ap- 
parent, for  the  changes  that  occur  are  not  only 
conspicuous,  but  pathognomonic. 

Rachitis  produces  another  important  effect  on 
the  skeleton.  Its  growth  is  stunted,  not  only 
during  the  rachitic  period,  but  subsequently,  so  that  those  who  have  been 
rachitic  in  childhood,  unless  very  mildly,  have  less  than  the  average  stature 
in  adult  life.  The  stunted  growth  is  apparent,  though  ample  allowance  be 
made  for  curvatures.  The  arrest  of  development  is  greater  in  some  bones 
than  in  others.  It  is  greatest  in  the  bones  of  the  face,  pelvis,  and  lower 
extremities.  As  a  rule,  the  older  the  child  is  when  rachitis  begins,  the  less 
is  the  skeleton  affected  and  the  less,  consequently,  is  the  deformity. 

Effect  of  Rachitis  on  Dentition. — As  might  be  expected  from  the  nature 
of  rachitis,  dentition  suffers  severely.  The  delay  in  dentition  has  been  con- 
sidered elsewhere  in  this  paper.  Teeth  which  appear  during  the  rachitic 
state  are  frail,  deficient  in  enamel,  and  crumble  readily.  They  decay  and 
break  before  the  usual  time.  If  certain  teeth  have  appeared  before  rachitis 
begins,  several  months  elapse  before  others  cut  the  gum.  It  is  even  said 
that  a  child  who  has  rachitis  severely  for  a  lengthened  period  may  never  have 
a  tooth,  and  may  remain  toothless  for  life  ;  but  I  have  never  observed  such  a 
case.  Ordinarily,  when  the  rachitic  state  ceases  and  the  health  is  fully 
restored  dentition  goes  on  in  the  normal  way. 

3.  Anatomical  Characters  of  the  Stage  of  Reconstruction. — This  stage 
will  be  better  understood  if  we  recollect  what  has  occurred  during  the  first  and 
second  stages.  The  vei'y  vascular  periosteum  is  drawn  tightly  over  the  con- 
vexities, the  pressure  upon  which  diminishes  the  hyperagmia  and  the  amount 
of  exudation  underneath.  Over  the  concavities  the  periosteum  is  loose  :  it 
is  hyperagmic  with  abundant  new  capillaries,  the  interspace  between  it  and 


Rachitic  deformities  of  the  fe- 
mur, tibia,  and  fibula  (Wood's 
Museum). 


RACHITIS.  Ill 

the  bone  being  filled  with  the  exuded  soft  material  having  a  gelatiniform 
appearance.  The  reparative  process  goes  forward  rapidly,  the  deposition  of 
lime  salts  being  more  abundant  upon  the  concave  surfaces,  where  there  has 
been  free  exudation  with  no  compression  of  the  capillaries,  than  elsewhere. 
The  lime  salts  are  deposited  from  the  blood.  Consequently,  from  the  increased 
capillary  circulation  and  hyperasmic  state  of  the  periosteum  produced  by 
rachitis,  the  earthy  material  is  rapidly  deposited  wherever  there  is  an  open 
space  under  the  periosteum  and  where  the  capillaries  are  in  a  state  of  enlarge- 
ment. Hence  the  reconstructed  bone  is  thicker  and  firmer  upon  the  concave 
aspect  of  the  long  bones  than  elsewhere,  and  thinnest  upon  the  convex  aspect, 
where  the  periosteum  is  more  tense  and  its  capillaries  more  or  less  com- 
pressed. 

Normal  ossification  does  not  at  first  take  place  during  the  reparative  stage. 
The  deposition  of  the  earthy  salts  is  designated  by  some  writers  as  a  petrifac- 
tion rather  than  a  true  bone-formation.  Trousseau  likens  it  to  the  formation 
of  a  callus  upon  a  fracture.  A.  deposition  occurs  of  lime  salts  more  compact 
than  in  ordinary  bone.  The  term  "  eburnation  "  has  been  applied  to  this  new 
osseous  formation,  and  I  have  designated  it  osteo-sclerosis.  It  resembles,  as 
regards  its  hardness  and  morphological  appearance,  the  enamel  of  the  tooth 
rather  than  true  bone,  the  Haversian  canals  and  lacunae  being  small  and  im- 
perfectly formed.  Of  course  after  complete  recovery  the  subsequent  form- 
ation of  bone  is  normal.  Recovery  from  rickets  is  gradual.  Little  by  little 
the  cartilaginous  and  periosteal  proliferations  cease,  the  hyperaemia  abates, 
and  the  various  parts  of  the  osseous  system  and  the  soft  tissues  resume  their 
normal  function  and  development. 

General  Symptoms  of  Rachitis. — -Preceding  and  accompanying  rachitis 
symptoms  may  be  present  which  are  due  to  indigestion  and  intestinal  catarrh, 
such  as  flatulence,  unhealthy  stools,  and  poor  and  capricious  appetite.  When 
rachitis  begins  the  infant  becomes  fretful ;  its  sleep  is  frequently  restless  and 
disturbed,  and  it  awakens  often.  It  repels  attempts  to  amuse  it,  and  is 
apparently  annoyed  by  them.  Nurse  and  mother  speak  of  it  as  a  cross  child. 
It  perspires  freely  from  the  head  and  neck  both  when  awake  and  when  asleep, 
while  its  extremities  and  trunk  are  dry.  Its  pillow  is  wet  with  perspiration 
during  sleep,  and  sweat-drops  may  be  seen  upon  forehead  and  face.  If  the 
surface  be  dry,  a  little  excitement  or  elevation  of  temperature  causes  perspira- 
tion to  appear.  The  rachitic  child  does  not  well  tolerate  the  bed-clothes,  and 
it  attempts  to  throw  them  off  from  its  limbs,  even  in  cool  weather,  lying  ex- 
posed and  causing  considerable  annoyance  to  the  nurse,  who  strives  to  pre- 
vent its  taking  cold.  Sometimes  miliaria  due  to  the  moist  state  of  the  skin 
appears  upon  the  face  and  neck.  We  have  elsewhere  stated  that  the  sub- 
cutaneous veins  that  return  blood  from  the  head  are  large  and  the  jugular 
veins  full,  xlnother  symptom  is  soon  observed,  to  wit:  tenderness  over  a 
considerable  part  of  the  surface,  perhaps  largely  due  to  the  morbid  state  of 
the  periosteum  over  so  many  bones,  though  it  is  also  experienced  when  pres- 
sure is  made  upon  soft  parts,  as  the  abdomen.  The  tenderness  is  probably  the 
cause  in  part  of  the  fretful  disposition.  The  little  patient  appears  to  dread 
to  be  touched  ;  its  flesh  is  sore  ;  it  repels  attempts  to  amuse  it,  and  wishes  to 
be  quiet.  Dangling  it  upon  the  arms,  swinging  it,  or  even  walking  with  it, 
which  delights  the  healthy  child  and  elicits  a  smile  or  notes  of  glee,  only 
adds  to  its  discomfort.  It  is  most  at  ease  when  left  alone  upon  a  soft  cot  or 
pillow,  or,  if  it  have  craniotabes,  when  quietly  held  over  the  shoulder.  Lan- 
guor, disinclination  to  use  the  limbs  or  to  play,  moderate  thirst,  with  other 
symptoms  referable  to  the  digestive  apparatus  which  are  present  in  many 
cases,  and  which  have  already  been  described,  are  soon  followed  by  changes 
in  the  skeleton  that  are  perceptible  to  the  sight  and  on  palpation.  The  pulse 
12 


178  CONSTITUTIONAL  DISEASES. 

and  temperature  in  a  large  proportion  of  tlie  ordinary  chronic  cases  do  not 
deviate  from  the  healthy  state,  except  that  in  some  patients  there  is  a 
moderate  rise  in  temperature  and  acceleration  of  the  pulse  in  the  latter  part 
of  the  day,  indicative  of  a  slight  fever. 

A  hruit  de  souffle  of  greater  or  less  intensity,  synchronous  with  the  pulse, 
has  frequently  been  heard  in  rachitic  cases  by  applying  the  ear  over  the  ante-, 
rior  fontanelle.  Drs.  AVhitney  and  Fischer,  New  England  physicians,  first 
called  attention  to  this  murmur,  believing  it  to  be  a  sign  of  chronic  hydro- 
cephalus. MM.  Rilliet  and  Barthez  heard  it  in  cases  of  rachitis,  and  therefore 
concluded  that  the  American  physicians  had  confounded  the  two  diseases. 
More  recent  observations  have  established  the  fact  that  this  bruit  has  little 
diagnostic  significance.  It  is  heard  whenever  there  is  sufiicient  patency  of 
the  anterior  fontanelle  both  in  health  and  disease.  It  is  conducted  from  the 
base  of  the  brain  through  the  brain-substance  to  the  membranous  covering 
of  the  fontanelle.  Dr.  Wirthgen  heard  the  bruit  in  22  of  52  infants,  of 
whom  all  except  4  were  in  good  health.  I  have  auscultated  the  anterior  fon- 
tanelle in  29  infants  who  were,  with  two  exceptions,  between  the  ages  of 
three  or  thirty  months.  All  were  well  or  afiected  merely  with  trivial  ail- 
ments which  did  not  disturb  the  cerebral  circulation.  In  most  of  them  a 
murmur  could  be  distinctly  heard  synchronous  with  the  respiratory  act,  and 
in  15  of  the  29  cases  no  other  sound  could  be  detected,  while  in  the  remain- 
ing 14  a  bruit  could  be  detected  synchronous  with  the  pulse. 

As  might  be  expected,  craniotabes  gives  rise  to  symptoms  quite  distinct 
from  those  of  the  general  rachitic  disease.  It  usually  occurs  during  the  first 
year  of  infancy,  and  most  frequently  prior  to  the  tenth  month.  The  brain  at 
this  age  is  soft  and  yielding,  since  it  contains  a  large  percentage  of  water. 
Unless  handled  with  care  at  an  autopsy,  it  is  readily  lacerated,  and  moderate 
pressure  upon  it  is  seen  to  disturb  and  move  it  a  considerable  distance  from 
the  point  of  contact.  It  will  assist  to  a  proper  understanding  of  the  symp- 
toms referable  to  the  cerebro-spinal  system  to  which  the  rachitic  are  liable,  to 
recall  to  mind  the  fact,  well  known  to  surgeons,  that  slight  depression  of  even 
a  small  portion  of  the  skull  is  likely  to  produce  grave  consequences.  It  is 
not  surprising,  therefore,  that  craniotabes,  when  there  is  a  space  of  consider- 
able size  in  the  cranial  arch  destitute  of  bone,  is  attended  by  symptoms  due  to 
the  mechanical  effect  of  external  pressure  whenever  a  substance  less  yielding 
than  the  brain  comes  in  contact  with  the  unprotected  part. 

Every  rachitic  child  is  fretful,  but  one  with  craniotabes  is  especially  so  if 
the  open  spaces,  in  which  the  lime  salts  are  lacking  or  constitute  a  thin  and 
yielding  layer,  are  of  considerable  size.  If  the  child  lie  upon  the  pillow  in 
the  position  that  is  most  natural  for  it,  the  unprotected  portion  of  the  brain 
may  be  so  pressed  upon  by  the  weight  of  the  head  that  it  is  uncomfortable 
and  restless.  It  does  not  have  quiet  sleep  because  the  cerebral  circulation 
and  functions  are  disturbed  since  the  cranial  arch  no  longer  protects  the  brain 
from  undue  pressure.  Carefully  placed  in  an  apparently  comfortable  position, 
it  awakens  often  and  frets  until  it  is  taken  in  the  nurse's  arms.  Sometimes 
it  instinctively  seeks  a  position  on  the  edge  of  the  pillow,  with  its  face  down- 
ward, and  it  becomes  more  quiet  when  resting  over  the  nurse's  shoulder  with 
no  pressure  or  support  upon  the  cranial  arch. 

But  if  fretfulness,  disturbed  sleep,  and  the  necessity  of  closer  attention 
on  the  part  of  mother  and  nurse  were  the  only  ill  effects  of  craniotabes, 
it  would  possess  much  less  pathological  significance  than  pertains  to  it. 
Pressure  upon  so  delicate  and  important  an  organ  as  the  brain  involves 
risks  and  produces  serious  symptoms  in  proportion  to  its  degree.  Even  a 
slight  injury  of  the  skull  which  causes  depression,  though  it  may  be  of 
trifling    amount,  will  cause    serious   forms    of   nervous    disorder.     Rachitic 


RACHITIS.  179 

craniotabes  sustains  a  causal  relation  in  not  a  few  instances  to  one  of  the 
most  dangerous  of  the  neuroses — to  wit,  laryngismus  stridulus,  or  spasm  of 
the  glottis.  Pressure  on  the  cardiac  and  vaso-motor  centres  of  the  medulla 
in  the  rachitic  infant,  in  whom  reflex  excitability  is  exaggerated,  causes  con- 
traction of  the  muscles  that  close  the  glottis.  It  is  certain  that  a  large 
proportion  of  those  who  sufler  from  laryngismus  stridulus  are  rachitic,  so 
that  it  is  more  common  and  severe  where  rachitis  is  prevalent,  as  in  England, 
than  where  it  is  rare,  as  in  the  rural  districts  of  America.  It  is  not  often 
the  cause  of  death  in  America,  and  the  fatal  cases  that  do  occur  are,  I 
think,  nearly  always  in  the  cities,  whereas  in  parts  of  Europe,  where 
rachitis  is  much  more  common  than  with  us,  it  is  said  to  cause  not  a 
few   deaths. 

Certain  infants  when  in  a  state  of  excitement  have  what  are  termed 
''  holding-breath  spells."  The  face  is  flushed  and  breathing  ceases  for  some 
seconds,  after  which  respiration  returns  and  is  normal.  The  attacks  are 
unimportant,  but  they  appear  to  be  the  same  in  nature  with  the  more  severe 
and  dangerous  seizures  of  laryngismus  stridulus.  They  have  no  pathological 
significance,  excepting  that  they  show  the  same  neuropathic  state  as  that  in 
laryngismus,  and  that  they  may  be  precursors  of  it. 

Laryngismus  stridulus,  or  glottic  spasm,  is  usually  preceded  by  more  or 
less  impairment  of  the  general  health  and  often  by  fretfulness,  which  is 
characteristic  of  the  rachitic  state  ;  but  the  attack  occurs  suddenly,  without 
premonition,  and  is  of  short  duration.  It  begins  with  an  arrest  of  respiration, 
a  true  apnoea,  as  if  from  paralysis  of  the  respiratory  centre  in  the  medulla ; 
the  lips  may  be  livid,  a  pallor  spreads  over  the  face  ;  sometimes  more  or  less 
rigidity  of  the  limbs  occurs,  with  carpo-pedal  contractions.  After  a  few 
seconds,  a  quarter  or  half  minute,  a  long  and  deep  but  difficult  inspiration 
through  the  narrow  chink  of  the  glottis  follows,  accompanied  in  many  patients 
by  a  whistling  or  crowing  sound,  and  the  attack  ends  with  perhaps  a  moment- 
ary appearance  of  bewilderment  or  dread  on  the  child's  face.  Laryngismus 
stridulus,  like  eclampsia,  does  not  have  a  uniform  causation.  In  certain  cases 
it  is  a  reflex  phenomenon  due  to  an  irritant  in  some  part  of  the  system,  as  in 
the  intestines,  but  many  observations  establish  the  fact  that  rachitis  is  prob- 
ably its  most  common  cause.  A  large  proportion  of  the  infants  aflfected  with 
it  exhibit  unmistakable  rachitic  signs  ;  and  it  has  been  held  that  the  exposed 
state  of  the  brain  in  craniotabes  aifords  explanation  of  the  symptom.  But 
from  observations  which  I  have  made  and  from  those  of  other  observers,  like 
Senator,  it  is  certain  that  laryngismus  stridulus  is  common  in  the  rachitic 
"who  do  not  have  craniotabes,  so  there  must  be  a  causal  relation  in  rachitis 
to  spasm  of  the  glottis  independent  of  the  cranial  softening. 

Distinguished  British  obseryers,  as  Gee  and  Jenner,  have  noticed  the  fact 
that  rachitic  infants  are  especially  liable  to  eclampsia.  The  immediate  or 
exciting  cause  seems  to  be  in  many  cases  the  severe  catarrh  of  the  respira- 
tory and  digestive  systems  to  which  rachitic  infants  are  especially  liable. 
Indigestion,  flatulence,  and  fermentative  diarrhoea,  common  disorders  of  the 
rachitic,  are  perhaps,  in  some  instances,  the  exciting  causes  of  the  eclampsia. 
Similar  remarks  may  be  made  in  reference  to  tetany,  which,  although  it 
occurs  in  the  adult,  and  is  comparatively  rare,  appears  to  be  more  frequent 
in  rachitic  than  in  other  children. 

Those  physicians  who  attend  in  institutions  in  which  children  coming 
from  tenement-houses  are  treated  in  a  large  city  like  New  York  have  noticed 
the  fact  that  the  various  tissues  of  the  body,  besides  those  that  are  con- 
spicuously affected  in  rachitis,  are  more  liable  to  inflammatory  diseases  than 
are  the  same  tissues  in  those  who  have  sound  constitutions.  The  frequency 
of  the  different  forms  of  dermatitis,  of  nasal,  post-nasal,  faucial,  and  bronchial 


180  CONSTITUTIONAL  DISEASES. 

catarrhs,  and  of  gastro-intestinal  maladies,  we  must  attribute  to  the  fact  that 
rachitis  diminishes  the  resisting  power  to  noxious  agents  in  the  various  soft 
tissues,  and  renders  them  more  liable  to  disease. 

If  the  deformity  in  the  thoracic  wall — to  wit,  the  lateral  depression  of  the 
ribs  and  anterior  projection  of  the  sternum — be  great,  we  would  naturally 
expect  that  the  two  important  organs  underneath,  the  heart  and  lungs,  would 
receive  some  detriment.  Upon  the  surface  of  the  heart,  at  the  point  where  it 
supports  the  softened  ribs,  a  white  patch  is  often  found,  due  to  thickening  of 
the  pericardium  and  proliferation  of  the  endothelial  cells,  just  as  thickening 
of  the  skin  in  the  palm  of  the  hand  occurs  from  friction  and  pressure  upon 
that  part.  It  is  probable  that  in  ordinary  cases  this  pressure  does  not 
seriously  impair  the  function  of  the  heart,  but  it  may  increase  the  weakness 
of  its  movements  in  supervening  asthenic  diseases,  which  may  occur  during 
the  rachitic  period.  The  injury  sustained  by  the  lungs  is  greater  and  more 
apparent.  If  the  lateral  depression  of  the  ribs  be  considerable,  full  inflation 
of  the  lungs  does  not  occur  in  those  parts  where  the  depression  is  greatest. 
The  semi-collapse  of  certain  lobules  is  likely  to  occur,  and  even  complete 
collapse  of  the  distant  thin  edges  of  the  lungs.  The  stress  of  respiration 
falls  unequally  upon  different  parts  of  the  lung.  The  anterior  portion,  which 
ascends  with  the  sternum  as  that  is  propelled  forward,  is  more  fully  dilated 
than  the  lateral  and  posterior  parts,  and  it  may  in  consequence  become 
emphysematous.  If  in  this  state  of  the  thorax  and  lungs  severe  bronchitis 
or  broncho-pneumonia  occurs,  the  muco-pus,  being  expectorated  with  diffi- 
culty, clogs  the  tubes,  produces  dyspnoea,  and  imperils  the  safety  of  the  child. 
Even  in  comparatively  mild  forms  of  inflammation  the  result  may  be  unfavor- 
able, owing  to  the  lack  of  full  expansion  in  the  lateral  and  depending  portions 
of  the  lung — a  condition  required  to  expel  the  mucus.  Severe  bronchitis  and 
broncho-pneumonia  are  the  causes  of  death  in  not  a  few  cases  of  rickets 
attended  by  marked  deformity  of  the  thorax. 

Rachitic  Paralysis. — In  not  a  few  instances  in  the  course  of  rachitis  the 
use  of  the  limbs  is  greatly  impaired,  so  as  to  resemble  paralysis,  and  be  desig- 
nated by  this  name,  though  the  term  "  paralysis  "  is  probably  a  misnomer. 
Cases  like  the  following,  related  by  Dr.  H.  W.  Berg  in  the  Neio  York  Medical 

Record^  which  closely  resemble  paralysis,  occasionally  occur :   J.  S ,  aged 

two  years  and  eight  months,  was  admitted  into  the  Orthopaedic  Dispensary 
Sept.  23,  1885.  The  parents  stated  that  the  child  had  never  walked  or  stood 
alone.  The  legs  were  wasted,  apparently  from  disease  ;  the  patellar  reflex  was 
good  ;  there  seemed  to  be  some  rigidity  of  the  muscles  about  the  knee ;  and 
the  patient  was  admitted  with  the  diagnosis  of  "  spastic  paralysis."  A  closer 
examination  disclosed  the  fact  that  the  disease  was  one  of  typical  rachitis, 
and  by  the  use  of  the  proper  diet,  with  iron  and  phosphorus  the  patient  was 
able  to  walk  in  November,  and  in  a  few  months  was  entirely  cured.  The 
British  Medical  Journal  Jan.  4,  1890,  contains  the  account  of  a  case  of 
rickets  discussed  by  the  Edinburgh  Medical  Society,  Dec.  4,  1889.  The 
patient,  a  boy  of  three  years,  had  the  waddling  gait  and  straddling  pose  of 
pseudo-hypertrophic  paralysis.  The  rachitic  nature  of  the  malady  was  made 
apparent  by  the  symptoms  of  the  case  and  its  history.  I  have  recently  in 
private  practice  observed  two  similar  cases  of  pseudo-paralysis  of  the  lower 
extremities  from  the  same  cause. 

Acute  Rickets. — Occasionally  rachitis  occurs  with  the  sudden  develop- 
ment of  severe  symptoms,  so  that  the  term  "  acute  "  is  applied  to  it.  Dr. 
Fiirst  relates  such  a  case  in  the  Jahrh.  filr  Kinderh.,  Band  xviii.  p.  192  :  The 
patient,  aged  two  years  and  one  month,  had  been  largely  fed  upon  starchy 
food,  and  at  six  months  had  dyspeptic  symptoms  and  sweating.  Dentition 
began  in  the  thirteenth  month,  and  ability  to  walk  several  months  later. 


RACHITIS.  181 

Spasmodic  croup  and  swelling  of  the  epiphyses  appeared  at  this  time.  At 
the  above-mentioned  age  the  child  suddenly  fell  ill  with  acute  febrile  symptoms. 
It  had  an  open  anterior  fontanelle,  craniotabes,  and  a  rachitic  chest ;  upper 
extremities  free  from  pain  and  not  swollen.  The  left  femur  and  both  tibiae 
showed  diffuse  cylindrical  swelling.  The  appearance  and  feel  of  the  limbs 
were  suggestive  of  diffuse  cellular  infiltration  proceeding  from  the  periosteum 
in  an  attack  of  osteo-myelitis.  The  skin  covering  the  limb  was  tightly  drawn 
and  of  a  reddish  hue.  In  a  few  days  the  right  forearm  was  affected,  and  soon 
after  the  right  arm  and  left  forearm,  and  the  parts  first  attacked  began  to 
improve.  In  four  weeks  the  fever  and  pain  had  abated,  but  swelling  of  the 
epiphyses  and  deformities  of  various  bones  continued.  Cases  like  the  above 
establish  the  fact  that  although  rachitis  is  ordinarily  a  chronic  disease,  insidi- 
ous in  its  commencement,  gradual  and  progressive  in  its  development,  occu- 
pying months,  there  is  an  acute  form  which  is  attended  by  more  marked 
febrile  movement  and  tenderness  than  occurs  in  the  usual  type,  and  in  which 
the  articular  swelling  appears  more  quickly. 

Treatment. — Hygiene. — We  recall  the  recent  statement  of  Prof.  Henoch 
of  Berlin  that  the  spread  of  rachitis  has  been  enormous  in  the  cities  of  Cen- 
tral and  Northern  Europe.  The  poor  of  these  cities,  among  whom  this  disease 
largely  prevails,  are  emigrating  in  large  numbers  to  the  United  States,  but,  as 
I  have  observed  in  the  asylums  and  dispensaries  of  New  York,  the  severest 
forms  of  imported  rachitis  come  from  Southern  Europe  (Italy).  Evidently, 
as  long  as  the  influx  of  this  class  of  foreigners  continues,  and  the  present 
insanitary  conditions  exist  in  our  cities,  causing  rachitis  in  the  native  born, 
this  will  continue  an  important  disease,  impairing  the  health  and  vigor  of 
coming  generations.  It  is  evident  from  the  nature  of  rachitis  that  success  in 
preventing  it  and  in  curing  those  who  unfortunately  exhibit  its  characteristic 
signs  requires  beyond  anything  else  the  employment  of  proper  hygienic 
measures.  The  details  of  the  hygienic  requirements  may  seem  prolix  and 
tedious,  but  we  cannot  expect  any  marked  diminution  of  rachitis  until  they 
are  better  known  and  heeded  by  the  masses. 

The  fact  that  inheritance  is  one  of  the  recognized  causes  of  rickets 
renders  it  very  important  that  the  parents  be  in  good  health.  The  mother 
especially  should  avoid  all  agencies  or  influences  which  impair  the  general 
health  during  the  procreative  period.  She  should,  so  far  as  possible,  encour- 
age good  appetite,  take  plain,  easily-digested,  and  nutritious  food,  and  lead  a 
quiet,  regular  life,  with  sufficient  out-door  exercise  to  promote,  so  far  as  prac- 
ticable, a  state  of  perfect  health.  Country  residence,  with  quiet  exercise  in 
the  open  air,  a  diet  consisting  of  fresh  vegetables,  meats,  fresh  and  abundant 
milk,  early  retirement  to  bed  and  sufficient  sleep,  are  much  more  conducive 
to  the  health  of  the  mother  and  her  child  than  are  the  excitement  and  irreg- 
ularities of  city  life. 

We  have  seen  that  there  is  sufficient  clinical  and  experimental  evidence 
that  the  common  and  predominating  factor  in  causing  rachitis  is  the  use  of  a 
faulty  diet,  but  general  insanitary  conditions  are  also  potent  agents.  The 
foul  air  and  noxious  effluvia  of  the  crowded  tenement-house,  so  conducive  to 
disease  and  fatal  to  infants  in  New  York,  should,  if  possible,  be  avoided. 
Even  if  poverty  compels  a  residence  in  the  small  and  dark  apartments  of  a 
tenement-house,  crowded  by  families,  many  of  them  entirely  neglectful  of 
sanitary  measures,  yet  parents  solicitous  for  the  welfare  of  their  children  can 
do  much  to  diminish  the  insanitary  influences  which  suiTOund  them.  Out- 
door air  is  everywhere  available,  and  every  child  after  the  age  of  two  or 
three  months,  unless  sufi"ering  from  acute  disease,  should  in  ordinary  weather 
be  in  the  open  air  one  or  more  hours  each  day,  as  a  means  of  improving  its 
digestion  and  of  producing  a  more  vigorous  state  of  the  system.    Any  mother 


182  CONSTITUTIONAL  DISEASES. 

or  nurse  capable  of  the  care  of  a  cliild  should  be  able  to  employ  such  meas- 
ures as  will  prevent  its  taking  cold  while  in  the  open  air. 

The  room  occupied  by  a  child,  whether  rachitic  or  not,  should  be  at  a 
uniform  temperature  of  about  70°  to  73°  F.,  and  it  should  receive  the  sun- 
light or  the  full  daylight,  which  is  often  excluded  by  faulty  construction. 
Tlae  undergarments  worn  during  infancy  and  childhood  should  be  of  wool, 
thin  and  light  during  the  summer,  thicker  and  heavier  in  the  winter.  No 
intelligent  mother  need  be  told  of  the  need  of  personal  cleanliness  of  her 
child  as  a  means  of  promoting  its  health  as  well  as  comfort.  This  is  a  hygienic 
measure,  and  we  need  not  repeat  that  the  more  complete  the  sanitary  condi- 
tions the  less  the  liability  to  contract  rachitis  or  any  disease  dependent  on 
cachexia.  Bathing  of  childi'en  should  always  be  before  the  fire  or  in  a  warm 
room.  The  bath  for  an  infant  under  the  age  of  six  months  should  be  at  about 
90°.  As  the  age  increases  the  temperature  of  the  bath  should  be  gradually 
reduced  to  80°  in  the  second  year,  to  75°  in  the  third  year,  and  to  70°  sub- 
sequently. The  bath  should  be  short,  only  long  enough  to  ensure  cleanliness. 
For  weakly  infants  it  is  sometimes  best  to  dispense  with  the  general  bath, 
and  employ  the  sponge  instead.  I  see  no  advantage  in  the  use  of  saline  or 
medicated  baths.  After  the  bath  the  extremities  should  be  warm,  and  to 
ensure  a  better  peripheral  circulation  friction  of  the  surface  by  warm  flannel 
or  otherwise,  or  the  application  of  warmth  to  the  limbs,  is  often  useful.  The 
extremities  of  a  chikl  should  always  be  warm,  for  the  normal  warmth  of  the 
surface  not  only  promotes  nutrition  of  superficial  parts,  but  it  tends  to  pre- 
vent internal  congestions  and  inflammations,  to  which  the  rachitic  are  espe- 
cially liable.  A  child  that  habitually  has  cool  extremities  cannot  be  at  the 
maximum  of  health,  and  this  is  often  the  state  of  the  poorly-fed  and  poorly- 
clad  children  of  the  tenement-houses.  The  measures  to  promote  their  normal 
circulation  and  warmth,  such  as  exercise  as  far  as  practicable,  artificial  heat, 
exclusion  of  cold  by  woollen  garments,  friction  of  the  limbs,  either  dry  or  by 
the  use  of  mildly  stimulating  lotions,  should  be  employed.  But  while  the 
hygienic  measures  which  we  have  detailed  are  important  as  a  means  of  invig- 
orating the  system  and  rendering  it  less  liable  to  rachitis  as  well  as  other 
cachectic  diseases,  we  repeat  that  the  most  common  and  potent  cause  of  the 
malady  which  we  are  considering  is  a  faulty  diet,  so  that  in  the  endeavor  to 
prevent  and  to  cure  rachitis  special  attention  must  be  given  to  the  feeding. 

Clinical  experience  abundantly  demonstrates  the  fact  that  in  order  to  pro- 
mote healthy  nutrition  the  food  of  the  infant  should  be  breast-milk  until  the 
age  of  ten  or  twelve  months ;  and  subsequently,  until  childhood  is  well 
advanced,  its  food  should  consist  largely  of  cow's  milk,  properly  preserved 
and  prepared. 

We  need  not  state  that  human  milk  varies  in  its  composition  according 
to  the  health,  diet,  mode  of  life,  and  temperament  of  the  individual  who  fur- 
nishes it.  Many  mothers  possess  the  requisite  moral  traits  to  be  good  wet- 
nurses,  and  do  all  in  their  power  for  the  welfare  of  their  infants,  but  have  an 
inadequate  lacteal  secretion.  Many  mothers,  not  only  in  the  tenement-houses, 
but  in  the  well-to-do  class,  are  unable  to  furnish  sufiicient  breast-milk,  and 
their  infants,  unless  they  receive  supplementary  food,  sufi"er  from  malnutri- 
tion and  are  liable  to  become  rachitic.  I  have  seen  during  the  last  year 
infants  wet-nursed  by  their  mothers,  fretful,  wasted,  and  at  the  verge  of  starv- 
ation, applied  every  half  hour  to  the  breast  during  the  hours  of  wakefulness. 
Mothers,  deprived  of  the  needed  sleep  and  sacrificing  their  own  health  in  the 
constant  endeavor  to  provide  for  the  wants  of  their  infants,  usually  have 
insufiicient  milk,  as  in  the  cases  alluded  to.  Under  such  circumstances  a 
medicine  designated  nutrolactis,  which  consists  largely  of  the  Galega  offici- 
nalis, has  been  employed  in  the  New  York  Infant  Asylum  with  apparent  bene- 


RACHITIS.  183 

fit  as  a  stimulator  of  the  lacteal  secretion.  But  if  suckling  by  the  mother 
continue  inadequate  and  her  infant  be  under  the  age  of  six  months,  a  wet- 
nurse  should  be  employed.  If  this  be  impossible,  supplementary  feeding- 
will  be  needed.  We  refer  the  reader  to  the  article  on  the  artificial  feeding 
of  infants  treated  of  in  the  first  part  of  this  book. 

The  prevention  and  the  cure  of  rachitis  require  strict  enforcement  of  the 
details  of  hygiene.  Hence  the  facts  detailed  in  the  foregoing  pages  relating 
to  the  mode  of  life  and  diet  of  children  should  be  observed  in  order  to  pre- 
vent cachexia  and  promote  a  healthy  growth. 

3Iedicmal  Treatment. — Medicines  which  aid  the  digestion  and  assimilation 
of  properly-selected  foods  are  sometimes  useful.  Irritability  of  the  stomach, 
imperfectly-digested  stools,  flatulence,  colicky  pains,  etc.  indicate  faulty  diges- 
tion, which  may  be  improved  by  pepsin  given  with  each  feeding.  Tonic  reme- 
dies designed  to  improve  the  appetite  and  digestion,  of  a  kind  suitable  for  the 
age  and  condition  of  the  patient,  are  often  useful.  In  anaemia  one  of  the 
readily-assimilated  preparations  of  iron  should  be  given.  The  complications 
which  are  so  common  require  special  management.  The  laryngismus  stridu- 
lus, eclampsia,  and  tetany  should  be  promptly  treated. 

The  bronchial  catarrh  to  which  rachitic  infants  are  liable  may  be  best 
treated  by  remedies  like  the  following : 

R.  Ammonii  chloridi,  5J  ; 

Syr.  tolutan.,  ^ij. — Misce. 

Sig.  Dose  fifteen  drops  every  hour  or  two  hours  for  an  infant  of  six  to  ten  months. 

R.  Ammonii  chloridi, 

Ferri  et  ammonii  citratis,         da.  ^ss. ; 
Syrupi,  f.|j  ; 

A  quse,  f J  iij .  — Misce . 

Sig.  Give  one  teaspoonful  every  two  to  four  hours  to  a  child  of  one  year. 

Some  of  the  rachitic  cases  with  protracted  bronchial  catarrh,  especially 
those  which  also  exhibit  scrofulous  symptoms,  may  be  most  relieved  by  the 
syrup  of  the  iodide  of  iron  and  cod-liver  oil  administered  three  times  daily, 
with  the  inhalation  of  moist  air  containing  turpentine  vapor. 

In  the  protracted  intestinal  catarrh  of  rachitic  infants  I  have  observed  the 
best  results,  so  far  as  medicine  is  concerned,  from  the  following  prescription : 

R.   Subnitrate  of  bismuth,  3i,i~iij  ! 

Elix.  of  digestive  ferments  or  essence  of  pepsin,     f  ^j  ; 
Distilled  water,  f^iij- — Misce. 

Sig.  Shake  bottle  ;  give  half  to  one  teaspoonful,  according  to  the  age,  every  two 
hours. 

But  a  remedy  is  needed  which  will  act  promptly  in  the  cure  of  rachitis  so 
as  to  prevent  the  evil  consequences  which  its  continuance  is  sure  to  produce. 
It  is  the  opinion  of  many  of  the  best  clinical  observers  who  have  had  ample 
experience  that  this  has  been  discovered  in  the  daily  use  of  minute  doses  of 
phosphorus. 

Wegner  fed  young  and  growing  animals  (rabbits  and  fowls)  for  months 
with  small,  non-poisonous,  and  easily-assimilated  doses  of  phosphorus,  with 
the  result,  he  believes,  of  expediting  ossification  and  producing  firmer  bone. 
He  states  that  under  the  influence  of  phosphorus  the  large  marrow  spaces 
diminish,  by  the  formation  of  true  bone,  to  the  size  of  the  Haversian  canals 
in  normal  bone.  According  to  Wegner,  the  administration  of  finely-divided, 
non-poisonous  doses  of  phosphorus  for  a  prolonged  period  to  older  fowls  pro- 
duced to  a  considerable  extent  the  conversion  of  cancellous  into  compact  bone 


184  CONSTITUTIONAL  DISEASES. 

of  normal  chemical  composition.  Kassowitz  lias  recently  promulgated  his  views 
at  some  length  on  the  pathology  and  treatment  of  rachiiis.  He  states  that  the 
lime  salts  are  not  needed,  since  the  ordinary  food  contains  sufficient  lime  ;  nor 
should  the  farinaceous  foods  be  restricted.  He  adds  that  phosphorus  in  small 
doses  restricts  the  formation  of  vessels  in  the  growing  bones  of  small  animals. 
Hence  it  is  useful  as  a  means  of  overcoming  the  hyperaemia.  Kassowitz 
administers  about  y-jg-  of  a  grain  in  a  teaspoonful  of  cod-liver  oil,  the  dose, 
of  course,  varying  according  to  the  age  of  the  infant.  The  distinguished 
paediatrist  of  Vienna,  Dr.  Widerhofer,  says  of  this  remedy  that  its  employ- 
ment "  impresses  him  with  the  belief  that  it  is  not  without  benefit  in  the 
second  year  of  life  and  upward."  He  thinks  that  it  may  be  useful  in  the 
hardening  of  long  bones,  but  he  has  not  been  able  to  obtain  good  results  in 
eraniotabes.  Starker  gives  an  analysis  of  23  rachitic  cases  treated  by  Prof. 
Thomas  of  Freiberg  in  his  clinic.     He  used  the  following  formula : 

R.   Phosphori,  1  centigramme  (about  \  grain); 

01.  morrhuse,  100  grammes  (about  3  ounces). — Misce. 

A  coffee-spoonful  was  administered  twice  daily,  but  variations  in  the  dose 
according  to  the  age  are  not  stated  in  the  report,  the  patients  being  between 
the  ages  of  a  few  months  and  four  years.  Improvement  in  the  general  con- 
dition in  18  cases ;  in  the  cranial  development  in  15  cases ;  in  dentition  in  14 
cases;  in  the  shapes  of  the  epiphyses  in  21  cases;  in  locomotion  in  17  cases; 
but  strict  attention  was  bestowed  upon  the  hygiene,  and  especially  upon  the 
diet.  Soltmann  states  that  good  results  occurred  from  the  use  of  phosphorus 
in  70  cases  which  he  had  under  observation,  and  in  no  instance  were  unfavor- 
able results  noticed.  W.  Meyer  obtained  similar  results  in  42  cases.  He 
regards  phosphorus  as  a  specific  for  rachitis.  When  properly  given  it  always, 
says  he,  produces  positive  results.  Petersen  has  treated  200  cases  with  phos- 
phorus, and  regards  it  as  a  specific.  Sigel  concludes,  from  the  observation 
of  40  cases  in  private  practice,  that  constitutional  treatment  is  of  the  greatest 
importance,  but  instead  of  the  administration  of  iron,  lime,  etc.,  phosphorus 
should  be  prescribed.  Unruh  also  made  many  observations  in  the  treatment 
of  rachitic  cases  by  phosphorus  in  the  Dresden  Hospital  in  1885  and  1886, 
and  considers  it  more  efficacious  than  other  remedies. 

Toplitz  of  Breslau  treated  518  cases  with  phosphorus  combined  with  cod- 
liver  oil.  No  ill  effects  were  observed,  and  in  all  the  cases  improvement 
occurred  in  the  general  condition.  Of  208  cases  of  eraniotabes,  176  were 
cured  in  eight  weeks.  In  58  cases  of  laryngismus  stridulus  the  attacks 
ceased  in  eight  to  fourteen  days,  after  having  continued  for  months  under 
other  forms  of  treatment.     Dentition  was  also  promoted. 

In  America,  Dr.  A.  Jacobi,  who  has  had  a  large  clinical  experience,  also 
highly  recommends  phosphorus  in  the  treatment  of  rachitis.  The  dose  should 
be  small,  even  minute,  not  more  than  2^^  to  j^-^  of  a  grain,  according  to  the 
age,  three  times  daily. 

As  regards  my  own  observations,  I  am  not  able  to  express  a  positive 
opinion  as  to  the  value  of  the  phosphorus  treatment,  for  reasons  which  I 
think  also  apply  to  many  of  the  cases  embraced  in  the  favorable  statistics 
of  the  distinguished  observers  mentioned  above — to  wit,  the  simultaneous  use 
of  cod-liver  oil  and  improvement  in  the  diet  and  general  hygiene. 

The  following  prescriptions  may  be  employed — first,  the  oleum  phospho- 
ratum,  made  according  to  the  following  formula : 

R.  Phosphorus,  1  part. 

Ether,  9  parts. 

Almond  oil,  90     "     —Misce. 

One  minim  contains  j^^  of  a  grain  of  phosphorus. 


RACHITIS.  185 

Or,  secondly,  the  following,  known  as  Thompson's  mixture : 

R.  Phospliori,  gr.  j. 

Alcoholis  (absolut.),  TTL  cccl. 

Spts.  men  til.  piperit.,  Tr\^x. 

Glycerini,  £513. — Misce. 

Sig.  Six  drops,  increased  to  ten,  three  times  daily,  to  a  child  of  two  or  four  years. 
Ten  minims  contain  j^-j  of  a  grain,  and  thirteen  minims  contain  j^ij  of  a 
grain. 

Phosphorus  should,  I  think,  be  given  after  the  meals,  in  order  to  prevent 
irritation  of  the  stomach. 

Dr.  H.  H.  Purdy,  physician  to  the  large  class  of  children's  diseases  in  the 
Out-door  Department  at  Bellevue,  has  preserved  statistics  of  the  treatment 
of  rachitis  during  the  last  year.  The  cases  which  furnish  the  statistics  num- 
bered about  80,  and  he  gives  a  resume  of  the  results  of  treatment  as  follows : 
"  Some  were  given  cod-liver  oil  alone,  some,  cod-liver  oil  with  phosphorus, 
and  others,  phosphorus  alone,  and  of  course  all  the  mothers  were  given 
instruction  in  feeding  and  hygiene.  Those  infants  that  received  only  phos- 
phorus were  the  slowest  to  improve.  Indeed,  in  several  cases  this  method  of 
treatment  was  abandoned  because  of  the  absence  of  the  signs  of  improvement. 
The  group  treated  with  cod-liver  oil  did  the  best.  In  fact,  all  of  the  infants 
that  could  tolerate  the  oil  apparently  derived  benefit  from  it.  The  group  that 
were  given  cod-liver  oil  with  phosphorus  did  very  well,  but  seemingly  no  better 
than  those  that  were  given  only  cod-liver  oil.  The  preparation  that  seems  to 
be  most  beneficial  is  one  that  is  used  at  the  Church  Hospital  and  Dispensary. 
It  is  an  emulsion  of  cod-liver  oil  made  with  the  yolk  of  eggs.  The  formula 
for  the  emulsion  is 

R.  Yolks  of  ten  eggs, 

Cod-liver  oil,  Oij. 

Syrup  of  wild  cherry,  Oj. 

Sherry  wine,  Oj. — Misce. 

Sig.  One  or  more  teaspoonfuls  administered  three  or  more  times  daily." 

In  my  opinion,  the  treatment  by  phosphorus  is  still  tentative,  notwith- 
standing its  recommendation  by  so  many  distinguished  physicians ;  and  the 
old  remedies,  cod-liver  oil  and  iron,  should  not  be  abandoned,  although  trial 
may  be  made  of  phosphorus  at  the  same  time. 

Care  should  be  taken  to  prevent  deformities  while  the  bones  are  soft  and 
yielding.  The  patient  should  not  be  encouraged  to  stand  or  use  the  limbs 
until  they  become  firmer.  He  should  lie  upon  a  soft  and  even  mattress.  Uni- 
form support  of  body  and  limbs  is  requisite  in  order  to  prevent  curvature. 
In  craniotabes  the  pillows  should  be  soft,  and  care  should  be  taken  that  the 
yielding  parts  of  the  cranium  be  not  unduly  pressed  upon.  Profuse  per- 
spiration may  be  relieved  by  sponging  with  vinegar  and  water.  The  patient 
may  be  bathed  in  water  a  little  cooler  than  the  body,  and  rock  salt  may  be 
added  to  the  bath. 

The  attacks  of  laryngismus  stridulus,  eclampsia,  and  tetany  which  so 
frequently  complicate  rachitis  should  be  promptly  treated  by  the  remedies 
which  are  appropriate  when  they  occur  under  other  circumstances.  Consti- 
pation may  be  treated  by  enemata  of  glycerin  and  water  if  not  relieved  by 
change  of  diet. 

The  surgical  treatment  of  rachitic  deformities  is  sometimes  important,  but 
Prof.  Ogston  of  the  University  of  Aberdeen  and  other  surgeons  who  have 
given  special  attention  to  this  subject  state  that  in  young  patients  these 
deformities  frequently  diminish  during  growth,  so  as  to  cau.se  little  incon- 
venience in  adult  life.  The  measures  employed  by  surgeons  in  order  to  cure 
or  minimize  the  deformities  are  treated  of  in  another  section. 


186 


CONSTITUTIONAL  DISEASES. 


CHAPTER   II. 


SCEOFULA. 


The  term  scrofula  (^scrofa,  a  pig,  from  the  resemblance  which  the  enlarged 
cervical  glands  of  a  scrofulous  individual  cause  to  a  swine's  neck)  is  applied 
to  a  diathesis  which  is  characterized  by  increased  vulnerability  of  the  tissues. 
The  nutritive  process  of  the  tissues  is  readily  disturbed  even  by  trifling  irri- 
tants or  agencies  in  those  who  have  this  diathesis,  and  therefore  the  scrofulous 
are  prone  to  inflammations  of  various  parts.  Inflammations  which  can  prop- 
erly be  considered  as  dependent  upon  this  diathesis  or  as  occurring  under  its 
influence  are  for  the  most  part  subacute  or  chronic,  and  they  difi"er  from 
ordinary  inflammations  in  the  fact  of  a  greater  cell-formation  and  greater 
liability  to  cheesy  degeneration  of  inflammatory  products,  so  that  return  to 
the  healthy  state  by  absorption  is  slow  or  impossible.  Moreover,  this  diath- 
esis, while  it  gives  rise  to  certain  inflammations  which  do  not  occur  or  are 
rare  in  other  states  of  the  system,  and  which  all  physicians  at  once  recognize 
as  scrofulous,  often  modifies  those  common  inflammations  to  which  all  per- 
sons, whether  scrofulous  or  non-scrofulous,  are  liable,  as  coryza  and  bron- 
chitis, rendering  them  more  protracted  and  less  amenable  to  ordinary  treat- 
ment. 

Scrofula  is  a  disease  chiefly  of  infancy  and  childhood.     Manhood,  espe- 

FiG.  35. 


cially  the  first  years  of  it,  is  not  entirely  exempt,  but  scrofulous  manifesta- 
tions after  the  age  of  twenty  years  are  feeble  and  infrequent,  disappearing 


SCROFULA.  187 

entirely  as  the  individual  advances  toward  middle  life.  The  diathesis  is  most 
active  prior  to  the  age  of  ten  years. 

Causes. — Scrofula  is  congenital  or  acquired.  Parents  who  had  scrofulous 
symptoms  in  early  life  or  who  are  in  a  state  of  decided  cachexia,  as  from  can- 
cer, syphilis,  intermittent  fever,  or  tuberculosis,  are  likely  to  beget  scrofulous 
children.  Insufficient  nourishment  of  the  mother  during  a  considerable  part 
of  her  gestation,  and  advanced  age,  and  therefore  feebleness,  of  the  father, 
are  occasional  causes.  Near  blood-relationship  of  the  parents  is  also  a  recog- 
nized cause,  and  to  this  has  been  attributed  the  scrofula  of  royal  families. 
Children  whose  father  and  mother  are  first  cousins  are,  according  to  my 
observations,  likely  to  be  scrofulous. 

Again,  those  born  with  sound  constitutions  may  acquire  scrofula  through 
antihygienic  influences  in  the  first  years  of  life.  Among  the  poor  of  New 
York  we  often  observe  one  child  in  a  family  who  presents  scrofulous  symp- 
toms, while  the  rest  of  the  children  are  well,  and  in  many  cases  we  are  able 
to  trace  back  the  diathesis  to  some  depressing  cause  or  causes  which  were 
sufiicient  to  efiect  the  peculiar  change  in  the  molecular  condition  of  the  tissues 
which  constitutes  this  disease.  Obviously,  the  causes  of  acquired  scrofula  are 
quite  numerous.  In  the  infant  it  is  sometimes  produced  by  insufiiciency  or 
poor  quality  of  the  breast-milk,  or  the  use  of  artificial  food  during  the  period 
when  breast-milk  is  required.  Too  protracted  nursing  at  the  breast  also,  espe- 
cially if  artificial  food  be  almost  wholly  withheld,  may  cause  it ;  as  may  also, 
in  those  who  have  been  weaned,  the  continued  use  of  a  diet  which  is  deficient 
in  nutritive  properties. 

Residence  in  damp,  dark,  and  filthy  apartments  or  streets  may  also  pro- 
duce it.  Hence  one  reason  of  its  frequent  occurrence  among  the  city  poor. 
Residence  in  a  small,  crowded,  and  imperfectly  ventilated  apartment  has  been 
known  to  cause  it,  even  with  personal  cleanliness  and  a  diet  sufiiciently 
nutritive. 

Scrofula  may  also  be  caused,  in  those  previously  robust  and  of  sound  con- 
stitution, by  disease  of  an  exhausting  nature.  The  eruptive  fevers,  as  small- 
pox, measles,  and  scarlet  fever,  if  severe,  occasionally  produce  this  result,  or 
they  render  active  the  diathesis  which  had  hitherto  been  latent.  In  this  city, 
where  chronic  entero-colitis  of  infancy  is  common,  I  have  sometimes  been  able 
to  trace  the  diathesis  to  the  cachectic  state  and  the  impaired  nutrition  which 
it  causes. 

The  theory  has  recently  been  promulgated  that  scrofula  has  a  specific 
principle,  and  that  this  is  a  modified  form  of  the  tubercle  bacillus.  This 
theory  receives  some  support  from  the  fact  that  scrofulous  glands  sometimes 
contain  the  tubercle  bacillus,  and  scrofula  in  many  instances  precedes  tuber- 
culosis. Van  Merris  considers  the  scrofulous  inflammation  as  a  local  tubercu- 
losis, and  Grancher  describes  scrofula  as  a  local  curable  tuberculosis.  On  the 
other  hand.  Dr.  Jacobi  regards  the  tubercle  bacillus  in  a  scrofulous  disease  as 
an  "  accidental  invasion,"  and  Lartigues  calls  attention  to  the  fact  that  the 
tubercle  bacillus  cannot  be  discovered  in  most  instances  in  the  lesions  of 
scrofula.  Alexander  also  states  that  wherever  we  can  trace  the  cause  of 
scrofula,  it  seems  to  be  distinct  from  any  probable  microbic  agency  (^Annual 
of  the  Univer.  Med.  Sci.,  vol.  iv.,  1889).  Noeldechen  states  that  the  close 
relationship  of  tuberculosis  to  scrofula  arises  from  the  fact  that  scrofulous 
ailments  afi'ord  the  most  favorable  soil  for  the  development  of  the  tubercle 
bacillus  {Deutsche  med.  Zeit..,  1887).  Rabl  also  mentions  the  fact  that  the 
tubercle  bacillus  is  often  not  present  in  scrofulous  glands.  He  tabulates 
1000  cases  of  scrofula,  as  regards  their  causation,  as  follows :  79  had  scrofu- 
lous parents,  446  had  tuberculous  parents,  356  lived  in  damp  dwellings,  25 
were  subjected  to  other  bad  hygienic  surroundings,  69  could  be  ascribed  to 


188  CONSTITUTIONAL  DISEASES. 

acute  infectious  diseases,  14  to  vaccination,  7  to  decrepitude,  and  4  to  con- 
sanguinity of  parents  (  Wien.  med.   Zeit.,  1887). 

Scrofula,  as  we  have  seen,  results  from  a  variety  of  depressing  agencies 
aflfecting  the  system  in  different  ways,  with  the  general  result  of  impairing  its 
vigor  and  lowering  its  tone.  The  theory  seems  improbable  that  these  many 
and  distinct  agencies  cause  the  phenomena  of  scrofula  through  the  action  of 
a  microbe  peculiar  to  this  disease. 

The  primary  scrofulous  ailments  by  which  the  diathesis  is  manifested 
occur  for  the  most  part  upon  one  of  the  free  surfaces — namely,  upon  some 
part  of  the  skin  or  mucous  membrane.  Certain  writers  attribute  this  to  the 
fact  that  these  parts  are  most  exposed  to  the  action  of  noxious  agencies. 
The  lymphatics  lying  in  the  inflamed  area  take  up  the  altered  lymph  and 
carry  it  to  the  adjacent  lymphatic  glands,  which  become  irritated  and  un- 
dergo hyperplasia,  and  perhaps  ultimately  suppuration.  This  is,  in  a  large 
proportion  of  cases,  the  beginning  of  scrofulous  ailments.  Nevertheless,  in 
not  a  few  instances  the  first  manifestations  are  in  deep-seated  and  covered 
parts,  as  when  scrofulous  periostitis  or  osteitis  occurs  without  any  peripheral 
lesion. 

E,abl  expresses  the  opinion  that  in  certain  cases  "scrofula  results  from 
syphilis  in  the  parent  or  grandparent.  He  believes  that  syphilis  in  the  parent 
causes  scrofula  in  the  child  by  diminishing  the  power  of  resistance  to  the 
causes  which  produce  the  latter  aff"ection.  He  thinks  that  in  this  manner 
parental  syphilis  gives  rise  in  some  children  to  symptoms  identical  with  those 
of  scrofula,  while  in  other  children  it  gives  rise  to  syphilitic  symptoms.  The 
author's  observations  in  this  particular  correspond  with  those  of  Rabl. 

Anatomical  Characters. — There  are  no  ascertained  anatomical  changes 
in  the  blood  which  are  peculiar  to  scrofula.  As  long  as  the  appetite  and  gen- 
eral health  remain  good  and  the  local  affections  have  not  occurred,  the  com- 
position of  this  fluid  is,  so  far  as  known,  unaltered.  In  the  cachexia  which  is 
present  when  the  general  health  is  impaired  the  blood  becomes  impoverished, 
the  red  corpuscles  lose  a  portion  of  their  coloring  matter,  and  the  watery  ele- 
ment predominates. 

The  question  arises  whether  the  glandular  hyperplasia  of  scrofula  pro- 
duces an  excess  of  white  corpuscles  in  the  blood.  Virchow  says :  "  During 
the  progress  of  an  attack  of  scrofula,  in  which,  if  the  disease  run  a  somewhat 
unfavorable  course,  the  glands  are  destroyed  by  ulceration  or  cheesy  thicken- 
ing, calcification,  etc.,  an  increased  introduction  of  corpuscles  into  the  blood 
can  only  take  place  as  long  as  the  irritated  gland  is  still,  in  some  degree, 
capable  of  performing  its  functions  or  still  continues  to  exist;  as  soon,  how- 
ever, as  the  glands  are  withered  or  destroyed  the  formation  of  lymph-cells 
likewise  ceases,  and  with  it  the  leucocytosis.  In  all  cases,  on  the  other  hand, 
in  which  a  more  acute  form  of  disturbance  prevails,  connected  with  inflamma- 
tory tumefaction  of  the  gland,  an  increase  of  the  colorless  corpuscles  always 
takes  place  in  the  blood."  (CelM.  Pathol).  Although  the  glandular  hyper- 
plasia occurring  in  scrofula  increases  the  number  of  white  corpuscles  in  the 
blood,  scrofula  cannot  be  regarded  as  sustaining  any  causal  relation  to  that 
great  and  constant  increase  of  white  corpuscles  which  characterizes  the  disease 
leukaemia ;  for  this  disease,  as  remarked  by  Niemeyer,  does  not  occur  in  child- 
hood, when  the  scrofulous  diathesis  is  active,  but  in  manhood,  when  it  has 
ceased  to  exist  or  has  become  latent. 

Strumous  inflammations  of  the  cutaneous  and  mucous  surfaces,  which  we 
have  seen  are  the  initial  lesions  in  a  large  proportion  of  scrofulous  cases,  do 
not  present  any  peculiar  anatomical  elements.  Some  of  them  are  attended 
by  an  abundant  formation  of  cells  and  by  dense  infiltration  of  the  inflamed 
tissues ;  but  inflammations  which  do  not  depend  on  the  strumous  diathesis 


SCROFULA.  189 

have  the  same  anatomical  elements.  The  most  marked  diiFerences  between 
the  strumous  and  non-strumous  inflammations  are  found  in  their  origin,  amount 
of  cell-formation  and  inflammatory  exudate,  and  duration. 

The  swelling  of  the  lymphatic  glands  which  is  so  common  in  the  neigh- 
borhood of  scrofulous  inflammations,  and  is  produced  by  the  lodgement  in  the 
glands  of  irritating  or  noxious  products  of  the  inflammation  taken  up  by  the 
lymphatics  and  conveyed  to  the  glands,  is  due  to  hyperplasia  of  the  lymph- 
cells,  with  comparatively  little  or  no  increase  of  the  stroma.  Thus,  hyper- 
plasia of  the  cervical  glands  is  common,  resulting  from  eczema  of  the  scalp 
or  face,  or  from  otitis  or  any  of  the  forms  of  stomatitis ;  and  so  pharyngitis 
often  gives  rise  to  hyperplasia  of  the  tonsils,  which  are  lymphatic  glands. 
The  scrofulous  nature  of  the  glandular  enlargement  is  apparent  from  the  fact 
that  it  continues  long  after  the  primary  inflammation  which  gave  rise  to  it 
has  abated.  Lymphatic  glands  sometimes  enlarge  in  those  who  are  not  scrofu- 
lous, but  the  tumefaction  is  commonly  less  in  degree,  and  in  most  instances  it 
soon  abates  when  the  exciting  cause  is  removed. 

The  glands  which  commonly  undergo  scrofulous  enlargement  are  the  cer- 
vical, inguinal,  bronchial,  and  mesenteric  ;  but  in  those  who  are  decidedly 
scrofulous  the  glands  in  the  vicinity  of  any  protracted  inflammation  are  very 
prone  to  hyperplasia.  Thus  I  have  seen  enlarged  and  cheesy  glands  in  the 
vicinity  of  scrofulous  osteitis  or  periostitis. 

Under  favorable  circumstances  the  glandular  enlargement  abates  after  a 
short  time  by  liquefaction  and  absorption  of  the  redundant  cells.  But  the 
products  of  hyperplastic  or  inflammatory  action  in  the  scrofulous  individual 
are  very  liable  to  undergo  cheesy  degeneration,  and  the  close  causal  relation  of 
this  cheesy  substance  with  tubercles  is  now  admitted.  If  resolution  does  not 
soon  occur  in  a  gland,  it  begins  to  undergo  cheesy  degeneration.  It  becomes 
firm  and  inelastic,  its  nutrient  vessels  narrowed  and  compressed,  so  that  cir- 
culation through  it  ceases,  and  its  cells,  losing  their  liquid  and  vitality,  shrivel 
away.  This  necrobiotic  process  appears  in  points  in  the  gland  which  enlarge 
and  unite,  till  finally  the  whole  gland  becomes  a  dead  mass,  with  shrivelled 
elements  of  a  whitish  appearance,  like  cheese,  the  resemblance  to  which  has 
suggested  the  name  by  which  the  degeneration  is  known. 

In  certain  patients  cheesy  glands  act  as  an  irritant  like  inorganic  matter, 
producing  suppurative  inflammation,  and  their  subsequent  history  is  that  of 
an  abscess.  Purulent  matter  mixed  with  the  cheesy  debris  escapes  by  ulcera- 
tion upon  the  nearest  surface,  and  scrofulous  ulcers  result  which  slowly  heal, 
leaving  permanent  cicatrices ;  calcification  of  a  cheesy  gland  occurs  in  excep- 
tional instances. 

The  cervical  lymphatic  glands  in  the  scrofulous  child,  having  undergone 
hyperplasia  of  their  cellular  elements,  not  infrequently  continue  painless  and 
indolent  for  a  considerable  time,  producing,  according  to  their  size,  an  unsightly 
appearance  without  undergoing  cheesy  degeneration.  Finally,  one  or  more 
become  inflamed,  and  the  broken-down  gland  substance  softens  and  is  expelled, 
mixed  with  pus,  through  an  ulcerated  opening  in  the  skin. 

In  order  to  complete  the  description  of  the  anatomical  character  of  scrofula, 
it  would  be  necessary  to  describe  the  various  inflammations  to  which  the  diath- 
esis gives  rise.  Those  which  are  most  common  and  important  occur  in  the 
skin,  mucous  membrane,  connective  tissue,  the  joints,  the  bones  with  their 
periosteal  covering,  and  the  eye  and  ear.  Eczema  and  coryza  are  also  very 
common  scrofulous  ailments.  Phlyctenular  keratitis  with  great  intolerance 
of  light,  otitis  externa,  causing  protracted  otorrhoea,  or  media  and  interna, 
causing  deep-seated  pain,  with  impairment  or  loss  of  hearing,  off"ensive  puru- 
lent discharge,  and,  in  the  gravest  cases,  caries  of  the  mastoid  cells  or  caries 
extending  along  the  petrous  portion  of  the  temporal  bone  even  to  the  brain, 


190 


CONSTITUTIONAL  DISEASES. 


causing  meningitis  and  death,  are  not  uncommon  manifestations  of  scrofula 
in  the  families  of  the  city  poor.  Strumous  cellulitis,  occurring  independently 
of  the  glandular  affection  and  quickly  ending  in  suppuration,  is  also  common. 
The  term  cold  is  applied  to  the  abscess  when  the  local  symptoms  are  slight 
and  there  is  but  little  heat  of  the  parts.  In  young  children  the  common  seat 
of  these  abscesses  is  directly  under  the  skin,  so  that  if  subcutaneous  cellulitis 
running  into  an  abscess  occur  in  a  young  child,  he  probably  has  the  strumous 
diathesis. 

The  osseous  system  is  very  prone  to  inflammation  in  the  scrofulous.  Peri- 
ostitis, osteitis,  and  arthritis,  rare  in  those  with  healthy  constitutions,  are 
common  in  the  scrofulous,  in  whom  they  result  even  from  very  slight  injuries, 
and  sometimes  without  the  recollection  of  an  injury,  and  apparently  from  the 
direct  influence  of  the  diathesis.  These  inflammations  are  more  common  in 
the  lower  extremities  than  in  the  upper.  Periostitis  often  occurs  in  scrofulous 
children  without  osteitis  when  its  usual  seat  is  upon  the  shafts  of  the  long 
bones,  and  it  also  accompanies  inflammations  of  the  bone,  as  pleurisy  accom- 
panies pneumonia.  The  osseous  inflammations  of  strumous  patients  are  of  two 
kinds :  first,  the  destructive,  producing  caries  with  suppuration  or  necrosis ; 
and  secondly,  the  so-called  fungous^  in  which  there  is  proliferation  of  tissue, 
as  in  white  swelling.  Often  both  these  processes  coexist,  granulations  and 
new  tissue  springing  up  while  the  carious  or  necrotic  process  is  extending. 

Dactylitis  is  in  most  instances,  when  occurring  in  young  infants,  a  syphil- 
itic affection,  but  in  children  of  one  year  or  more,  in  whom  no  marked  syphilitic 
symptoms  have  previously  occurred,  it  originates  from  the  sti'umous  cachexia, 

Fic4.  36. 


as  in  the  following  case  :   Charles  R ,  aged  twenty  months,  was  admitted 

into  the  New  York  Infant  Asylum  in  1876.  He  had  always  been  pallid  and 
had  a  strumous  aspect.  A  physician  acquainted  with  his  parentage  states 
positively  that  he  is  free  from  syphilitic  taint,  but  when  a  few  months  old 
he  had  a  mild  form  of  coryza,  which  gradually  abated  under  antistrumous 


SCROFULA.  191 

treatment.  At  the  age  of  five  months  he  had  purpura  haemorrhagica  of  a 
severe  form,  but  apparently  not  accompanied  by  hemorrhage  from  any  of  the 
mucous  surfaces.  The  patches  of  extravasated  blood  were  quite  numerous 
and  large  over  the  trunk  and  limbs,  and  it  was  nearly  three  months  before 
they  entirely  disappeared.  A  few  months  subsequently  he  began  to  have 
offensive  otorrhoea  on  one  side,  which  did  not  entirely  cease.  In  December, 
1876,  at  the  age  of  eighteen  months,  well-marked  dactylitis  was  first  observed, 
involving  the  first  phalanx  of  the  left  middle  finger.  The  swelling  was  some- 
what tender,  and  the  skin  which  covered  it  had  a  slightly  reddish  or  pinkish 
tinge,  indicating  the  inflammatory  natui'e  of  the  malady.  Neither  joint  at  the 
extremity  of  the  phalanx  was  involved,  so  that  the  movements  were  unim- 
paired. The  dactylitis  increased  somewhat  after  it  was  first  discovered,  and 
then  began  to  decline  under  treatment  with  cod-liver  oil  and  syrup  of  iodide 
of  iron.  The  accompanying  woodcut  represents  the  outlines,  obtained  by 
tracing  the  hand  of  the  infant  when  pressed  on  paper. 

Symptoms. — The  scrofulous  diathesis  is  exhibited  by  certain  physical 
signs  which  are  present  in  infancy,  but  are  more  manifest  in  childhood.  In 
one  class  of  strumous  children  they  are  as  follows :  Form  tall  and  slender ; 
quickness  of  movement  and  perception ;  intelligence  good  ;  skin  thin  and 
semi-transparent,  through  which  the  superficial  veins  are  distinctly  seen; 
features  delicate ;  cheeks  habitually  pallid  or  florid,  and  flushed  by  slight 
excitement;  eyes  bright,  with  bluish  conjunctiva;  muscles  and  bones  slender 
in  proportion  to  their  length.  Those  children  who  present  these  peculiarities 
are  said  to  have  the  erethitic  form  of  the  diathesis. 

Others  have  what  has  been  designated  the  torpid  scrofulous  habit,  which 
is  characterized  by  softness  and  flabbiness  of  the  flesh,  distended  abdomen, 
large  head,  broad  face,  slow,  languid  movements,  and  an  over-production 
of  fat  in  the  subcutaneous  connective  tissue  in  certain  situations,  especially 
the  nose  and  upper  lip.  Though  typical  cases  can  be  readily  referred  to  one 
or  the  other  of  these  forms,  there  are  many  which  are  intermediate. 

One  of  the  earliest  of  scrofulous  manifestations  is  subcutaneous  cellulitis, 
alluded  to  above,  giving  rise  to  abscesses,  commonly  not  lai-ge,  with  little  sur- 
rounding induration,  little  pain,  tenderness,  and  heat,  and  slow  in  discharging  ; 
in  a  word,  indolent.  The  most  frequent  seat  of  these  abscesses  is  upon  the 
extremities,  but  they  may  occur  upon  the  scalp  or  elsewhere.  They  gradu- 
ally heal  when  the  pus  escapes,  their  site  being  indicated  for  a  considerable 
time  by  the  depression  and  reddish  discoloration  of  the  skin.  Ordinarily, 
these  abscesses  do  no  harm  apart  from  the  reduction  of  the  general  health 
which  they  effect,  but,  when  occurring  in  localities  where  the  connective 
tissue  lies  upon  the  periosteum,  as  upon  the  fingers,  periostitis  may  result, 
with  destruction  of  the  surface  of  the  bone.  Again,  thrombi  may  occur  in 
the  vessels  of  the  inflamed  part,  giving  rise  to  emboli,  embolismal  pneumonia, 
and  death.  Specimens  from  such  a  case  were  presented  by  me  to  the  New 
York  Pathological  Society  in  1868. 

The  scrofulous  affections  of  the  skin  often  also  occur  at  an  early  age,  even 
before  dentition.  They  are  more  frequent  in  infancy  than  in  childhood.  The 
most  common  are  eczema  and  impetigo,  and,  of  rare  occurrence,  ecthyma  and 
lupus.  But  all  these  may  occur  in  those  who  are  not  strumous  or  who  do 
not  present  the  characteristics  of  the  strumous  diathesis. 

Scrofulous  affections  of  the  mucous  surfaces  are  scarcely  less  frequent 
than  those  of  the  skin.  They  present  the  ordinary  features  of  mucous 
inflammations  of  a  subacute  and  chronic  character. 

Sometimes  they  occur  without  obvious  exciting  cause ;  in  other  cases 
there  is  a  cause  of  this  kind,  such  as  exposure  to  cold ;  but  the  inflamma- 
tion, once  established,  continues  on  account  of  the  diathesis.     It  is  often 


192  CONSTITUTIONAL  DISEASES. 

doubtful  whether  inflammations  in  strumous  subjects  be  of  such  a  character 
that  it  is  proper  to  designate  them  strumous,  especially  if  they  occur  upon 
such  surfaces  as  are  frequently  the  seat  of  ordinary  inflammation.  If  the 
child  have  heretofore  presented  symptoms  of  scrofula,  if  the  inflammation 
be  subacute,  and  there  be  no  apparent  cause  to  originate  or  sustain  it  apart 
from  the  diathesis,  it  is  probably  of  a  strumous  character.  The  diagnosis 
is  rendered  more  certain  by  observing  the  eff"ect  of  antistrumous  remedies. 
The  most  frequent  of  these  scrofulous  inflammations  of  mucous  surfaces 
are  coryza,  tracheo-bronchitis,  and  conjunctivitis.  More  rarely,  stomatitis, 
pharyngitis,  vaginitis,  and,  according  to  some,  entero-colitis,  are  of  a  stru- 
mous character.  Coryza  gives  rise  to  snuffling  respiration,  the  formation 
of  crusts  around  and  within  the  nares,  and  excoriation  of  the  upper  lip. 
The  tracheo-bronchitis  is  attended  by  thickening  of  the  mucous  membrane, 
increased  production  of  mucous  and  epithelial  cells,  and  a  loud  tracheal  rale 
accompanjdng  each  inspiration. 

Strumous  inflammation  of  the  mucous  membrane  of  the  trachea  and 
bronchial  tubes  is  a  not  very  infrequent  disease  in  this  city.  It  sometimes 
originates  in  a  simple  inflammation  from  cold  or  the  tracheo-bronchitis  of 
measles  or  pertussis,  and  it  may  continue,  with  its  rales,  cough,  and  scanty 
expectoration,  for  months,  unless  relieved  by  a  proper  course  of  treatment. 

Among  the  most  common  of  the  strumous  affections  are  inflammation  of 
the  eyelid,  designated  psorophthalmia,  and  that  of  the  eye  itself.  The 
former  is  characterized  by  redness  and  thickening  of  the  lids,  detachment  of 
the  eyelashes,  and  inflammation  and  altered  secretion  of  the  "  Meibomian 
glands  ;"  the  latter — to  wit,  strumous  ophthalmia — by  pain,  lachrymation, 
photophobia,  and  a  moderate  degree  of  hypersemia  of  the  affected  organ. 
One  of  the  most  common  serious  results  of  strumous  conjunctivitis  and 
keratitis  is  the  formation  of  phlyctenulje  and  ulcers  on  the  margin  of  the 
conjunctiva  and  upon  the  cornea,  fed  by  newly-formed  vessels.  If  not  con- 
trolled by  proper  treatment  they  may  result  in  opacities  more  or  less  perma- 
nent, or  possibly,  worse  still,  in  perforation,  with  its  consequent  ill  effects. 

Inflammations  of  the  external  and  middle  ear  have  their  origin  very  gen- 
erally in  the  strumous  diathesis.  Occasionally  there  is  an  exciting  cause  of 
the  otitis,  as  an  injury  or  severe  constitutional  disease,  like  scarlet  fever. 
Protracted  otitis,  whether  external  or  internal,  and  especially  that  form  of 
it  which  leads  to  ulceration,  destruction  of  the  ossicles,  and  caries  of  the 
petrous  portion  of  the  temporal  bone,  it  is  proper  in  a  large  proportion  of 
cases  to  regard  and  treat  as  strumous. 

The  stubbornness  and  frequent  disastrous  consequences  of  scrofulous 
inflammation  of  the  bones  are  well  known.  Nearly  every  bone,  as  well  as  its 
periosteum,  is  liable  to  this  form  of  inflammation,  but  some  are  more  fre- 
quently affected  than  others.  Inflammation  of  the  bone  may  terminate  by 
resolution,  by  the  formation  of  an  abscess,  or  (and  frequently)  by  carious  or 
necrotic  destruction  of  the  bone  itself.  Necrosis  most  frequently  occurs  in 
the  shafts  of  the  long  bones ;  caries  in  the  spongy  extremities  of  these  bones 
and  in  the  spongy  portions  of  the  short  bones.  If  abscesses  form,  the  pus 
may  finally  escape  from  the  system  by  a  tedious  ulcerative  process,  or, 
retained,  may  undergo  cheesy  degeneration.  Scrofulous  arthritis,  if  early 
detected  and  properly  treated,  may  resolve,  leaving  no  ill  effect ;  if  other- 
wise, suppuration,  ulceration,  cartilaginous  and  osseous,  and  ankylosis  often 
occur. 

Scrofulous  children  are  perhaps  no  more  liable  to  inflammation  of  the 
internal  organs  than  other  children,  but  the  inflammatory  products  are  more 
liable  to  cheesy  degeneration,  and  the  prognosis  is  therefore  less  favorable. 
The  most  frequent  of  these  inflammations  and  the  one  of  chief  interest  is 


SCROFULA.  193 

pneumonia.  Catarrhal  pneumonia,  so  frequent  in  early  life,  whether  primary 
or  secondary,  in  connection  with  measles,  pertussis,  etc.,  is  a  disease  often 
involving  grave  consequences  in  those  who  are  decidedly  scrofulous,  since, 
instead  of  resolving,  the  affected  lung-tissue  presents  a  strong  tendency  to 
caseous  degeneration,  ending  in  tuberculosis  of  the  lungs  and  death.  I  have 
most  frequently  noticed  cheesy  pneumonia  during  extensive  epidemics  of 
measles  as  a  complication  or  sequel  of  this  disease.  It  may  occur  in  those 
who  are  not  scrofulous  if  the  vital  powers  be  greatly  reduced,  but  it  is  so 
much  more  common  in  the  scrofulous  that  some  recent  writers  have  desig- 
nated this  form  of  inflammation  by  the  term  of  scrofulous  instead  of  cheesy 
pneumonia.  From  the  fact,  however,  of  its  sometimes  occurring  in  the  non- 
scrofulous,  the  term  cheesy  or  caseous — especially,  too,  as  it  expresses  the 
anatomical  state — seems  more  appropriate. 

The  caseous  substance  which  results  from  degeneration  of  the  products 
of  scrofulous  inflammations  affords  a  nidus  in  which  the  tubercle  bacillus 
frequently  obtains  lodgement  and  conditions  favorable  for  its  propagation. 
Hence  the  close  etiological  relations  of  scrofula  or  scrofulous  inflammations 
to  tuberculosis. 

Prognosis. — As  scrofula  may  be  acquired  through  antihygienic  influ- 
ences, so  it  may  disappear  or  become  latent  through  influences  of  an  opposite 
character.  Therefore  the  manifestations  of  scrofula  may  be  limited  to  a  brief 
period,  or  they  may  occur  at  intervals  through  the  whole  of  childhood  and 
the  first  years  of  youth.  "When  the  diathesis  is  inherited  and  fostered  by 
unfavorable  circumstances,  the  scrofulous  affections  appear  earliest,  are  most 
varied  and  severe,  and  continue  longest. 

In  most  cases,  with  proper  treatment,  the  prognosis  is  good,  but  the  dan- 
ger to  life  depends  on  the  nature  and  extent  of  the  scrofulous  inflammation. 
The  most  common  unfavorable  result  is  the  occurrence  of  pulmonary  or  gen- 
eral tuberculosis,  the  caseous  substance,  as  we  have  said,  affording  a  favorable 
nidus  for  the  development  and  propagation  of  the  tubercle  bacillus.  This  is 
the  usual  result  in  cheesy  pneumonia.  The  next  most  common  cause  of 
death,  either  directly  or  indirectly,  is  inflammation  of  the  osseous  system. 
Many  deaths  occur  from  inflammation  of  the  vertebrae  or  of  the  hip  or  knee- 
joint  when  it  has  been  allowed  to  continue  a  considerable  time  without  proper 
treatment.  Protracted  suppurative  inflammation  of  the  bones  is  liable  to 
produce  amyloid  degeneration  of  organs,  which  is  permanent  and  likely  to 
prove  fatal,  or  death  may  occur  from  exhaustion,  with  or  without  tubercu- 
losis. Among  the  city  poor  meningitis  is  not  very  uncommon,  consequent 
on  long-continued  otitis  media  and  caries  of  the  petrous  portion  of  the  tem- 
poral bone.  Permanent  impairment  of  sight  and  hearing  often  results  from 
neglected  strumous   ophthalmia  and  otitis. 

At  puberty  the  strumous  affections  gradually  become  less  frequent,  and 
they  finally  disappear  in  advancing  age.  Among  the  most  robust  adults  are 
some  who  in  early  life  presented  indubitable  symptoms  of  the  strumous 
diathesis. 

Treatment. — Prophylactic. — Measures  designed  to  prevent  scrofula  are 
impossible  without  the  co-operation  of  willing  and  intelligent  parents.  It  is 
evident  that  the  prevention  of  congenital  scrofula  requires  the  treatment  of 
disease  or  impaired  health  in  the  parent.  If  parents  should  be  taught  or 
should  remember  that  good  health  in  themselves  is  the  necessary  condition  of 
the  inheritance  of  a  sound  constitution  in  the  child,  and  would  adopt  such 
therapeutic  and  regimenal  measures  as  would  procure  this,  the  number  of 
cases  of  inherited  scrofula  would  be  materially  reduced. 

As  the  first  years  of  life  are  very  important,  both  for  correcting  the 
diathesis  when  inherited  and  for  preventing  its  development  in  those  of  sound 
13 


194  CONSTITUTIONAL  DISEASES. 

constitution,  care  should  be  taken  that  the  regimen  of  the  child  be  such  that 
it  does  not  cause  deterioration  of  the  general  health.  The  nursing  infant, 
if  the  mother  be  in  poor  health,  should  be  provided  with  a  healthy  wet-nurse, 
for  in  young  children  the  diathesis  may  be  acquired  solely  by  the  use  of  food 
that  is  scanty  or  of  poor  quality.  Those  old  enough  to  be  weaned  should 
have  plain  and  nutritious  diet,  with  a  proper  admixture  of  animal  food.  More 
or  less  outdoor  exercise  and  residence  in  a  salubrious  locality,  with  sufficient 
air  and  sunlight,  are  also  requisite. 

Curative. — Since  scrofula  originates  in  a  state  of  weakness  existing  in  the 
parent  in  the  congenital,  and  in  the  child  in  the  acquired,  foi'ra  of  the  disease, 
and  is  characterized  by  feeble  resistance  of  the  tissues  to  irritating  agents, 
the  inference  is  reasonable  that  all  tonics  have,  to  a  certain  extent,  an  anti- 
scrofulous  effect  upon  the  system.  The  ordinary  vegetable  tonics,  and  some- 
times the  ferruginous,  are  indeed  useful  in  the  treatment  of  scrofula. 
Employed  in  connection  with  proper  regimenal  measures,  they  are  sufficient, 
in  many  cases,  to  remove  the  diathesis  after  a  time  or  render  it  latent. 
Besides  the  medicinal  agents,  which  tend  to  correct  the  scrofulous  diathesis 
by  their  general  tonic  effect,  there  are  certain  others  which  experience  has 
shown  to  be  beneficial  in  the  treatment  of  scrofulous  affections,  and  which 
are  therefore  largely  used.  One  of  these  is  cod-liver  oil,  which  contains 
iodine  among  its  many  ingredients. 

Cod-liver  oil  is  useless  or  nearly  so  in  the  torpid  form  of  the  diathesis, 
which  is  characterized  by  an  increased  deposit  of  fat  in  the  subcutaneous 
connective  tissue,  slow  circulation,  and  sluggish  muscular  movements.  On 
the  other  hand,  in  the  treatment  of  the  erethitic  form  it  possesses  real  value. 
Its  protracted  use  in  such  cases  does  so  modify  the  molecular  condition  of 
the  tissues  that  they  are  less  liable  to  inflammation,  and  the  diathesis  is  there- 
fore rendered  milder  or  removed.  From  one  to  three  teaspoonfuls,  according 
to  the  age,  should  be  given  three  times  daily.  While  we  frequently  expe- 
rience so  much  difficulty  in  administering  it  to  adults  affected  with  tubercu- 
losis, and  sometimes  find  it  necessary  to  discontinue  its  use  on  account  of  its 
nauseating  effect,  scrofulous  children  rarely  refuse  to  take  it,  and  it  does  not 
seem  to  diminish  their  appetite. 

Iodine  is  justly  celebrated  as  a  remedy  in  the  treatment  of  scrofulous 
maladies,  but  it  is  a  question  whether  it  has  not  been  overrated  as  a  remedy 
for  the  diathesis  itself.  Iodine  employed  internally  is  especially  serviceable 
in  glandular  hyperplasia  and  in  scrofulous  thickening  and  induration  of  the 
connective  tissue  and  periosteum.  In  general,  it  should  not  be  administered 
to  children  in  its  isolated  state,  on  account  of  its  irritating  properties,  but 
one  of  its  compounds  should  be  employed.  The  compounds  which  are  chiefly 
prescribed  in  the  treatment  of  scrofula  are  the  iodides  of  starch,  iron,  potas- 
sium, and  sodium.  If,  as  is  frequently  the  case,  the  patient  be  pallid  and  his 
appetite  poor,  the  iodide  of  iron  should  be  preferred  ;  if  not  in  this  cachectic 
state,  the  iodide  of  starch  may  be  used.  Pharmaceutists  prepare  syrups  of 
both  these  iodides,  so  that  they  can  be  readily  administered  to  the  youngest 
child.  The  iodide  of  starch  may  be  administered  by  dropping  from  one  to 
five  drops  of  the  officinal  tinctui'e  of  iodine  on  a  little  powdered  starch  and 
giving  it  in  syrup.  These  iodides  are  preferable  to  the  iodides  of  potassium 
and  sodium  for  internal  administration  to  children,  since  they  are  not  irritat- 
ing to  the  mucous  membrane  and  the  iodine  is  readily  set  free.  Prof.  Dalton 
has,  indeed,  demonstrated  that  the  iodide  of  starch  is  decomposed  in  most  of 
the  liquids  of  the  body  and  the  iodine  liberated. 

In  New  York  City  a  large  proportion  of  the  scrofulous  children  are  cachec- 
tic and  need  iron,  and  the  iodide  of  iron  is  more  frequently  employed,  and 
with  good  results,  than  any  other  iodine  compound.    The  syrup  of  the  iodide 


SCROFULA.  195 

of  iron,  whicli  is  readily  absorbed,  should  be  given  in  one-  to  two-drop  doses 
three  times  daily  to  a  child  of  six  months,  and  one  additional  drop  be  added 
for  each  additional  year.  Among  the  vaunted  remedies  of  scrofula  are  phos- 
phoric acid  and  the  phosphate  of  lime.  I  have  not  employed  these  agents 
without  at  the  same  time  using  other  remedies,  and  cannot  say,  therefore,  to 
what  extent  they  have  been  curative  in  my  practice.  Probably  there  is  no 
better  combination  of  remedies  for  the  strumous  diathesis  than  the  following, 
which  is  now  used  in  some  of  the  institutions  of  New  York,  and  which  we 
have  already  recommended  in  the  treatment  of  rachitis : 

R.  01.  morrhuse,  2  parts  ; 

Syr.  calcis  lactophosphat. ,  1  part ; 

Aquse  calcis,  1  part. — Misce. 

Dose  :  One  teaspoonful  to  a  dessertspoonful  three  or  four  times  daily. 

The  syrup  of  the  iodide  of  iron  should  be  given  at  the  same  time  in  three 
daily  doses,  but  not  mixed  with  the  above  preparation  of  oil  and  lime,  as  a 
double  decomposition  occurs  from  the  admixture. 

The  internal  use  of  mercury  as  an  antidote  for  scrofula  is  now  generally 
discarded.  Unless,  perhaps,  in  those  cases  in  which  the  diathesis  is  imme- 
diately dependent  on  syphilis,  its  use  for  this  purpase,  from  what  we  know 
of  its  therapeutic  eifects,  would  probably  be  more  injurious  than  beneficial. 
Among  the  medicines  which  have  from  time  to  time  been  employed  for  the 
cure  of  scrofula,  some  of  which  have  had  considerable  reputation,  but  have 
nearly  fallen  into  disuse,  are  walnut-leaves,  sarsaparilla,  elecampane,  conium, 
digitalis,  horseradish,  compounds  of  silver,  gold,  arsenic,  baryta,  and  bromine. 
It  is  probable  that  none  of  these  has  any  effect  on  scrofula  or  scrofulous  ail- 
ments except  such  as  improve  the  appetite  and  general  health,  as  horseradish. 

The  same  hygienic  measures  are  required  in  the  treatment  of  scrofula  as 
are  employed  in  the  prophylaxis  of  it.  The  nursing  infant  should  have 
healthy  breast-milk,  and  if  its  mother  belong  to  a  tubercular  or  scrofulous 
family  or  be  feeble,  a  healthy  wet-nurse  should  be  employed,  or  it  should  be 
sent  to  the  country,  where  suitable  cow's  milk  as  well  as  pure  air  can  be 
obtained.  The  expressed  juice  of  beef  slightly  boiled,  the  peptonized  beef 
or  beef  tea  prepared  as  recommended  for  rachitic  infants,  given  several  times 
daily  in  small  quantity  to  infants,  aid  materially  in  restoring  a  better  nutri- 
tion of  the  tissues.  Obviously,  similar  care  is  necessary  in  the  selection  and 
preparation  of  the  food  of  children  who  have  passed  beyond  the  period  of 
infancy.  While  the  diet  should  be  highly  nutritious,  it  should  be  plain  and 
easily  digested,  and  given  at  sufficient  intervals,  so  as  not  to  overtax  diges- 
tion. The  cow's  milk  employed  should  be  of  the  best  quality,  and  for  young 
children  it  may  be  best  to  peptonize  it. 

Fresh  air,  outdoor  exercise,  daily  bathing,  personal  and  domiciliary  clean- 
liness, are  very  necessary  for  the  successful  treatment  of  the  diathesis.  Since 
scrofula  is  comparatively  infrequent  in  farming  sections,  scrofulous  families 
are  greatly  benefited  by  farm-life,  with  all  the  accessories  to  health  which 
pertain  to  it.  The  use  of  sea-air  and  sea-bathing  has,  according  to  the  testi- 
mony of  several  observers,  been  very  efficacious.  Dr.  F.  P.  Henry  states 
that  no  other  remedial  measure  is  so  efficacious  as  these  (^Annual  of  Univer. 
Med.  Sci.,  1889).  Dr.  Valeourt,  who  is  in  charge  of  the  Maritime  Hospital 
at  Cannes,  where  scrofulous  children  receive  daily  sea-baths  during  a  consider- 
able part  of  the  year,  read  an  interesting  paper  in  commendation  of  its  use 
before  the  Psediatric  Section  of  the  Ninth  International  Medical  Congress  in 
1887.  Alexander  quotes  the  statistics  prepared  by  Cazin,  which  show  that 
the  mortality  of  scrofulous  children  is  much  less  in  the  hospital  at  Barek, 


196  CONSTITUTIONAL  DISEASES. 

where  sea-bathing  is  employed,  than  in  two  Parisian  hospitals  (JLiverjp.  Medico- 
Chir.  Journ.,  1888). 

The  local  scrofulous  ailments  require  additional  and  special  treatment. 
Those  located  on  the  cutaneous  and  mucous  surfaces  are  less  dangerous,  as 
a  rule,  than  the  deeper-seated  inflammations ;  still,  they  should  be  promptly 
treated,  not  only  for  the  inconvenience  and  annoyance  which  they  cause,  but 
because  they  may  give  rise  to  hyperplasia  of  the  neighboring  glands,  as  we 
have  stated  elsewhere.  Thus,  pharyngitis  may  cause  a  peripharyngeal  ade- 
nitis and  abscess,  and  a  bronchitis  may  cause  adenitis  of  the  bronchial  glands, 
with  the  probability  of  their  cheesy  degeneration.  The  so-called  bronchial 
phthisis  is  believed  to  result,  in  a  large  proportion  of  cases,  from  a  strumous 
bronchitis  which  has  been  allowed  to  continue  uncontrolled  by  medicine,  and 
a  similar  state  of  the  mesenteric  glands  may  result  from  intestinal  catarrh. 
Inflammation  of  the  skin  or  mucous  surface  occurring  in  the  strumous  requires 
the  continued  use  of  antistrumous  remedies,  conjoined  with  such  treatment, 
designed  to  act  locally,  as  is  appropriate  for  the  case. 

It  is  the  common  practice  to  treat  the  enlarged  glands  of  struma  by  daily 
applications  over  them  of  the  stronger  iodine  preparations.  This  treatment 
does  not  cause  absorption  of  the  redundant  gland-substance.  It  causes  pro- 
liferation of  the  epidermic  cells,  and  quickens  the  cell-change  in  the  adjacent 
gland  and  accelerates  suppurative  inflammation.  I  once  produced  accident- 
ally such  an  amount  of  vesication  over  an  enlarged,  hard,  and  apparently 
indolent  gland  in  an  infant  of  fourteen  months  that  I  was  very  anxious  lest 
a  sore  should  result  which  would  heal  with  diiEculty,  and  yet,  instead  of  dis- 
persion of  the  glandular  swelling,  the  pathological  processes  were  so  promoted 
that  suppuration  and  discharge  of  pus  occurred  by  the  time  that  the  cuticle 
had  re-formed. 

When  scrofulous  glands  have  undergone  degeneration  they  should  be 
removed  with  the  knife.  It  is  necessary  to  completely  extirpate  the  gland 
by  a  dissection  which  includes  the  entire  gland-structure.  Merely  opening 
the  gland,  removing  its  contents,  and  curetting  its  cavity,  as  are  sometimes 
practised,  is  not  sufficient.  It  is  well  also  to  cut  away  all  cicatricial  tissues 
in  order  to  secure  union  with  as  little  deformity  as  possible. 

We  know  no  better  substance  for  the  local  treatment  of  strumous  adenitis 
than  iodine,  and  it  should  be  applied,  in  my  opinion,  in  such  a  manner  that  it 
is  absorbed  with  the  least  possible  irritation  of  the  gland.  The  following  will 
be  found  useful  ointments  and  solutions  for  the  treatment  of  these  cases : 

R.  Potas.  iodidi,  .^j  ; 

Ung.  stramonii,  ^j. 

To  be  rubbed  over  the  gland  several  times  daily.  It  should  not  be  applied 
as  a  plaster,  since  it  is  too  irritating  and  will  vesicate.  I  have  known  a 
glandular  swelling  which  had  continued  about  three  months  to  disappear  in 
three  weeks  under  its  use  in  connection  with  internal  remedies.  Lanolin  may 
be  employed  in  place  of  the  stramonium  ointment,  inasmuch  as  it  is  believed 
to  be  more  readily  absorbed  than  most  oleaginous  substances.  Another  useful 
iodine  mixture  for  these  cases  is  the  following : 

R.  Liq.  iodinii  composita, 

Glycerini,  equal  parts. 

To  be  applied  as  an  inunction.  Glycerin  renders  the  skin  soft  and  in  a  state 
favorable  for  absorption. 

In  The  Iledical  Press  and  Circular  for  August  3, 1870,  J.  Waring  Curran 
states  that  he  has  used  with  great  success  what  he  designates  a  new  iodine 
paint,  consisting  of  half  an  ounce  of  iodine,  the  same  quantity  of  iodide  of 
ammonium,  twenty  ounces  of  rectified  spirits,  and  four  ounces  of  glycerin. 


SCROFULA. 


197 


Mercurial  ointments  have  been  recommended  by  writers  of  reputation  for 
the  treatment  of  these  glands.  I  have  employed  them  and  know  them  to  be 
employed,  but  cannot  say  that  I  have  ever  observed  any  benefit  whatever 
from  their  use.  In  the  children's  class  at  the  Out-door  Department  at  Belle- 
vue  we  have  discarded  them  entirely  for  this  purpose,  although  both  the 
citrine  and  white  precipitate  ointments,  diluted  with  an  equal  quantity  of 
lard,  have  been  used  with  apparent  benefit  for  chronic  coryza  of  a  strumous 
nature,  and  also  occasionally  for  external  otitis  of  the  same  natui'e. 

The  application  of  cold  over  an  inflamed  lymphatic  gland  and  the  adjacent 
inflamed  connective  tissue  is  a  useful  adjuvant  to  the  treatment  in  many  cases 
at  an  early  stage.  A  small  India-rubber  bag  containing  ice,  or  muslin  fre- 
quently wrung  out  of  ice-water  and  applied  over  the  inflamed  parts,  contracts 
the  vessels,  diminishes  the  activity  of  the  morbid  process  going  on  underneath, 
and  aids  materially  in  the  resolution.  When  the  gland  becomes  so  actively 
inflamed  or  the  inflammation  so  advanced  that  redness  of  the  skin  occurs, 
applications  of  iodine  are  no  longer  proper.  They  increase  the  local  disease. 
There  is  no  longer  any  probability  of  resolution  of  the  gland,  and  poultices 
should  be  applied. 

It  is  important  that  the  diseases  of  the  osseous  system  should  receive  early 
treatment,  but,  unfortunately,  it  is  in  reference  to  these  inflammations  that 
error  of  diagnosis  is  frequently  made.  Thus  I  have  known  periostitis,  with 
the  diff"used  redness  of  the  skin  and  heat  which  it  produces,  to  be  mistaken 
for  erysipelas,  until  the  diagnosis  was  corrected  from  its  persistence  and  non- 
extension.  It  is  remarkable  that  strumous  arthritis  sometimes  appears  in 
two  or  more  joints  at  once,  as  in  the  case  related  below.  I  have  known  it  to 
occur  nearly  simultaneously  in  three  joints,  though  only  for  a  brief  time  in 
two  of  the  joints,  while  it  was  chronic  in  the  other.  Hence,  the  fact  that 
this  inflammation  is  often  mistaken  for  inflammatory 
rheumatism,  and  treated  as  such  for  some  days  till  its 
nature  becomes  apparent,  and  in  like  manner  the  febrile, 
movement,  lassitude,  abdominal  pain,  etc.  of  vertebral 
caries  are  in  a  large  propoi'tion  of  cases  attributed  to 
something  else,  and  the  true  disease  not  suspected  till 
irreparable  damage  has  occurred,  or  much  longer  con- 
finement and  treatment  required  than  would  have  been 
necessary  with  an  earlier  diagnosis. 

The  common  strumous  inflammations  of  the  osseous 
system  which  involve  the  joints,  as  Pott's  disease,  hip 
disease,  and  white  swelling,  are  usually  quite  amenable 
to  treatment,  early  applied,  which  ensures  complete 
rest ;  but,  as  a  rule,  cases  neglected  or  wrongly  treated 
go  from  bad  to  worse.  There  are  exceptions,  for  a  case 
may  do  well  or  terminate  with  moderate  deformity 
without  treatment,  as  in  the  following  interesting  in- 
stance, which  also  shows  the  difficulty  which  often 
attends  diagnosis : 

Anna  D ,  aged  six  years,  came  to  the  children's 

class  in  the  Out-door  Department  at  Bellevue  in  February, 
1877,  with  the  following  history  :  Her  health  was  good  till 
two  years  ago,  when  she  complained  of  pain  of  a  mild  form 
in  both  knees.  Her  parents  attributed  it  to  her  rapid 
growth,  and  she  was  always  able  to  walk  with  little  suffer- 
ing. Slowly  but  steadily  these  joints  began  to  swell.  She 
has  had  no  pain  in  other  joints,  and  no  member  of  the  family  has  had  rheumatism 
except  a  grandparent.     She  walks  without  complaint  to  the  rooms  of  the  Bureau. 


Fig.  37. 


198  CONSTITUTIONAL  DISEASES. 

The  affected  joints  are  about  equally  swollen,  and  it  is  evident  on  examination  that 
they  contain  some  serous  effusion.  Direct  pressure  is  not  painful,  but  pressing  the 
bones  together  with  a  twisting  or  rotating  movement  gives  some  pain.  She  is  pale 
and  has  a  strumous  aspect.  A  sister  of  fifteen  years  has  a  similar  swelling  of  one 
knee  which  began  at  the  age  of  seven  or  eight  years,  but  which  has  received  no 
regular  treatment,  has  not  prevented  the  free  use  of  the  limb,  and  has  given  her 
little  inconvenience. 

The  physicians  who  have  examined  this  child,  one  of  whom  is  an  expert  in 
orthopaedic  surgery,  agree  that  the  disease  is  strumous  and  not  rheumatic,  and  that 
it  did  not,  during  two  years  of  neglect  and  unrestrained  motion,  go  on  to  suppura- 
tion and  destruction  of  the  joints  was  probably  due  to  her  good  general  health. 

Thougli  the  result  in  the  above  case  was  good,  since  there  was  little 
impairment  in  the  use  of  the  joints  and  no  suffering,  yet  delay  and  neglect 
in  the  treatment  of  those  strumous  inflammations  which  involve  the  joints 
are  exceedingly  dangerous,  for  if  left  to  themselves  they  most  frequently 
end  in  suppurative  inflammation  and  ulceration,  with  all  the  sad  conse- 
quences which  these  entail.  Strumous  inflammations  of  the  osseous  system 
now  receive  more  early  and  correct  treatment  than  formerly,  and  orthopaedia, 
almost  unknown  till  within  the  last  twenty  years,  has  become  an  important 
branch  of  surgery.  Formerly  in  New  York,  especially  in  the  tenement- 
houses,  we  often  met  emaciated  bed-ridden  children  with  strumous  osteitis 
and  arthritis,  their  limbs  swollen  and  painful  in  motion,  and  offensive  from 
the  discharge,  for  the  most  part  shunned  by  physicians,  and  with  no  prospect 
of  relief  except  by  amputation.  Now  this  spectacle  is  comparatively  infre- 
quent. The  early  symptoms  of  these  diseases  being  better  understood  and 
sooner  recognized,  the  plaster-of-Paris  or  starch  dressing  to  ensure  immo- 
bility, or  ingeniously  devised  steel  splints  which  produce  extension  and  allow 
motion  of  the  limb  without  friction  of  the  inflamed  surfaces,  coming  into 
general  use,  a  large  proportion  of  cases  do  not  go  beyond  the  first  stage  and 
are  cured. 

Strumous  Ophthalmia. 

[Written  by  Dr.  0.  D.  Pomeroy,  Surgeon  to  the  Manhattan  Eye  and  Ear  Hospital.] 

Strumous  ophthalmia  in  young  children,  as  described  by  the  older  writers, 
is  simply  a  keratitis  or  inflammation  of  the  cornea,  and  is  usually  of  the  fol- 
lowing varieties:  phlyctenular  or  herpetic  keratitis  and  diffuse  or  paren- 
chymatous keratitis.  Perhaps  it  is  a  misnomer  to  designate  these  affections 
strumous.  This  general  principle  governs  most  cases  of  these  inflamma- 
tions— to  wit,  depressed  vital  energy,  which  is  a  prominent  characteristic  of 
the  strumous  diathesis.  As  is  well  known,  the  cornea  is  a  tissue  of  low 
vitality,  and  any  constitutional  state  accompanied  by  depression  predisposes 
to  an  attack  of  keratitis.  One  of  the  commonest  hospital  experiences  is  to 
see  a  mild  case  of  catarrhal  conjunctivitis  which  should  be  self-limiting 
gradually  extend  to  the  cornea,  causing  an  ulcerative  keratitis.  I  believe  all 
ophthalmic  surgeons  hold  that  the  presence  of  corneal  disease,  not  dependent 
on  an  obvious  or  specific  cause,  points  to  .diminished  vitality  on  the  part  of  the 
patient. 

Herpetic  or  Phlyctenular  Keratitis  is  the  most  frequent  variety  of 
corneal  disease  in  children.  It  is  a  question  whether  it  commences  with  a 
vesicle  on  the  cornea  or  a  papula ;  but  in  either  case  it  soon  becomes  an 
ulcer.  Ciliary  injection  probably  precedes  it,  although  this  can  by  no  means 
be  always  observed.  In  some  patients  the  characteristic  symptom — to  wit, 
photophobia — may  exist  for  a  long  time  without  injection  of  the  eyeball  or 
any  corneal  changes  whatever,  but  sooner  or  later  it  is  probable  that  other 
characteristic  signs  of  the  disease  will  make  their  appearance.     The  photo- 


SCROFULA.  199 

phobia  is  frequently  accompanied  by  blepharospasm,  making  it  wellnigli 
impossible  to  separate  the  eyelids.  When,  however,  this  is  accomplished, 
abundant  tears  gush  forth,  the  child  exhibiting  signs  of  extreme  distress. 
When  the  vesicle  or  papula  is  in  a  state  of  ulceration  in  the  earlier  stage, 
there  may  only  be  seen  a  minute  loss  of  corneal  tissue,  without  any  opacity 
whatever.  Soon,  however,  the  ulcer  becomes  more  or  less  opaque,  perhaps 
seeming  to  be  only  a  minute  whitish  spot  on  the  cornea.  This  usually  shows 
the  commencement  of  reparative  action.  If  the  disease  continue  long,  a 
general  conjunctivitis  sets  in,  more  especially  of  the  ocular  conjunctiva. 
Frequently  there  will  be  only  one  or  not  more  than  two  or  three  ulcers,  but 
in  exceptional  cases  the  cornea  may  have  the  periphery  studded  with  phlyc- 
tenulae,  which,  instead  of  promptly  healing,  proliferate  so  as  to  form  elevated 
nodules,  the  so-called  "  scrofulous  nodular  bands."  If  the  ulcers  in  any  case 
continue  long,  a  number  of  blood-vessels  shoot  out  from  the  conjunctival 
border  of  the  cornea,  quite  up  to  the  ulcer,  producing  what  may  be  termed 
a  vascular  keratitis.  The  discharge  from  the  eye  is  often  very  acrid,  causing 
catarrh  of  the  lachrymal  canals,  and  even  of  the  nares.  Herpetic  or  ec- 
zematous  eruptions  on  the  cheeks  or  the  lip  near  the  nostrils  are  often  seen,  and 
may  sometimes  appear  to  be  the  cause  of  the  disease  rather  than  the  effect. 
In  this  condition  the  upper  lip  may  swell  considerably,  giving  the  patient  a 
very  "  strumous  "  appearance. 

The  DURATION  of  phlyctenular  keratitis  is  exceedingly  variable  ;  two  or 
three  weeks  may  bring  it  to  a  close  or  it  may  continue  many  months.  The 
patient's  general  condition  probably  determines  its  duration  as  much  as  any 
other  factor.  If  an  ulcer  perforate  the  cornea,  staphyloma  and  anterior 
synechia  may  result,  rendering  recovery  more  tedious  and  incomplete.  The 
DIAGNOSIS  of  this  malady  is  not  difficult.  The  photophobia  so  characteristic 
of  keratitis  is  present  in  no  other  disease  except  iritis,  and  this  disease  chil- 
dren rarely  have ;  the  little  speck,  spot,  or  abrasion  on  the  cornea,  together 
with  the  intolerance  of  light,  is  wellnigh  diagnostic.  Photophobia  is  present 
in  most  forms  of  corneal  disease,  though  not  in  all.  The  causes  of  phlyc- 
tenular keratitis  are  as  follows :  Any  condition  of  the  system  known  as 
strumous,  or  whatever  tends  to  lower  the  vital  powers  of  the  patient,  affords 
a  predisposing  cause.  Exposure  to  cold  or  sudden  change  of  temperature  is 
the  common  exciting  cause,  leaving  out  of  the  question  any  cutaneous  dis- 
eases. Naturally,  any  cause  which  produces  a  conjunctivitis  may  also  pro- 
duce this  disease  secondarily.  The  process  of  dentition  may  have  something 
to  do  with  the  eye  disturbance,  or  any  disorder  of  the  intestinal  canal ;  the 
latter,  however,  being  rather  predisposing  than  exciting  causes.  This  dis- 
ease also  frequently  occurs  in  patients  affected  with  aural  or  nasal  catarrh, 
but  the  condition  of  such  children  approximates  closely  the  state  designated 
"  strumous." 

The  prognosis  in  a  large  number  of  cases  is  very  favorable.  The 
opacities  of  the  cornea  left  after  the  healing  of  the  ulcerations  are  the 
principal  difficulties  in  the  way  of  a  good  recovery.  If  the  opacities  are 
in  the  proper  substance  of  the  cornea,  we  are  not  certain  that  they  will  dis- 
appear by  absorption,  though  they  may.  Nothing  is  more  difficult  than  to 
determine  this  point.  In  the  epithelial  and  Bowman's  layers,  as  well  as  the 
posterior  layer,  opacities  readily  disappear.  When  the  ulcer  perforates  the 
cornea  we  have  an  anterior  synechia  and  the  appearance  known  as  myo- 
cejjhalon,  which  usually  disfigures  the  eye  more  or  less  for  life. 

One  discouraging  point  about  these  opacities  is  that,  although  they  dis- 
appear, the  cornea  is  left  with  a  somewhat  distorted  curvature,  causing  irreg- 
ular astigmatism,  and  if  they  chance  to  be  near  the  centre  of  the  cornea 
great    disturbance    to   vision   results.     I   have    often,    in   fitting    spectacles, 


200  CONSTITUTIONAL  DISEASES. 

noticed  that  the  patient's  vision  was  less  than  normal,  and  on  investigation 
have  found  a  history  of  an  infantile  keratitis  which  had  done  all  the  mis- 
chief. In  those  cases  described  as  having  "  scrofulous  nodular  bands  "  the 
proliferative  nodules  ai"e  very  likely  to  undergo  a  variety  of  degenerations 
which  do  not  end  in  a  properly  restored  cornea.  One  great  difficulty  in  mak- 
ing an  exact  statement  here  is  the  tendency  of  the  keratitis  to  recur,  and  it 
cannot  be  determined  where  the  process  will  cease  after  a  number  of 
recurrences. 

Treatment. — As  the  fifth  nerve  presides  over  the  ciliary  vaso-motory 
system  of  the  corneal  nutritive  supply,  it  is  obvious  that  treatment  calcu- 
lated to  correct  any  of  its  morbid  manifestations  would  be  rational.  Such  is 
found  to  be  the  fact.  Sulphate  of  atropia,  in  solution  of  one  to  two  grains  to 
the  ounce,  dropped  into  the  eye  three  times  daily,  is  probably  superior  to  any 
other  treatment.  It  inclines  to  break  up  the  orbicular  spasms,  relieving  the 
photophobia  and  ciliary  neuralgia,  diminishes  vascularity,  and  contributes 
more  to  the  relief  of  the  patient  than  any  other  one  remedy.  If  the  pain 
be  severe,  the  atropine  may  be  used  six  or  eight  times  daily,  or  it  may  be 
even  instilled  every  fifteen  or  twenty  minutes  until  pain  is  relieved.  If  an 
over-eff'ect  be  reached,  the  patient  complains  of  dryness  in  the  throat,  possi- 
bly pain  in  the  head,  or  he  may  have  other  cerebral  disturbances,  when  the 
drops  may  be  discontinued  for  a  time.  Muriate  of  pilocarpine  in  two-grain 
solutions  may  be  used  in  a  similar  manner  and  for  the  same  purpose ;  but  it 
contracts  the  pupil  and  renders  the  accommodation  tense,  the  very  opposite 
to  the  atropine  eff"ect.  I  have  not  as  much  confidence  in  this  remedy.  A  2 
per  cent,  solution  of  cocaine,  instilled,  will  sometimes  relieve  the  spasm  and 
pain  temporarily.  Powdered  calomel  may  be  dusted  into  the  eye  every 
second  day.  A  small  quantity  only  should  be  used,  since  it  is  apt  to  col- 
lect in  masses  which  act  as  foreign  bodies  (we  desire  to  produce  irritation  for 
a  few  minutes  only).  A  drachm  of  table-salt  to  a  pint  of  water  may  be  used 
to  bathe  the  eyes  freely  four  or  five  times  a  day,  used  warm  or  cold  accord- 
ing to  the  patient's  pleasure,  although  warm  applications  are  more  likely  to 
be  well  received.  Red  precipitate  ointment  (R.  Vaseline,  5j  ;  hyd.  ox.  rub. 
in  very  fine  powder,  gr.  j  to  ij. — Misce.)  placed  under  the  eyelids  every  day 
or  two,  is  often  very  beneficial ;  also  the  yellow  precipitate  ointment,  made  in 
the  same  manner,  has  a  similar  effect.  Occasionally  the  ulcers  show  a  disin- 
clination to  heal,  when  they  may  be  touched  with  Arg.  nit.  gr.  x  to  xxx ; 
aqua3  dest.,  §j. — Misce.  Wind  a  bit  of  absorbent  cotton  on  a  probe,  dip  this 
into  the  solution,  and  touch  the  ulcer,  but  no  other  point.  Cupri  sulph.,  in 
solution  of  the  same  strength,  may  be  used  for  the  same  purpose.  A  platinum 
probe,  heated  to  a  red  heat  in  a  spirit  lamp,  is  much  used  at  present.  A  few 
di'ops  of  a  2  per  cent,  solution  of  cocaine,  previously  instilled,  will  prevent 
pain  from  these  applications.  A  protective  bandage  exerting  moderate  pres- 
sure on  the  eye  sometimes  does  good,  but  it  should  not  cause  discomfort. 
If  there  be  much  spasm  of  the  orbicularis,  however,  it  is  not  indicated.  If 
the  pain  in  the  eye  continue  and  the  orbicularis  be  in  a  state  of  spasm,  can- 
tholysis  may  be  performed  ;  that  is,  divide  the  external  canthus  so  as  to  cause 
the  lid  no  longer  to  press  hard  upon  the  eyeball,  and  close  the  wound  thus 
made  by  stitching  the  skin  to  the  conjunctiva  above  and  below  the  incision, 
placing  one  stitch  in  the  extreme  outer  canthus.  The  result  of  the  ope- 
ration is  temporarily  to  break  the  power  of  the  orbicularis,  so  as  to  arrest 
the  spasm.     This  measure  accomplishes  in  some  cases  what  nothing  else  will. 

If  the  eye  be  painful,  without  spasm  of  the  lid,  and  there  be  great  pho- 
tophobia, whether  the  eyeball  be  too  hard  or  not,  paracentesis  may  be  done. 
The  mode  of  performance  is  described  in  the  treatment  of  ophthalmia  neonati 
in  another  place  in  this  book.     After  a  while  the  accompanying  conjunctivitis 


SCROFULA.  201 

may  need  treatment  in  the  ordinary  way.  Indeed,  astringents  may  often  be 
used  quite  early  to  obviate  the  irritating  eifects  which  occasionally  result 
from  the  use  of  atropine.  If  an  ulcer  refuse  to  heal  after  the  treatment 
already  laid  down,  iridectomy  may  be  performed,  although  this  is  not  often 
resorted  to.  Occasionally  an  ulcer  may  be  cut  across  by  passing  a  narrow 
Graefe's  knife  through  it,  making  a  puncture  on  one  side  and  a  counter-punc- 
ture on  the  opposite  side,  and  then  cutting  out  quite  through  the  ulcer,  divid- 
ing it  into  two  equal  parts.  All  needful  treatment  for  the  constitutional 
condition  of  the  patient  should  be  attended  to.  So  necessary  are  fresh  air 
and  sunlight  that  I  would  never  shut  the  patient  in  a  dark  room.  Blue  or 
smoke-colored  glasses  may  be  worn  to  protect  the  eyes  from  a  strong  light, 
and  in  some  cases  the  eyes  may  be  protected  by  a  bandage  of  some  dark 
material,  so  that  the  patient  may  be  taken  for  an  airing  without  suffering.  I 
would,  however,  advise  that  the  eyes  be  accustomed  to  the  light  as  much  as 
is  possible  without  causing  pain. 

In  Parenchymatous  or  Diffuse  Keratitis  we  have  quite  a  different  array 
of  symptoms.  The  margin  of  the  cornea  near  the  limbus  may  show  a  decided 
zone  of  injection  of  the  conjunctival  and  episcleral  vessels.  It  may  be  so 
excessive  as  to  consist  apparently  of  a  rosy  ring  surrounding  the  cornea. 
These  vessels  after  a  time  shoot  inward,  and  may  involve  a  large  part  or  even 
the  whole  of  the  cornea.  In  other  cases,  designated  non-vascular  diffuse 
keratitis^  the  injection  is  very  slight  indeed,  and  sometimes  apparently  want- 
ing altogether.  In  either  case,  however,  the  same  consequences  result :  the 
cornea  becomes  diffusely  clouded,  the  process  generally,  but  not  always,  com- 
mencing at  the  limbus.  This  cloudiness  may  be  quite  without  lines  or  dots 
of  opacity,  like  ground  glass.  Again  it  may  appear  composed  of  innumer- 
able minute  opaque  points  or  lines  running  in  various  directions.  At  first, 
the  corneal  epithelium  escapes,  presenting  a  regular  and  uniform  polish,  but 
afterward  it  becomes  opaque.  Again,  if  the  process  involve  the  whole  of  the 
cornea,  minute  opaque  spots  may  be  seen  in  Descemet's  membrane,  giving  it 
some  of  the  characteristics  of  keratitis  punctata.  In  the  earlier  stages  there 
may  be  some  pain  and  intolerance  of  light,  but  as  a  rule  the  disease,  for  a 
corneal  affection,  is  comparatively  painless.  The  duration  of  this  disease  is 
never  short ;  it  may  continue  for  many  months,  and  it  shows  a  strong  tend- 
ency to  relapse.  The  most  frequent  causes  are  hereditary  syphilis  and 
struma.  Mr.  Hutchinson  of  London  always  examines  the  teeth  of  these 
patients  to  see  if  there  be  anything  characteristic  of  hereditary  syphilis. 
As  similar  teeth  are  often  noticed  in  strongly-marked  sti'umous  subjects,  it 
becomes  doubly  interesting  to  make  the  observation.  One  point  is  apparent 
in  most  of  these  cases :  that  there  are  in  almost  every  patient  some  signs  of 
badly-developed  physiqvte — that  is  faulty  tissue-ielaboration.  As  a  rule,  both 
eyes  sooner  or  later  become  affected,  pointing  to  a  constitutional  origin  of  the 
affection. 

In  TREATMENT  WO  are  often  disappointed  in  our  efforts.  At  the  first,  if 
there  be  pain  or  photophobia,  atropine  may  be  instilled  and  the  eyes  bathed 
with  warm  or  tepid  water  several  times  a  day.  Tonics  or  alteratives  are 
always  indicated.     One  of  the  most  useful  prescriptions  is  the  following ; 

B .  Hydrarg.  chlor.  corros.,         gr.  j.  ad  jss  ; 
Tine,  cinchon.  comp., 

Syr.  aurantii,  da.  ^iv. — Misce. 

Dose  :  One  teaspoonful  three  times  daily  after  eating. 

Iodide  of  potassium  is  frequently  given,  and  may  very  properly  alternate 
with  the  mercurial  treatment ;  children  will  bear  very  large  doses  of  the  iodide, 
and  indeed  they  are  often  necessary  in  order  to  obtain  the  curative  effects  of 


202  CONSTITUTIONAL  DISEASES. 

the  drug  ;  I  would  suggest  from  three  to  twenty  grains  three  times  daily,  well 
diluted  with  water.  Both  these  remedies  may  be  continued  for  months,  but 
ptyalism  should  always  be  avoided.  Cod-liver  oil  with  extract  of  malt  may 
be  administered.  Whatever  tends  to  improve  the  patient's  general  condition 
is  indicated.  Exercise  in  the  fresh  air  is  good,  but  the  pernicious  effects  of 
cold  must  be  avoided.  Paracentesis  of  the  cornea  rarely  does  good,  but  occa- 
sionally iridectomy  may  be  of  benefit.  The  complication  of  iritis  or  irido- 
choroiditis  is  not  common,  though  it  does  occur.  When  the  disease  becomes 
very  chronic  there  will  be  hardly  vascularity  enough  for  the  purposes  of 
repair.  This  being  the  case,  stimulating  collyria  may  be  used,  similar  to 
those  indicated  in  conjunctivitis.  Olive  oil  and  spirits  of  turpentine,  in  equal 
parts,  may  be  applied  to  the  eye  every  second  day.  Bathing  with  warm 
water  sufficiently  to  congest  the  eye  will  sometimes  be  serviceable.  An  attack 
of  acute  conjunctivitis  has  been  known  to  do  good.  But,  do  what  we  may, 
this  affection  sometimes  runs  on  unchecked  for  a  very  long  time.  It  rarely 
destroys  the  sight,  but  I  recently  treated  a  case  from  the  beginning,  and  in 
spite  of  treatment  there  was  only  perception  of  light  remaining.  I  have 
heard  of  only  one  other  similar  case.  From  some  recent  experiences  I  am 
inclined  to  believe  that  bichloride  of  mercury  internally  and  atropine  as  a 
collyrium  are  of  as  much  value  as  any  other  agents  in  the  treatment  of 
this  obstinate  malady. 


CHAPTER    III. 

TUBERCULOSIS. 

The  term  "  tuberculosis  "  is  applied  to  a  disease  which  is  characterized 
by  the  formation  of  small  tubercles  or  nodules  in  one  or  more  organs. 
Though  more  prevalent  in  some  countries  or  localities  than  in  others,  it 
occurs  in  all  or  nearly  all  parts  of  the  globe  from  which  we  have  exact 
information,  and  it  has  been  more  destructive  to  human  life  than  any  other 
one  disease. 

Etiology. — One  of  the  most  important  discoveries  of  recent  years  relat- 
ing to  the  etiology  of  diseases  is  that  of  the  specific  principle  of  tuberculosis. 
It  has  long  been  suspected  by  observing  physicians  that  a  specific  cause  did 
exist,  and  that  this  disease  is  to  a  certain  extent  infectious,  but  it  is  only 
recently  that  patient  microscopic  investigations  have  triumphed  over  the 
difficulties  which  surround  this  subject,  and  have  detected  the  micro-organ- 
ism which  has  been  so  fatal  to  the  human  race.  The  honor  of  its  discovery 
belongs  mainly  to  Dr.  Koch  of  Berlin.  In  his  investigations  Koch  invariably 
found  a  certain  bacillus  in  all  recent  tubercles,  proving  beyond  a  doubt  that 
they  always  accompany  the  development  of  the  tubercular  nodule.  By 
inoculating  guinea-pigs,  rabbits,  and  cats  with  tubercular  material  he  com- 
municated tuberculosis,  reproducing  the  tubercular  nodule,  in  which  he 
always  found  the  same  bacillus.  But  it  still  remained  to  determine  the  rela- 
tion of  the  bacillus  to  the  tubercle,  whether  it  was  merely  an  accidental 
accompaniment,  or  whether  it  sustained  a  causal  relation,  producing  the 
nodule  by  its  irritating  action  on  the  cellular  elements  of  the  part  where  it 
happened  to  lodge.  After  many  trials  Koch  succeeded  in  preparing  a  pabu- 
lum in  which  the  bacilli  grew  and  reproduced  their  kind.  By  adding  a  little 
of  the  first  cultivation  to  the  pabulum,  he  produced  a  second  cultivation,  and 


TUBERCULOSIS.  203 

after  a  series  of  cultivations  Le  produced  a  bacillus  whicli  was  evidently  freed 
from  all  other  substances.  With  the  bacillus  of  the  last  cultivation  he  was 
able  to  produce  the  tubercular  nodule,  having  all  the  characteristics  which 
are  observed  when  it  is  developed  in  the  usual  way  in  man.  Different  micro- 
organisms take  coloration  differently,  and  Koch  was  enabled  to  discriminate 
the  tubercular  bacillus  under  all  circumstances  from  other  microbes  by  the 
peculiar  color  imparted  to  it. 

The  tubercle  bacilli  have  the  form  of  "  delicate  rods  from  a  quarter  to 
half  the  diameter  of  a  blood-corpuscle  in  length."  The  more  severe  the 
tuberculosis,  the  greater  the  number  of  bacilli.  They  occur  not  only  in  the 
recent  tubercle,  but  also  in  immense  numbers  in  the  periphery  of  the  caseous 
masses  of  a  tubercular  patient.  They  are  found  not  only  elsewhere,  but  also 
in  the  interior  of  the  giant-cells,  as  many  as  twenty  even  in  some  cells.  They 
do  not  seem  to  have  the  power  of  movement,  and  oval  spores  are  found  in 
some  of  them.  They  grow  in  a  temperature  of  86°  to  104°  F.,  and  not  in  a 
temperature  outside  these  limits. 

As  might  be  expected,  these  microscopical'  researches  of  Koch  have 
attracted  wide  attention,  and  have  led  to  a  repetition  of  his  experiments  by 
many  pathologists,  and  to  new  experiments  relating  to  the  etiology  of  tuber- 
culosis. The  result  has  been  to  establish  more  firmly  the  views  of  Koch,  and 
the  doctrine  that  tuberculosis  is  a  specific  disease,  and  that  the  bacillus  is  the 
specific  principle. 

Among  the  most  thorough  and  convincing  researches  bearing  on  the  causal 
relation  of  micro-organisms  to  tuberculosis,  growing  out  of  Koch's  discovery, 
were  those  contained  in  a  report  to  the  London  Association  for  the  Advance- 
ment of  Medicine  by  Research  (^Practitioner ;  London  Lancet,  March  17, 1883). 
Experiments  were  made  with  the  cultivated  bacilli  obtained  from  Koch. 
"  Twelve  animals  were  inoculated  with  these  organisms,  chiefly  into  the 
anterior  chamber  of  the  eye,  and  all  of  them  became  tuberculous.  The 
tubercles  produced  in  these  cases  were  infective  and  caused  tuberculosis  in 
animals.     On   examination  of  tuberculous  material   Koch's   tubercle  bacilli 

are  always  found,  though  in  varying  numbers About  eighty  organs 

of  tuberculous  animals  and  thirty-six  cases  of  human  tuberculosis  were 
examined,  and  in  all  of  these,  without  exception,  tubercle  bacilli  were 
found." 

The  discovery  of  Koch  has  already  proved  of  great  importance  as  an  aid 
in  diagnosis,  for  the  sputum  of  tubercular  patients  contains  the  bacillus. 
Tubercular  sputum  affords  a  soil  in  which  the  bacillus  thrives  and  multiplies, 
as  it  does  in  the  tissues  of  a  tubercular  patient,  and  by  careful  microscopic 
examination  we  are  able  to  discover  it  in  this  sputum,  while  it  is  absent  from 
non-tubercular  sputum.  According  to  Frisch  (  Wiener  mecl.  Woch.,  No.  46, 
1883),  the  bacilli  were  found  without  an  exception  in  the  sputum  of  140 
patients  with  confirmed  tuberculosis,  while  the  sputum  of  150  non-tubercular 
patients  was  in  every  instance  free  from  them.  Heitler  (  Wiener  mecl.  Woch., 
No.  43,  1883)  examined  the  sputum  of  140  tubercular  patients,  1  of  whom 
had  miliary  tubercles,  and  1  other  caseous  pneumonia.  All  the  other  cases 
were  chronic  and  were  grouped  by  the  author  as  follows:  1st,  6  cases  of  old 
infiltration  of  the  apices  ,of  the  lungs,  cured,  with  the  persistence  of  dulness 
on  percussion,  without  rales  ;  no  bacilli  observed.  2d,  12  cases  of  tuberculo- 
sis with  slight  dulness  and  dry  rales.  In  2  of  these,  notwithstanding  marked 
physical  signs,  fever  was  absent  and  the  tubercular  process  was  arrested 
apparently  ;  no  bacilli.  In  the  sputum  of  the  remaining  10  cases  bacilli  were 
present  in  all  the  examinations  except  2.  The  third  group  contained  cases 
of  advanced  and  progressive  tuberculosis,  and  the  fourth  group  cases  of 
advanced  chronic  phthisis,  but  with  remissions.     In  the  sputum  of  these  two 


204  CONSTITUTIONAL  DISEASES. 

groups  bacilli  were  always  observed.  That  Heitler  in  6  instances  witnessed 
the  disappearance  of  bacilli  when  the  tubercular  process  was  arrested  is  an 
interesting  fact,  as  showing  the  relation  of  the  bacilli  to  tuberculosis.  He 
examined  the  sputum  of  29  non-tubercular  patients,  patients  with  pneumonia, 
bronchitis,  bronchial  dilatation,  and  putrid  bronchitis  with  gangrene,  and  in 
no  instance  found  the  bacilli  of  tuberculosis. 

As  usually  happens  when  a  great  discovery  is  announced,  there  are  dis- 
sentients ;  there  are  those  apparently  competent  to  express  an  opinion,  as 
Spina  and  Formad,  who  do  not  accept  or  only  partly  accept  the  views  of 
Koch.  But  the  testimony  of  many  observers,  constantly  accumulating,  tends 
to  establish  more  securely  the  doctrine  of  the  microbic  origin  of  tuberculosis, 
and  it  is  now  apparently  as  securely  established  as  any  doctrine  in  pathology. 

Koch's  discovery  necessitated  revision  of  the  teachings  long  accepted 
relating  to  tuberculosis.  The  tubercle  nodule  is,  as  we  will  see,  an  aggre- 
gation of  cells  produced  from  the  cellular  elements  of  the  part  where  the 
nodule  appears  through  a  proliferating  process  caused  by  an  irritant,  and  in 
the  light  of  our  present  knowledge  we  consider  the  bacillus  to  be  the  irritant. 
A  local  corpusculation  and  a  cellular  nodule  may  be  produced  in  the  lungs  or 
elsewhere  by  the  lodgement  of  a  non-specific  irritant,  whether  organic  or  inor- 
ganic, as  putrid  cheese,  particles  of  dust,  or  metallic  particles,  and  thus  far  no 
cells  have  been  discovered  in  nodules  thus  produced  which  are  characteristic 
of  tuberculosis.  The  giant-cells  which  at  one  time  were  thought  to  be  pecu- 
liar to  the  tubercular  nodule  have  been  found  in  growths  of  another  nature, 
as  in  gummata.  The  characteristic  and  peculiar  element  in  the  tubercular 
nodule  is  the  bacillus. 

It  has  long  been  the  belief  from  clinical  observations  in  Southern  Europe, 
and  of  certain  observing  physicians  in  the  temperate  regions  of  Europe  and 
America,  that  phthisis  is  contagious,  and  the  acceptance  of  the  parasitic 
theory  will  probabl)'  soon  render  this  belief  an  established  principle  in  pathol- 
ogy. Already  many  instances  have  been  published  in  the  journals  which 
show  the  infectiousness  of  tuberculosis,  as  the  following :  In  an  inland  town 
in  Europe  a  midwife  with  advanced  phthisis  had  been  in  the  habit  of  blowing 
into  the  mouths  of  new-born  infants,  and  so  many  of  them  perished  of  tuber- 
cular disease  as  to  excite  attention  and  cause  alarm,  while  those  attended  by 
a  healthy  midwife  remained  well.  Dr.  E.  I.  Kempf  relates  the  following 
striking  example  in  the  Louisville  Medical  Neivs  for  March  22,  1884 :  In  the 
fall  of  1880  a  girl  of  eighteen  years,  whose  brother  had  died  of  consumption, 
was  found  to  have  tubercles  at  the  apices  of  both  lungs.  She  belonged  to  a 
sisterhood,  and  slept  in  the  general  dormitory  with  the  other  sisters.  In  four 
months  nine  of  her  companions  began  to  cough  and  were  found  to  have 
tubercles.  No  one  of  the  sisterhood  had  previously  had  disease  of  this  kind. 
Dr.  A.  OUivier,  physician  to  I'Hopital  des  Enfants-malades,  Paris,  states  that 
a  family  having  uniform  robust  health  occupied  two  small  rooms  opening  into 
a  narrow  court.  The  parents,  a  young  son,  and  the  baby  slept  in  one  of  the 
rooms.  An  older  son,  who  had  been  living  elsewhere,  contracted  phthisis, 
returned  home,  and  slept  in  the  same  apartment.  He  died  January  16,  1883. 
His  mother,  who  was  constantly  at  his  bedside,  began  to  cough,  emaciated, 
and  died  of  the  same  disease  in  the  following  May.  Seven  days  after  the 
death  of  the  mother  the  infant  had  tubercular  meningitis,  of  which  it  per- 
ished ;  and  the  older  child,  who  occupied  the  same  apartment,  sickened  and 
died  like  the  ^mother.  The  father  only  survived  of  those  who  occupied  the 
small  room  {Etudes  d' Hygiene  jmblique,  1886).  The  fact  that  wives  devoted 
in  their  attendance  on  consumptive  husbands  frequently  perish  of  the  same 
disease  has  been  long  known  to  physicians,  but  it  has  usually  been  attributed 
to  the  depressed  state  of  system  incident  to  long  watching  and  grief,  and  not 


TUBERCULOSIS.  205 

to  any  contagious  property.  But  now  that  a  clearer  insight  has  been  obtained 
into  the  nature  of  tuberculosis,  and  both  microscopical  researches  and  clinical 
facts  show  its  communicability,  more  caution  will  be  exercised  in  the  inter- 
course with  patients. 

The  recent  experiments  of  Cornet  (^Wiener  med.  Wochen.,  June  2,  1888) 
have  shown  that  the  walls  and  furniture  of  a  room  occupied  by  a  phthisical 
patient  may  be  infected  by  the  lodgement  of  the  tubercle  bacillus  upon  them, 
so  that  any  one  occupying  this  apartment  subsequently  is  in  danger  of  con- 
tracting the  disease.  He  rubbed  the  walls  and  bedsteads  in  the  ward  occu- 
pied by  phthisical  patients  with  disinfected  sponges,  avoiding  such  surfaces  as 
might  be  infected  by  the  hands  and  sputum  of  patients ;  94  animals  were 
inoculated  with  these  sponges,  and  52  of  them  died,  apparently  of  causes 
diiFerent  from  tuberculosis;  the  remaining  44  were  killed  after  forty  days,  and 
20  of  them  had  tubercles.  168  animals  were  inoculated  with  the  dust  from 
the  walls  of  rooms  occupied  by  phthisical  patients  in  family  practice.  Of 
these  animals  90  died  soon  afterward.  .  Of  the  remaining  78,  34  contracted 
tuberculosis.  In  control-experiments,  the  dust  being  used  from  surgical 
wards,  operating-rooms,  and  from  crowded  thoroughfares,  the  result  was  neg- 
ative as  regards  the  production  of  tuberculosis.  "  It  has  been  abundantly 
demonstrated  by  numerous  experiments  that  the  milk  from  tuberculous  cows 
is  capable,  when  ingested,  of  causing  tuberculosis.  How  serious  is  this  dan- 
ger may  be  seen  from  the  statistics  of  Bollinger,  who  found  the  milk  from 
cows  affected  with  extensive  tuberculosis  infectious  in  80  per  cent,  of  the 
cases,  and  that  from   cows  with  moderate  tuberculosis  infectious  in  33  per 

cent,  of  the  cases Bollinger  estimates  that  at  least  5  per  cent,  of  the 

cows  in  dairies  are  tuberculous.  From  statistics  furnished  me  by  3Ir.  A.  W. 
Clement.  Y.  S.,  the  number  of  tuberculous  cows  in  Baltimore  which  are 
slaughtered  is  not  less  than  3  to  4  per  cent."  ^ 

It  has  been  shown  by  tests  with  tuberculin  that  the  proportion  of  milch 
cows  having  tuberculo.sis  in  dairies  supplying  Xew  York  City  is  large,  and 
physicians  aware  of  this  fact  advise  their  families  to  Pasteurize  milk  designed 
for  the  nursery  :  that  is.  subject  it  to  a  heat  of  167°  for  twenty  minutes.  The 
sterilization  of  milk  we  have  treated  of  elsewhere.  I  may  repeat  that  tuber- 
cles are  found  in  the  milk  of  tuberculoixs  cows  even  when  the  udders  and 
teats  or  lacteal  tract  is  healthy.  The  frequency  of  tubercular  milch  cows  in 
America  is  apparent  when  I  state  that  more  than  fifty  cows  have  been  con- 
demned and  slaughtered  in  a  single  dairy  supplying  New  York  City. 

The  causal  relation  of  scrofula  to  tuberculosis  we  have  considered  elsewhere, 
but  we  may  here  repeat  that  scrofulous  ailments,  especially  the  caseous  prod- 
ucts, afford  the  soil  which  is  favorable  to  the  growth  and  multiplication  of 
the  bacilli.  Hence  these  microbes  are  not  infrequently  found  in  scrofulous 
products,  showing  that  the  tubercular  has  supervened  on  the  scrofulous  dis- 
ease. Kanzler  treats  of  the  relation  of  scrofula  to  tuberculosis  in  the  Berlin 
Min.Woch.,  January  14,  1884.  He  believes  that  the  two  diseases  are  distinct, 
but  that,  as  expressed  by  the  French  reviewer,  la  scrofide  offre  vri  terrain  de 
predilection  pour  le  developpement  de  la  tubercidose.  He  has  discovered  bacilli 
only  in  a  minority  of  the  local  manifestations  of  scrofula,  never  in  glands 
which  had  not  undergone  suppuration  or  caseation,  never  in  eczema,  impetigo, 
suppurative  otitis  media,  and  never  in  the  nasal,  conjunctival,  pharyngeal, 
and  vaginal  catarrhs  of  the  scrofulous.  It  is  not  till  degenerative  changes 
have  occurred  in  the  inflammatory  products  of  scrofula  that  the  bacilli  of 
tuberculosis  appear,  indicating  the  supervention  of  the  latter  disease. 

Anatomical  Characters  of  the  Tubercle. — As  Yirchow  pointed  out,  the 
tubercular  nodule  when  recent  is  semi-translucent  and  small,  attaining  about 

'  Prof.  W.  H.  Welch's  Address  before  the  Amer.  Med.  Asso.,  1889. 


206  CONSTITUTIONAL  DISEASES. 

the  size  of  a  millet-seed  and  consisting  mainly  of  cells.  The  cells  of  which 
it  is  chiefly  composed  resemble  the  white  corpuscles  of  the  blood  in  appear- 
ance and  size,  but  some  are  smaller  and  others  larger  than  those  corpuscles. 
They  have  been  designated  the  lymphoid  cells.  Each  cell  when  fully 
developed  has  a  bright  homogeneous  nucleus,  small  and  spherical  or  large  and 
oval,  and  nucleoli.  A  large  cell  sometimes  contains  two  or  more  nuclei. 
The  lymphoid  cells  appear  to  be  developed  from  the  cellular  element  of  the 
connective  tissue.  This  is  Virchows  belief.  In  addition  to  these  cells,  which 
constitute  the  greater  part  of  the  tubercle,  large  uninuclear  cells  are  also- 
observed,  designated  epithelioid  cells.  They  resemble  large  and  swollen 
endothelial  or  epithelial  cells,  and  they  are  believed  by  pathologists  to  be  pro- 
duced from  these  cells,  which  lie  within  the  area  of  the  nodule.  A  third  cell 
also  occurs,  known  as  the  giant-cell  from  its  size.  It  has  many  nuclei,  and 
occupies  chiefly  the  central  part  of  the  nodule.  All  these  cells,  as  has  been 
recently  shown,  occur  in  other  pathological  products  besides  the  tubercular 
nodule,  and  no  one  of  them  is  therefore  characteristic  of  it.  But  the  element 
which  is  of  greatest  importance,  since  it  sustains  a  causal  relation  to  the 
disease,  was,  as  we  have  seen,  the  last  discovered.  The  bacillus  is  always 
found  in  the  recent  tubercle  lying  without  the  cells,  as  we  have  stated,  but 
also  in  the  interior  of  the  giant-cells,  for  which  it  appears  to  have  an  affinity. 
A  fibrous  network  with  more  or  fewer  blood-vessels  surrounds  the  cells  and 
holds  them  together.  The  blood-vessels  belong  to  the  normal  tissues,  and  are 
not  a  new  growth,  the  tubercle  having  developed  around  them.  The  nodules 
are  single  or  in  clusters,  forming  masses  of  considerable  size. 

When  the  nodule  has  attained  a  certain  age,  caseation  always  occurs  in 
its  centre  and  extends  outward,  causing  an  opaque  and  yellowish-white  dead 
mass,  in  which  fragmentary  cells  can  be  observed  under  the  microscope. 
Caseation  is  now  known  to  be  a  form  of  decay  which  is  common  to  path- 
ological products  of  different  kinds,  and  is  not  peculiar  to  tuberculosis,  as 
was  supposed  before  the  time  of  Virchow.  It  occurs  in  consequence  of 
abundant  exudation  or  cell-formation  and  the  compression  and  obliteration 
of  vessels.  It  is  therefore  more  common  in  scrofula  than  in  any  other  disease, 
since  scrofulous  inflammations  aff'ord  the  conditions  in  which  it  is  especially 
liable  to  occur.  The  yellow  tubercle  is  only  an  advanced  stage  of  the 
semi-transparent  miliary  tubercle.  In  the  cheesy  metamorphosis  granules 
of  fat  are  deposited  within  and  around  the  cells,  and  the  cells  shrivel  and 
disintegrate.  The  shrunken  granular  and  fragmentary  cells  were  believed  to 
be  the  true  tubercular  cells  until  Virchow  pointed  out  their  character.  When 
the  nodule  or  nodular  mass  becomes  yellow  or  caseous,  and  circulation  ceases 
in  it,  it  is  surrounded  by  a  vascular  zone  in  which  circulation  still  continues. 
It  is  very  seldom,  perhaps  never,  absorbed,  although  particles  of  it  may  enter 
the  lymphatics  or  blood-vessels  and  be  carried  elsewhere  with  the  bacilli.  It 
is  an  irritant,  producing  inflammation  in  the  surrounding  tissues,  with  thick- 
ening, induration,  and  abundant  production  of  pus-cells,  which  mingle  with 
the  elements  of  the  nodule.  Its  history  henceforth  is  that  of  an  abscess,  and 
ulceration  and  discharge  of  the  liquefied  substance  upon  one  of  the  free  sur- 
faces is  the  common  result.  In  rare  instances  the  tubei-cular  nodule,  instead 
of  cheesy  degeneration,  undergoes  fibroid  degeneration  or  cretefaction. 

Various  pathological  conditions  furnish  the  soil  in  which  the  bacillus 
obtains  lodgement  and  grows,  and  in  this  way  becomes  a  cause  of  tubercu- 
losis. Cheesy  pneumonia  and  exhausting  suppurating  surfaces  often  aff'ord 
a  nidus  favorable  for  the  development  of  the  tubercle  bacillus.  During 
epidemics  of  measles  many  cases  occur  of  cheesy  pneumonia  ending  in 
tuberculosis.     Cheesy  and  disintegrating  lymphatic  glands,  as  the  bronchial,. 


TUBERCULOSIS.  207 

often  become  tubercular,  as  do  tlie  inflamraatory  products  of  the  grippe  or 
influenza. 

Inheritance. — Csoker  states  that  a  cow  advanced  in  pregnancy  died  of 
tuberculosis.  In  the  hepato-duodenal  ligament  of  the  foetus  were  six  enlarged 
lymphatic  glands  partly  caseous  and  partly  cretefied,  but  containing  numerous 
bacilli  and  tubercles  (^Deutsche  med.  Zeitg.,  Jan.  29,  1891).  Birch-Hirschfeld 
states  that  a  woman  seven  months  pregnant  died  of  general  tuberculosis. 
Twenty  months  before  her  death  the  foetus  which  she  carried  was  alive.  A 
Csesarean  section  was  performed,  but  both  mother  and  child  died  soon  after. 
The  mother  had  acute  general  tuberculosis  ;  the  placenta  contained  numerous 
tubercles,  and  portions  of  the  liver,  spleen  and  kidneys,  inoculated  in  the 
guinea-pig  and  rabbit,  communicated  phthisis.  Baumgarten  from  his  obser- 
vation expresses  the  opinion  that  infection  of  the  foetus  occvirs  in  three  ways — 
by  a  diseased  ovum  or  fructifying  sperm  and  by  a  diseased  placenta. 

Prausnitz  inoculated  guinea-pigs  with  scrapings  obtained  from  railway- 
coaches  running  from  Berlin  to  Meran,  in  which  consumptives  are  accustomed 
to  travel.  The  scrapings  of  five  coaches  contained  virulent  tubercle  bacilli, 
and  Prausnitz  urges  the  disinfection  of  railway-carriages.  Schnirer  found 
similarly  infected  dust,  which  communicated  tuberculosis,  lodged  upon  grapes. 

Inhalation. — The  observations  of  Cornet  have  disclosed  the  fact  that 
the  inhalation  of  the  dried  sputum  of  phthisical  patients  is  probably  the  most 
frequent  mode  in  which  this  disease  is  contracted  through  the  respiratory 
organs ;  but  the  inhalation  of  the  moist  breath  of  the  consumptive  has  in 
numberless  instances  conveyed  the  disease. 

Anatomical  Characters  in  Infancy  and  Childhood. — The  anatomical  cha- 
racters of  tuberculosis  in  the  first  years  of  life  vary  in  certain  particulars  from 
the  form  which  they  present  in  the  adult,  but  after  the  age  of  three  years  the 
diiferences  are  fewer  and  less  pronounced  than  previously. 

Tubercular  laryngitis,  so  common  in  the  adult,  is  absent  in  a  large  pro- 
portion of  cases  under  the  age  of  three  years,  and  when  present  it  has  little 
intensity.  Ulceration  of  the  larynx  very  seldom  occurs.  This  has  been 
attributed  to  the  fact  that  there  is  so  little  expectoration  in  young  children, 
the  sputum  being  an  irritant.  Niemeyer,  however,  does  not  consider  the 
sputum  of  tuberculosis  sufiiciently  irritating  to  cause  laryngitis  and  laryn- 
geal ulceration ;  but  the  arguments  in  favor  of  this  mode  of  causation,  in 
my  opinion,  more  than  counterbalance  those  which  have  been  presented 
against  it. 

I  have  never  met  a  case  of  tubercular  ulceration  of  the  larynx  or  trachea 
in  the  post-mortem  examination  of  young  children,  nor  do  I  recollect  ever 
treating  a  case  in  which  there  was  that  degree  of  dysphonia  which  indicated 
ulceration.  Rilliet  and  Barthez,  in  more  than  300  necropsies  of  tubercular 
cases,  found  no  ulcers  in  the  larynx  or  trachea  under  the  age  of  three  years, 
but  met  8  cases  between  the  ages  of  three  and  ten  years,  and  8  between  ten 
and  fourteen  years.  The  ulcers,  whether  seated  in  the  larynx  or  in  the 
trachea — and  they  are  in  most  cases  in  the  former,  since  the  inequalities 
upon  the  surface  of  the  larynx  favor  the  retention  of  the  sputum — are  com- 
monly small,  superficial,  round  or  elongated,  and  with  little  thickening  or 
infiltration  of  their  borders.  Occurring  in  the  folds  of  the  mucous  mem- 
brane— as,  for  example,  around  the  vocal  cords — their  form  is  usually 
elongated. 

Bronchitis  is  not  infrequent.  This  inflammation  is  due  to,  and  dependent 
on,  the  pulmonary  tubercles,  and  is  therefore  most  intense  in  the  part  of  the 
lung  where  the  tubercles  are  most  abundant  and  farthest  advanced.  Conse- 
quently, it  is  more  intense  on  one  side  than  on  the  other,  and  it  may  be 
unilateral.      It  differs  in  this  respect  from  idiopathic  bronchitis,  which  is 


208  CONSTITUTIO^^AL  DISEASES. 

commonly  nearly  uniform  on  tlie  two  sides.  It  differs  also  in  the  fact  that 
it  is  sometimes  accompanied  by  ulcerations.  The  ulcers  are  round  or  elon- 
gated in  the  direction  of  the  axes  of  the  tubes,  and,  like  those  of  the  larynx 
or  trachea,  are  superficial.  Circumscribed  inflammation  may  attack  a  bron- 
chial tube,  as,  indeed,  the  trachea,  and  give  rise  to  ulceration  and  perforation 
from  the  pressure  of  a  diseased  lymphatic  gland  external  to  the  tube.  This 
subject  will  be  treated  of  hereafter. 

Lungs. — It  is  well  known  that  in  the  adult  tubercles  are  always  present 
in  the  lungs  if  they  occur  in  any  part  of  the  system.  I  have  met  2  cases  in 
which  the  lungs  were  free  from  tubercles  in  36  post-mortem  examinations  of 
children  who  died  of  tuberculosis.  One  of  the  two  was  an  infant,  but  its  exact 
age  is  not  stated  in  the  records.  It  had  cheesy  degeneration  of  the  thymus 
and  bronchial  glands,  enlargement  of  the  mesenteric  glands,  but  without 
cheesy  degeneration,  and  disseminated  tubercles  in  liver  and  spleen.  The 
other,  fifteen  months  old  at  death,  had  tubercular  meningitis,  with  numerous 
granulations  upon  the  convexity  of  the  brain,  and  the  other  usual  lesions  of 
meningeal  inflammation,  with  bronchial  and  mesenteric  glands  slightly  enlarged 
and  cheesy,  and  one  of  the  former  softened.  In  1  case,  then,  in  18,  the  lungs 
had  escaped  the  disease.  Rilliet  and  Barthez  in  their  statistics  of  the  state 
of  the  lungs  in  infancy  and  childhood  found  these  organs  non-tubercular  in 
47  cases  in  312.  and  Hillier  in  25  cases  in  160.  Therefore,  the  lungs  were 
exempt  from  tubercles  in  about  1  case  in  7.  But  it  is  to  be  recollected  that 
the  observations  of  these  physicians  were  made  at  a  time  when  all  cheesy 
degenerations  were  thought  to  be  tubercular,  so  that  their  published  statistics 
may  not  have  been  strictly  accurate. 

Pulmonary  tubercles  in  children  under  the  age  of  three  years  are,  as  a 
rule,  discrete  and  disseminated  through  the  lungs.  In  cases  at  this  age  which 
have  advanced  to  a  fatal  termination  we  find  yellow  tubercles  from  the  size 
of  a  pin's  head  to  that  of  a  shot  in  the  different  lobes ;  many  still  semi-trans- 
parent if  the  disease  have  been  of  short  duration,  but  if  protracted  most  of 
them  yellow,  and  here  and  there  one  softened  and  surrounded  by  condensed 
fibrous  tissue.  Around  the  semi-transparent  or  gray  tubercles,  many  of  which 
were  growing,  and  therefore  were  in  a  state  of  active  cell-proliferation  at  the 
time  of  death,  vascular  zones  can  often  be  detected  by  the  naked  eye. 

Under  the  age  of  three  years  tuberculosis  exhibits  but  little  tendency, 
perhaps  none,  to  affect  the  upper  lobes  sooner  or  in  greater  degree  than 
the  lower. 

The  following  are  the  statistics  relating  to  the  site  of  the  tubercles  in  the 
lungs  in  the  cases  which  I  have  examined ;  all,  it  is  to  be  remembered,  were 
under  the  age  of  three  years : 

Cases. 

Tubercles  disseminated  throughout  the  lungs 26 

Tubercles  disseminated  throughout  the  two  upper  lobes 3 

Tubercles  disseminated  through  right  middle  lobe  and  left  lower  lobe 

only 1 

Tubercles  disseminated  through  left  upper  lobe  only 2 

Tubercles  disseminated  (few  and  semi-transparent)  in  left  lung  only  .  1 
Tubercles  disseminated  in  three  points  in  right  and  two  in  left  lung  .  1 
No  tubercles  in  lungs 2 

36 

Between  the  ages  of  three  and  fifteen  years  statistics  show  that  the  upper 
lobes  are  more  liable  to  tubercles  than  the  lower ;  but  the  difference  in  liabil- 
ity is  not  great.  In  many  cases  occurring  in  this  period  the  different  lobes 
are  affected  nearly  simultaneously,  and  not  very  infrequently  the  upper  lobe 
is  the  last  which  is  involved.     In  October,  1866,  I  made  the  post-mortem 


TUBERCULOSIS.  209 

examination  of  a  boy  who  died  in  the  Children's  Service  of  Charity  Hospital 
at  the  age  of  fifteen  years,  and  small  scattered  tubercles  were  found  in  the 
lower  lobe  of  the  left  lung,  while  all  other  portions  of  these  organs  were 
healthy.  Rilliet  and  Barthez,  who  include  in  the  same  statistics  all  cases 
from  birth  to  the  age  of  fifteen  years,  found  gray  semi-transparent  tubercles — 

Cases. 

In  the  right  superior  lobe  in 63 

In  the  right  middle  lobe  in 43 

In  the  right  lower  lobe  in      55 

In  the  left  superior  lobe  in 65 

In  the  left  inferior  lobe  in 54 

The  same  observers  found  yellow  tubercles  in  the 

Kight  superior  lobe  in 40 

Eight  middle  lobe  in      28 

Eight  inferior  lobe  in 39 

Left  superior  lobe  in 35 

Left  inferior  lobe  in 31 

Tubercular  nodules,  especially  when  softening  commences,  act  as  an  irri- 
tant, exciting  inflammation  around  themselves.  Inflammation  occurring  from 
this  cause  is  obviously  likely  to  be  protracted,  continuing  for  weeks  or  months 
unless  the  tubercular  matter  be  eliminated  by  ulceration.  The  highly  vas- 
cular and  delicate  lungs  of  the  young  child  are  very  liable  to  inflammation 
when  they  are  the  seat  of  tubercles,  and  as  the  tubercles  are  disseminated, 
the  pneumonia  is  commonly  more  extensive  than  when  it  occurs  from  ordi- 
nary cases.  In  fifteen,  or  nearly  one-half,  of  my  cases  there  was  pneumonia 
affecting  portions  of  one  or  more  lobes  or  an  entire  lobe.  From  the  extent 
and  position  of  the  solidified  portions  it  was  obvious  that  in  most  instances 
the  inflammation  originated  from  the  irritating  efi'ect  of  the  tubercular  matter, 
while  in  others  it  was  due  to  hypostatic  congestion,  occurring  in  consequence 
of  the  long-continued  recumbent  position  and  feebleness  of  circulation.  In 
these  15  cases  the  seat  and  extent  of  the  pneumonia  were  as  follows : 

Cases. 

Nearly  entire  right  lung 2 

Nearly  entire  middle  and  lower  lobe  of  right  lung 1 

Entire  left  upper  lobe 2 

A  considerable  part  of  both  lungs - 1 

Posterior  parts  of  both  lower  lobes 4 

Posterior  part  of  left  lung 1 

Left  lower  lobe,  and  right  middle  and  lower  lobes 1 

Left  upper  lobe  (contained  a  large  cavity)  and  posterior  part  of  left 

lower  lobe 1 

Nodules  of  inflamed  lung  around  tubercles 2 

The  inflammation  in  about  one-third  of  the  cases  was  due  to  hypostasis,  since 
it  occurred  in  depending  portions,  extended  but  little  into  the  lungs,  and  sus- 
tained no  relation  to  the  amount  of  tubercle.  It  was  in  the  stage  of  red — or, 
more  rarely,  of  gray — hepatization. 

In  7  of  the  cases  there  were  pulmonary  cavities  as  large  in  proportion  as 
we  ordinarily  find  in  tuberculosis  of  the  adult.  The  seat  of  1  was  in  the 
right  lower  lobe;  of  2,  the  left  upper  lobe;  of  1,  the  right  upper  lobe;  of 
another,  the  right  lung,  its  exact  seat  not  stated ;  and  in  the  remaining  case 
the  cavity,  which  was  the  largest  of  all,  occupied  the  interior  of  all  three 
lobes  on  the  right  side.  Some  idea  of  the  size  of  these  cavities  may  be 
learned  by  the  following  extracts  from  the  records:  1st  Case.  "A  small 
14 


210  CONSTITUTIONAL  DISEASES. 

superficial  cavity  communicating  on  one  side  with  a  bronchial  tube,  and  ont 
the  other  side  with  a  small  circumscribed  collection  of  pus  in  the  pleural 
cavity."  2d  Case.  "  Cavity  of  the  size  of  a  hickory-nut."  3d  Case.  "  Cavity 
of  the  size  of  a  large  hickory-nut."  4th  Case.  "  Cavity  three-fourths  of  an 
inch  in  diameter."  5th  Case.  "  A  large  abscess."  6th  Case.  "The  cavity 
occupied  nearly  the  whole  of  the  interior  of  the  left  upper  lobe."  7th  Case. 
"  About  half  the  right  lung  excavated  into  a  cavity  which  extended  through 
the  three  lobes." 

Circumscribed  pleuritis,  produced  by  tubercles  underneath  the  pleura,  was 
observed  in  7  cases.  It  was  ordinarily  attended  by  little  exudation  except 
the  fibrin,  but  in  one  case  a  sufiicient  amovint  of  serum  had  been  exuded  to 
compress  considerably  the  lung.  Pus  was  not  observed  in  any  notable 
quantity. 

Emphysema  was  present  in  several  cases,  chiefly  in  the  upper  lobes,  some- 
times vesicular,  with  fulness  or  bulging  of  the  lung,  an  anjemie  appearance 
of  it,  and  doughy,  inelastic  feel.  In  other  cases  emphysema  was  interstitial, 
producing  little  bladders  of  air  under  the  pleura,  especially  toward  the  root 
of  the  lung,  or  separating  the  lobules  by  wedge-shaped  or  irregular  inter- 
spaces filled  with  air.  In  one  case  air  had  escaped  from  an  emphysematous 
bladder  into  the  right  pleural  cavity,  causing  pneumothorax  and  collapse  of 
the  lung. 

Next  to  the  lungs,  the  bronchial  glands  are  more  frequently  diseased  than 
any  other  organs  in  the  tuberculosis  of  infancy  and  childhood.  They  undergo 
the  successive  structural  changes  which  characterize  glandular  infiammations 
— to  wit,  hyperplasia — and  more  or  fewer  of  them  cheesy  degeneration  and 
softening.  In  the  state  of  hyperplasia  their  firmness  is  diminished  and  they 
have  a  pale  flesh-color.  Cheesy  degeneration  commences  in  one  or  more 
points  in  the  gland,  sometimes  in  the  peripheral,  sometimes  in  the  central 
portion,  and  it  extends  till  the  whole  gland  presents  the  well-known  cheesy 
appearance.  When  the  gland  softens  the  thick  liquid  has  a  puriform  appear- 
ance, consisting  of  amorphous  matter,  fatty  particles,  and  the  shrivelled  and 
disintegrated  cells  of  the  gland.  Soon  pus-cells  occur,  and  their  number 
increases.  The  cheesy  gland  may  or  may  not  be  tubercular.  If  it  be  tuber- 
cular, the  tubercle  bacillus  will  be  found  in  it. 

Rilliet  and  Barthez  state  that  the  bronchial  glands  were  tubercular 
(caseous)  in  249  cases  in  children,  while  the  lungs  were  tubercular  in  265. 
All  cheesy  glands,  it  is  to  be  recollected,  are  considered  tubercular.  In  4 
of  the  36  cases  which  I  have  examined  no  record  was  preserved  of  the  state 
of  the  bronchial  glands ;  in  1  case  there  was  no  perceptible  hyperplasia  and 
no  cheesy  degeneration ;  in  2  there  was  hyperplasia,  but  no  cheesy  degenera- 
tion, while  in  the  remaining  29  cases  cheesy  degeneration  had  occurred  in 
some  of  the  glands  or  in  parts  of  them,  with  occasional  softening.  The 
enlarged  and  caseous  bronchial  glands  afi"ord  an  explanation  in  part  of  the 
fact  that  the  symptoms  in  the  tuberculosis  of  yoiing  children  diff"er  from  those 
in  the  adult,  since  Louis  found  the  bronchial  glands  involved  in  only  28  per 
cent,  of  the  adult  cases  of  tuberculosis  which  he  examined,  and  Lombard 
in  only  9  per  cent.  A  gland  pressing  upon  the  recurrent  laryngeal  or  pneu- 
mogastric  nerve  or  the  trachea  may  give  rise  to  dyspnoea  and  a  cough  ;  or 
on  the  descending  vena  cava  or  one  of  the  venfe  innominatse  to  congestion  of 
the  brain  and  meninges,  intracranial  serous  efi"usion,  and  even  thrombosis  in 
the  cranial  sinuses.  That  a  softened  bronchial  gland  is  not  infrequently 
eliminated  from  the  system  by  ulceration  into  a  bronchial  tube  or  into  the 
trachea  is  well  known.  In  one  case  which  I  observed  the  ulceration  had 
destroyed  portions  of  three  of  the  cartilaginous  rings  of  a  bronchus,  and  the 
aperture  was  plugged  by  a  cheesy  fragment  of  a  softened  gland  which  pro- 


TUBERCULOSIS.  211 

truded.  Occasionally,  it  is  stated  by  authors,  the  ulceration  is  into  one  of  the 
large  vessels  of  the  mediastinum,  or  even  into  the  oesophagus. 

The  following  is  an  example  of  bronchial  phthisis  as  it  commonly  occurs : 

This  case,  which  is  not  included  in  the  foregoing  statistics,  was  seen  almost  daily 
by  me  during  its  entire  progress  :  On  September  3,  1874, 1  examined  an  infant  in  the 
New  York  Infant  Asylum  who  had  wheezing  respiration  during  the  last  eight  days. 
The  wheezing  occurred  both  in  inspiration  and  expiration,  and  also,  though  less  pro- 
nounced, during  sleep  ;  pulse  96,  respiration  40,  temperature  normal.  Its  mother, 
who  had  charge  of  it,  and  had  till  recently  wet-nursed  it,  had  unequivocal  symp- 
toms of  tuberculosis  for  several  months.  The  child  was  pallid  and  its  flesh  was 
soft  and  flabby.  The  fauces  were  perhaps  a  little  redder  than  usual,  but  were  other- 
wise normal,  and  a  careful  exploration  of  the  chest  revealed  no  cause  of  the  embar- 
rassed respiration.  Auscultation  and  percussion  gave  a  negative  result.  In  the 
latter  part  of  September  a  troublesome  diarrhoea  occurred,  which  continued  more 
or  less  till  near  death.  The  temperature  on  September  28th,  October  8th,  10th,  and 
nth,  was  100i°,  100°,  99 J°,  and  100°.  The  pulse  on  October  10th  and  11th  was 
120  and  126.  On  October  8th  the  percussion-sound  over  the  upper  part  of  the  right 
lung  seemed  somewhat  duller  than  onj  the  other  side,  though  the  respiration  was 
not  observed  to  be  notably  changed  in  the  area  of  the  dulness.  There  was  but 
little  cough  during  the  entire  sickness.  Death  occurred  on  October  20th.  At  the 
autopsy  the  bronchial  glands  were  found  enlarged  and  cheesy,  and  underneath  the 
right  bronchus,  near  the  bifurcation,  was  a  softened,  almost  difiiuent  gland,  as 
large  as  a  small  hickory  nut  and  compress- 
ing the  bronchus.  This,  no  doubt,  had  pro-  Fig.  38. 
duced  the  wheezing  respiration,  which  had 
been  the  chief  local  symptom.  The  lungs, 
spleen,  and  in  less  degree  the  liver,  con- 
tained numerous  small  miliary  tubercles. 
Certain  of  the  mesenteric  glands  were  also 
cheesy,  but  to  a  less  extent  than  the  bron- 
chial. The  disease  of  the  bronchial  glands 
was  evidently  primary,  the  tubercles  of  the 
lungs  and  abdominal  organs  being  appar- 
ently quite  recent.  The  accompanying  wood- 
cut, from  a  photograph  by  Mr.  Mason,  the 
photographer  at  Bellevue  Hospital,  repre- 
sents a  posterior  view  of  the  lungs  and 
air-passages. 

In  no  case  have  I  found  tubercles  in 
the  heart  or  pericardium,  though  they 
have  been  observed  in  rare  instances  in 

the  latter.  The  mesenteric  glands  were  enlarged  by  hyperplasia  and  more 
or  less  cheesy  in  30  cases,  were  apparently  normal  in  2  cases,  while  in  the 
remaining  4  cases  their  condition  was  not  stated.  In  most  of  the  patients 
the  mesenteric  glands  were  smaller  and  less  cheesy  than  the  bronchial,  but 
in  a  few  instances  they  were  larger  than  the  bronchial  and  more  cheesy. 

It  is  a  noteworthy  fact,  as  bearing  on  the  causal  relation  of  these  glands 
to  tubercles,  that  not  infrequently  the  amount  of  hyperplasia  and  cheesy 
degeneration  occurring  in  the  former  was  very  considerable,  while  the  tuber- 
cles in  the  lungs  or  elsewhere  were  small,  even  minute,  semi-transparent,  and 
apparently  of  recent  formation.  It  was  evident  in  such  cases  that  the  gland- 
ular hyperplasia  and  degeneration,  bronchial  or  mesenteric,  or  both,  preceded 
the  tubercular  disease,  and  furnished  the  conditions  favorable  for  the  lodge- 
ment and  propagation  of  the  tubercle  bacillus.  Since  the  cases  which  fur- 
nished the  above  statistics  occurred  my  clinical  experience  with  tubercu- 
losis has  greatly  increased,  but  nothing  new  or  different  has  been  observed 
at  autopsies. 

Abdominal  Viscera — Bollinger  says  :  "  The  upper  half  of  the  alimentary 


212  CONSTITUTIONAL  DISEASES. 

tract  (mouth,  throat,  oesophagus,  stomach,  duodenum,  and  jejunum)  offers  an 
unfavorable  site  for  tuberculosis.  The  lymph-follicles  of  the  ileum  and  large 
intestine  are  the  organs  usually  infected  when  the  disease  has  its  origin  in 
the  alimentary  tract.  However,  primary  tuberculosis  of  the  cervical  lymph- 
atics in  children  occurs  through  infection  of  the  throat.  Primary  tubercu- 
losis of  the  intestine,  combined  with  tuberculosis  of  the  peritoneal  lymphatic 
glands,  occurs  oftener  in  children  than  in  adults,  the  cause  of  which  is  prob- 
ably to  be  sought  for  in  the  feeding  of  young  children  with  the  milk  from 
tubercular  cows."  In  children  tubercles  in  the  solid  organs  of  the  abdomen 
rarely  give  rise  to  appreciable  symptoms,  since  they  are  small  and  dissemi- 
nated, not  impairing  materially  the  function  of  the  part  in  which  they  are 
located.  On  the  other  hand,  peritoneal  and  intestinal  tubercles  and  the 
enlarged  and  cheesy  mesenteric  glands  give  rise  to  symptoms  which  require 
description.  The  most  frequent  seat  of  peritoneal  tubercles  is  upon  the 
attached  surface  of  the  peritoneum,  where  they  are  formed  in  the  connective 
tissue.  They  are  distinctly  seen  through  the  peritoneum,  and  cause  some 
prominence  of  it.  Exceptionally  their  seat  is  upon  its  free  surface.  Every 
portion  of  the  peritoneum,  whether  visceral,  parietal,  or  omental,  is  liable  to 
tubercles,  but  general  tuberculization  of  so  extensive  a  surface  seldom  occurs 
in  any  one  case.  The  tubercles  are  spherical  or  lenticular,  and  most  of  them 
small.  Sometimes  they  are  very  numerous,  but  so  minute  as  to  be  scarcely 
visible.  They  are  gray  or  yellow  according  to  their  age.  Peritoneal  tuber- 
cles often  produce  circumscribed  peritonitis,  causing  adhesion  of  opposite  sur- 
faces. The  tubercles  in  themselves  cannot  be  detected  by  external  palpation ; 
but  masses  composed  of  tubercles  and  inflammatory  products  are  sometimes 
so  large  that  they  can  be  felt  through  the  abdominal  walls. 

The  symptoms  of  peritoneal  tuberculosis  are  attributable,  for  the  most 
part,  to  the  peritonitis.  Among  them  may  be  enumerated  abdominal  tender- 
ness or  pain,  meteorism,  ascites — usually  slight — and  derangement  of  the 
bowels,  commonly  diarrhoea.  Since  tubercles  in  this  situation  occur,  in  most 
cases,  subsequently  to  tubercles  elsewhere,  the  symptoms  which  have  been 
described  are  associated  with  and  are  subordinate  to  others. 

Stomach  and  Intestines. — The  most  common  seat  of  gastro-intestinal  tuber- 
cles is  the  small  intestine,  and  more  frequently  its  lower  portion,  near  the 
ileo-caecal  valve,  than  its  upper  or  central.  They  are  rare  in  the  duodenum 
or  contiguous  part  of  the  jejunum.  They  are  developed  ordinarily  in  the 
connective  tissue,  either  that  lying  under  the  mucous  or  the  serous  surface. 

Gastro-intestinal  tubercles  are  often  accompanied  by  ulceration  of  the 
adjacent  mucous  membrane.  But  in  a  certain  proportion  of  cases,  probably, 
the  tubercles  do  not  cause  the  ulcers,  for  ulceration  of  this  membrane  is  not 
infrequent  in  the  tuberculosis  of  children,  when  there  are  no  tubercles  in  the 
walls  of  the  stomach  or  intestines.  The  following  statistics  of  Rilliet  and 
Barthez  relating  to  this  point  will  aid  to  an  understanding  of  the  symptoms : 

rpii-         npi         1,    n  f  with  ulcers,  6  cases. 

Tubercles  m  walls  of  stomach,  7  <^^^^^,  {^YMhont  ulcers,  1  case. 

Ulcers  of  gastric  mucous  membrane,  without  gastric  tubercles,  14  cases. 
rr<  T.      1      •  n  •  X    ^'        oo  f  with  ulcei's,  70  cases. 

Tubercles  m  small  mtestme,  82  cases,  {.without  ulcers,  12  cases. 

Ulcers  without  tubercles  in  small  intestine,  51  cases. 

rr,  1       1      ,     1  .  ^    ^.        -,  _  f  with  ulcers,  10  cases. 

Tubercles  m  large  mtestme,  lo  cases,  |  without  ulcers,  5  cases. 

Ulcers  in  large  intestine,  without  tubercles,  47  cases. 

The  ulcers  have  vascular,  thickened,  and  infiltrated  borders.  Their  diam- 
eters vary  from  a  line  to  half  an  inch  or  more,  and  their  general  form  is 


TUBERCULOSIS.  213 

circular,  or,  if  two  or  more  unite,  irregular.  Tubercular  ulcers  of  the 
stomach  are  mostly  in  the  great  curvature,  those  in  the  small  intestines  in 
the  ileum  and  lower  part  of  the  jejunum,  and  those  of  the  large  intestine  in 
the  caecum. 

The  following  table  exhibits  the  state  of  the  principal  abdominal  viscera 
in  the  36  cases  embraced  in  my  statistics : 

Liver.  Spleen.  Kidneys. 

Tubercular 12  22                  1 

Non-tubercular 16  6                21 

Not  stated 8  8                14 

Fatty 5  0                  0 

In  no  instance  did  I  observe  tubercular  softening  in  the  abdominal  organs, 
and  a  large  proportion  of  the  tubercles  in  the  liver,  spleen,  and  kidneys  were 
still  in  the  first  stage.  In  the  5  cases  in  which  the  liver  was  recorded  fatty, 
this  state  of  the  organ  was  obvious  to  the  sight,  as  it  is  in  tuberculosis  of 
the  adult.  A  moderate  excess  of  fat  in  the  hepatic  cells  may  have  been 
present  in  some  of  the  other  cases,  but  it  was  not  sufficient  to  be  appreciable 
without  the  microscope.  It  is  to  be  remarked  that  in  the  5  cases  in  which 
the  liver  was  recorded  fatty  this  organ  contained  no  tubercles.  The  spleen 
is  seen  to  have  been  the  most  frequent  seat  of  tubercles  of  all  the  viscera, 
except  the  lungs.  In  14  cases  the  intestines  were  examined ;  and  in  5 
tubercles  discovered,  developed  in  their  connective  tissue.  The  intestinal 
tubercles  were  small,  and  ulceration  had  occurred  of  the  mucous  membrane 
which  covered  them. 

The  brain  was  examined  in  15  cases.  In  12  the  amount  of  cerebro-spinal 
fluid  varied  from  gss  to  ^v  by  estimation.  In  2  others  the  records  state  that 
there  was  a  considerable  amount  of  this  fluid,  the  exact  quantity  not  being 
given,  while  in  the  remaining  case  congestion  of  the  brain  and  meninges  was 
noticed,  but  nothing  was  recorded  in  regard  to  the  amount  of  cerebro-spinal 
fluid.  The  increase  of  the  cerebro-spinal  fluid  in  tuberculosis  is  attributable 
to  wasting  of  the  brain,  a  hydrocephalus  ex  vacuo^  and  in  some  cases  to  passive 
congestion  and  serous  transudation,  due  to  feeble  circulation,  or  obstructed 
flow  from  the  pressure  of  bronchial  glands  on  the  vessels  within  the  thorax, 
as  already  stated. 

Tubercles  were  present  in  the  pia  mater  in  3  cases  :  in  2  with  fibrinous 
exudation  ;  in  the  other  without  fibrin  or  other  evidence  of  inflammation. 
Tubercular  meningitis  is  described  in  another  part  of  this  book. 

Symptoms. — The  symptoms  in  tuberculosis  of  children  arise  in  part  from 
the  diathesis  and  in  part  from  the  tubercles.  Before  the  period  of  tubercles 
there  are  signs  of  failing  health,  such  as  loss  of  appetite,  flabbiness  of  the 
soft  parts,  or  emaciation,  lassitude,  and  loss  of  strength.  These  symptoms 
continue  after  the  formation  of  tubercles,  and  increase. 

The  features  are  ordinarily  pallid,  but  during  the  paroxysms  of  fever,  to 
which  tubercular  patients  are  subject,  they  may  be  flushed.  Lividity  of  the 
features,  due  to  imperfect  decarbonization  of  the  blood,  occurs  if  there  be 
enlarged  bronchial  glands  which  compress  the  vessels  within  the  thorax,  or 
if  there  be  extensive  pulmonary  tuberculization  or  pulmonary  tuberculiza- 
tion, whether  extensive  or  not,  which  is  complicated  by  capillary  bronchitis 
or  pneumonia. 

The  skin  is  nearly  natural,  or  it  loses  its  flexibility  and  softness  and 
becomes  dry  and  rough.  In  some  patients  there  is,  at  times,  general  or  par- 
tial furfuraceous  desquamation  of  the  skin,  due  to  exaggerated  development 
of  the  epidermis.  Children,  like  adults,  notwithstanding  the  general  dryness 
of  the  surface,  are  liable  to  perspirations  at  night  and  in  sleep.     This  symp- 


214  CONSTITUTIONAL  DISEASES. 

torn  is  less  frequent  at  the  commencement  tlian  at  an  advanced  period,  in 
acute  than  in  chronic  cases,  and  in  those  under  three  or  four  months  than  in 
older  children.  It  is  more  abundant  about  the  head  and  limbs  than  else- 
where, and  is  sometimes  confined  to  these  parts. 

Anasarca  is  not  infrequent.  It  sometimes  arises  from  obstructed  circula- 
tion in  consequence  of  compression  of  the  thoracic  vessels  by  enlarged 
lymphatic  glands ;  in  other  cases  it  is  due  to  diminished  plasticity  of  the 
blood,  a  result  of  the  tubercular  cachexia.  The  latter  is  the  more  common 
cause.  It  is  not  an  important  symptom,  on  account  of  the  small  amount  of 
serous  transudation  and  the  character  of  the  parts  in  which  it  occurs. 

Emaciation,  already  alluded  to,  is  early,  constant,  and  progressive.  Under 
the  age  of  six  or  eight  months  it  is  less  marked  than  in  older  children,  many 
preserving  considerable  rotundity  of  features  and  form  even  in  advanced 
tuberculosis.  The  failure  of  the  strength  corresponds  in  amount  and  prog- 
ress with  the  emaciation.  Slight  at  first,  and  exhibited  only  by  a  degree  of 
lassitude,  it  gradually  increases,  till  for  weeks  before  death  the  little  patient 
is  fatigued  by  the  ordinary  muscular  movements,  and  is  inclined  to  be  quiet. 

The  nervous  system  is  not  ordinarily  affected  except  in  cases  of  intra- 
cranial tubercles.  In  acute  tuberculosis  or  tuberculosis  complicated  by 
severe  inflammation  there  may  be  agitation  and  delirium,  especially  at 
night. 

In  most  patients  the  mucous  membrane  of  the  buccal  cavity  presents  its 
normal  appearance,  with  the  exception  of  a  moist  fur  upon  the  tongue  and  a 
paler  hue  than  normal  of  its  surface  generally.  In  acute  tuberculosis  and  in 
cases  complicated  by  inflammation  the  tongue  is  sometimes  dry  and  brown. 
The  appetite  may  be  normal  till  the  close  of  life  or  it  is  poor  or  changeable. 
Occasionally  it  is  increased,  although  the  disease  is  progressing.  The  bowels 
are  regular  or  relaxed.  Diarrhoea  may  be  a  prominent  symptom,  even  when 
there  are  no  intestinal  tubercles  or  ulceration.  Meteorism  and  fulness  of  the 
abdomen  are  common. 

Fever,  constant,  but  usually  with  evening  exacerbation,  is  rarely  absent. 
It  continues  for  weeks  or  months.  During  the  exacerbation  the  pulse  rises 
to  120,  140,  or  even  to  180  beats  per  minute,  and  there  is  a  corresponding 
exaltation  of  the  temperature,  which  in  the  latter  part  of  the  day,  without 
inflammatory  complication,  ranges  from  100°  to  102°  or  103°.  The  febrile 
movement  is  a  symptom  of  diagnostic  value  as  regards  the  nature  of  the  dis- 
ease, though  it  does  not  indicate  the  seat  of  the  tubercles. 

In  addition  to  the  symptoms  now  described,  there  are  special  symptoms 
due  to  tuberculization  of  the  diff"erent  organs.  In  young  children,  on  account 
of  the  fact  already  referred  to — to  wit,  the  tendency  to  a  generalization  of 
tubercles — there  is  often  a  blending  of  the  symptoms  which  arise  from  dif- 
ferent organs,  but  with  care  it  is  not  difficult  in  most  instances  to  isolate  and 
refer  them  to  their  proper  source.  The  following  are  the  symptoms  which 
arise  from  tuberculization  of  the  more  important  organs : 

Encephalon. — The  symptoms  produced  by  tubercles  of  the  encephalon 
vary  according  to  their  seat  and  size  and  the  structural  changes  in  surround- 
ing parts  to  which  they  give  rise.  Meningeal  tubercles,  which  are  located 
for  the  most  part  in  the  meshes  of  the  pia  mater,  and  ordinarily  along  the 
course  of  the  small  arteries,  are,  as  a  rule,  small,  not  more  than  a  line  in 
diameter,  and  they  may  remain  latent  for  a  considerable  time.  In  the 
majority  of  cases,  however,  they  sooner  or  later  cause  meningitis,  the 
symptoms  of  which  are  well  known  and  need  not  be  described.  But 
tubercles  in  this  situation  do  sometimes  give  rise  to  symptoms  when 
there  is  no  meningeal  inflammation.  They  occasion  congestion  of  the  sur- 
rounding vessels  and  serous  transudation,  and,  if   developed  on  the  under 


TUBERCULOSIS.  215 

surface  of  the  pia  mater,  they  may  produce  symptoms  by  encroaching  upon 
and  irritating  the  brain  ;  for  they  are  sometimes  so  much  imbedded  in  the 
convolutions  that  careful  examination  is  required  in  order  to  determine  that 
they  are  meningeal  and  not  cerebral.  Among  these  symptoms  may  be 
mentioned  headache,  frontal  or  occipital,  sometimes  intermittent,  nausea, 
melancholy,  and  in  certain  cases  the  symptoms  produced  by  serous  trans- 
udation. 

The  symptoms  of  cerebral  are  in  part  similar  to  those  of  meningeal 
tuberculosis,  but  in  most  cases  others  of  a  neuropathic  character  are 
present,  which'  serve  for  differential  diagnosis.  The  differences  as  regards 
the  symptoms  of  different  patients  having  cerebral  tubercles  are  attribut- 
able in  part  to  their  size  and  rapidity  of  growth,  but  more  to  the  differ- 
ence in  their  seat ;  for  any  part  of  the  brain  may  be  the  seat  of  tubercles, 
though  certain  portions,  as  the  cerebellum,  are  more  frequently  affected  than 
others. 

The  child  with  cerebral  tubercles  is  quiet,  but  irritable,  and  easily  excited. 
Delirium  is  not  common,  but  many  before  the  close  of  life  exhibit  a  degree 
of  mental  dulness.  The  headache,  common  in  cases  of  cerebral  as  well  as 
meningeal  tubercles,  may  be  nearly  general,  or  it  is  frontal,  parietal,  or  occip- 
ital according  to  the  seat  of  the  tubercles.  It  is  often  lancinating,  often 
intermittent. 

Clonic  convulsions  occur  toward  the  close  of  life.  Exceptionally,  they 
are  among  the  earliest  symptoms.  Observations  have  failed  to  establish  any 
relation  between  the  seat  of  the  tubercles  and  the  localization  of  the  convul- 
sions. The  convulsions  may  be  unilateral,  while  the  tubercles  are  in  both 
hemispheres  ;  or  general,  while  the  tubercles  are  on  one  side  only. 

The  severity  and  duration  of  the  convulsive  attacks,  and  the  frequency 
of  their  occurrence  in  tuberculosis  of  the  brain,  vary  greatly  in  different 
patients.  They  have  been  attributed  to  softening  of  the  cerebral  substance, 
which  sometimes  occurs  immediately  around  the  tubercles,  to  local  conges- 
tions excited  by  them,  and  also  to  serous  effusions  in  the  ventricles.  The 
convulsions  sooner  or  later  end  in  paralysis  or  coma. 

Contraction,  or  tonic  spasm  of  certain  muscles,  is  sometimes  observed. 
Its  most  frequent  seat  is  in  the  muscles  of  the  back  and  of  one  or  both  of 
the  lower  extremities.  It  is  a  late  symptom.  It  occurs  in  those  cases  in 
which  there  is  softening  around  the  tubercles,  and  usually  in  the  muscles  of 
the  opposite  side. 

Paralysis  is  also  a  late,  but  not  an  infrequent,  symptom.  It  is  preceded 
by  headache,  and  sometimes,  as  already  stated,  by  convulsions.  Occurring 
as  a  symptom  of  tuberculosis  of  the  brain,  it  is  due  either  to  pressure  on  a 
cranial  nerve  or  to  compression  and  perhaps  softening  of  the  cerebral  sub- 
stance. The  paralysis  may  be  paraplegic,  commencing  as  feebleness  of  the 
lower  extremities,  and  increasing  until  it  becomes  complete,  or  more  or  less 
complete,  hemiplegia.  In  paraplegia  due  to  tubercles  of  the  brain  the  cere- 
bellum is,  as  a  rule,  their  seat ;  while  paralysis  of  one  side  or  of  certain  mus- 
cles of  one  side  indicates  tubercles  of  the  opposite  cerebral  hemisphere  ;  but 
there  are  exceptions.  Paralysis  of  the  third  cranial  nerve  gives  rise  to  ptosis 
— of  the  sixth,  to  paralysis  of  the  external  motor  nerves  of  the  eye.  and 
therefore  to  internal  strabismus. 

Feebleness  or  loss  of  vision,  inequality,  oscillation,  and  finally  dilatation 
of  the  pupils,  are  not  infrequent  symptoms  of  tuberculosis  of  the  brain,  and 
they  possess  great  diagnostic  value.  Atrophy  of  the  optic  nerve,  causing 
amaurosis,  sometimes  results  from  tubercles  as  well  as  other  tumors  of  the 
brain.  Atrophy  of  this  nerve  occurs  not  only  when  the  tubercles  are  so 
located  as  to  press  on  the  optic  tract,  in  which  case  the  explanation  is  appar-  .. 


216  CONSTITUTIONAL  DISEASES. 

ent,  but  also,  in  certain  patients,  when  the  tubercles  are  in  other  parts  of 
the  brain.  In  these  last  cases  it  is  thought  by  Brown-Sequard  and  others 
that  the  imperfect  nutrition  of  the  nerve  is  due  to  contraction  of  its  nutrient 
vessels,  produced  by  the  tubercles  through  reflex  action. 

In  tuberculosis  of  the  brain  symptoms  pertaining  to  the  respiratory,  cir- 
culatory, and  digestive  systems  are  either  absent  or  are  quite  subordinate  to 
those  of  a  neuropathic  character.  Slowness  of  the  pulse,  with  or  without 
intermittence,  has  sometimes  been  observed,  and  it  is  therefore  a  symptom  of 
some  diagnostic  value.  Toward  the  close  of  life  both  pulse  and  respiration 
are  usually  accelerated.  Vomiting,  constipation,  and  retraction  of  the  abdo- 
men, which  are  so  common  in  meningitis,  are  only  occasional  symptoms. 

Bronchial  Glands, — During  the  progress  of  tuberculosis,  hyperplasia, 
cheesy  degeneration,  and  softening  of  various  lymphatic  glands  may  occur 
throughout  the  body,  but  the  bronchial  and  mesenteric  are  not  only  those 
which  are  most  frequently  affected,  but  they  are  the  only  glands,  unless  in 
exceptional  instances,  which  materially  increase  the  danger  or  give  rise  to 
special  symptoms.  These  symptoms  either  have  a  mechanical  cause — to  wit, 
the  pi'essure  exerted  by  the  enlarged  glands  on  contiguous  parts — or  they  are 
due  to  softening  of  the  glands  and  consecutive  inflammation  and  ulceration. 

The  following  are  the  principal  symptoms  due  to  compression ;  some  of 
them  are  not  infrequent,  others  are  rare :  Compression  of  the  pulmonary 
veins  retards  the  flow  of  blood  from  the  lungs  to  the  left  auricle,  giving  rise 
to  congestion  and,  in  extreme  cases,  cedema  of  the  lungs,  with  sanguineous 
extravasation  into  the  lung-substance,  congestion  of  the  right  cavities  of  the 
heart,  hepatic  veins,  and  of  the  systemic  capillaries  generally.  Compression 
of  the  pneumogastric  nerve  or  of  the  recurrent  laryngeal,  which  is  the  motor 
nerve  of  the  laryngeal  muscles,  modifies  the  voice  and  produces  a  cough 
which  is  often  spasmodic.  The  cough  resembles  that  of  pertussis,  and  has 
been  mistaken  for  it,  but  it  is  not  so  violent  or  protracted.  The  voice,  clear 
and  natural  at  first,  becomes  by  degrees  hoarse  or  feeble  from  deficient  in- 
nervation of  the  laryngeal  muscles. 

An  enlarged  gland  or  mass  of  glands  lying  against  the  trachea  or  one  of 
the  bronchial  tubes  (this  may  occur  with  tubes  up  to  the  third  or  fourth 
division),  and  pressing  its  walls  inward,  obviously  obstructs  more  or  less  the 
current  of  air.  If  there  be  considerable  obsti'uction,  a  loud,  sonorous  rale  is 
produced,  which  is  heard  distinctly  at  a  distance  from  the  chest,  obscuring 
other  rales.  It  is  loudest  when  the  patient  is  agitated,  and  it  sometimes 
intermits.  Feeble  respiratory  murmur,  dyspnoea,  and  a  cough  are  not  infre- 
quent in  bronchial  phthisis.  Diminished  intensity  of  the  respiratory  murmur 
is  general  or  partial,  according  to  the  seat  of  the  compression.  It  has  been 
most  frequently  observed  at  the  summit  of  the  lungs.  In  certain  patients 
this  symptom  is  not  constant,  the  respiration  being  for  a  time  feeble  and 
then  normal.  The  dyspnoea  may  be  a  prominent  and  distressing  symptom, 
the  alae  nasi  dilating,  and  the  inframammary  region  sinking  with  each  respira- 
tion. The  cough  which  occurs  when  a  gland  presses  on  the  trachea  or  bron- 
chial tube  is  due  to  the  tracheitis  or  bronchitis  to  which  the  pressure  gives 
rise.  If  ulceration  occur  at  the  point  of  pressure,  the  cough  continues  as 
long  as  the  ulcer  remains.  Compression  of  the  large  veins  within  the  thorax 
which  return  blood  from  the  head  and  upper  extremities  causes  more  or  less 
congestion  of  these  parts,  with,  perhaps,  transudation  of  serum  in  the  sub- 
cutaneous connective  tissue  and  within  the  cranium.  Rarely,  a  softened 
gland  by  ulceration  gives  rise  to  other  symptoms  than  those  mentioned — to 
wit,  hemorrhage  by  ulceration  into  a  vessel  or  pleuritis  or  pneumonitis  if  the 
ulceration  be  toward  the  lungs. 

Improvement  in  the   condition   of  the    patient    afl'ected   with   bronchial 


TUBERCULOSIS.  217 

phthisis  is  not  unusual.  It  may  be  permanent,  but  in  most  patients  it  is 
temporary,  so  that  in  a  few  weeks  or  months  the  symptoms  are  as  severe  as 
before.  The  improvement  is  due  to  softening  and  elimination  of  a  gland 
which  had  given  rise  to  symptoms  by  its  mechanical  effect  or  by  the  inflam- 
mation which  it  had  excited. 

Physical  Signs. — From  Tubercular  Bronchial  Glands. — These  are  absent 
or  obscure  in  the  incipient  disease  when  the  glands  are  small,  and  they  are 
most  marked  in  those  cases  in  which  the  glands  are  so  large  as  to  press  on 
the  thoracic  walls,  since  they  then  become  the  medium  for  the  transmission 
of  sounds  to  the  ear.  The  part  of  the  thorax  against  which  they  most  fre- 
quently press  is  the  dorsal  vertebrae  from  the  first  to  the  sixth,  and  each  side 
of  the  vertebrae,  and  less  frequently  the  upper  third  of  the  sternum.  The 
physical  signs  are  dulness  on  percussion  over  the  interscapular  space,  and 
perhaps,  though  to  a  less  extent,  over  the  upper  part  of  the  sternum,  and 
bronchial  respiration  in  the  same  sitvxations.  Occasionally  a  bruit  can  be 
detected,  due  to  the  pressure  of  a  gland  on  one  of  the  large  vessels  of  the 
chest. 

Lungs. — A  cough  is  one  of  the  earliest  and  most  persistent  of  the  symp- 
toms of  pulmonary  tuberculosis.  It  is  so  rarely  absent  that  those  of  large 
experience  do  not  meet  with  more  than  one  or  two  such  cases.  It  varies  in 
severity  and  frequency.  If  the  tuberculosis  be  acute,  and  its  course  rapid, 
the  cough,  even  from  its  commencement,  is  frequent,  so  as  to  weary  the 
patient  and  deprive  him  of  needed  rest.  But  in  ordinary  cases — that  is, 
when  the  disease  is  chronic — it  commences  gradually,  attracting  at  first  little 
attention  by  its  infrequency,  but  becoming  more  frequent  and  painful  as  the 
malady  advances. 

Ordinarily,  the  cough  is  dry  in  the  first  weeks  or  months,  but  it  becomes 
looser  in  the  course  of  the  disease,  from  the  greater  amount  of  bronchial 
inflammation.  In  exceptional  instances  it  has  a  spasmodic  character,  like 
that  produced  by  pressure  of  an  enlarged  bronchial  gland  on  the  pneumo- 
gastric  or  recurrent  laryngeal  nerve.  This  occurs  from  the  accumulation  of 
viscid  mucus  in  one  or  more  of  the  bronchial  tubes,  usually  in  dilated  portions 
of  them,  from  which  it  is  with  difficulty  expectorated. 

The  respiration  in  pulmonary  tuberculosis  is  accelerated  in  proportion  to 
the  degree  of  tuberculization.  Tuberculization  of  a  considerable  part  of  both 
lungs  gives  rise  to  dyspnoea,  especially  when,  as  is  ordinarily  the  case,  bron- 
chial, pulmonary,  or  pleuritic  inflammation  has  supervened.  Pneumonitis  or 
pleuritis  gives  rise  to  the  expiratory  moan,  and  as  these  inflammations,  when 
induced  by  tubercles,  are  protracted,  the  symptom  may  continue  for  weeks 
or  months. 

Patients  under  the  age  of  six  years  do  not  expectorate,  or  but  rarely. 
After  this  age  expectoration  is  not  common  in  the  commencement  of  pul- 
monary tuberculosis,  but  in  the  confirmed  disease  it  is  a  pretty  constant 
attendant  of  the  cough.  Hasmoptysis  is  also  rare  under  the  age  of  six  years, 
and  less  frequent  subsequently  than  in  the  adult.  It  is  most  likely  to  occur 
in  those  cases  in  which  there  is  already  passive  congestion  of  the  lungs  pro- 
duced by  the  pressure  of  enlarged  bronchial  glands  in  the  manner  already 
described.  Patients'  old  enough  to  express  their  sensations,  sometimes  com- 
plain of  fugitive  pains  under  the  sternum  or  between  the  shoulders. 

In  young  children  the  physical  signs  of  incipient  pulmonary  tuberculosis- 
are  wanting,  or  are  so  obscure  as  not  to  be  readily  recognized.  This  is  due 
to  the  small  size  and  dissemination  of  the  tubercles.  In  older  children  the 
physical  signs  appear  early,  and  are  readily  recognized,  because,  as  a  rule, 
the  tubercles  are  aggregated,  and  are  more  frequently  at  the  apices  of  the 
lungs,  as  in  the  adult,  than  elsewhere.     In  the  advanced  disease,  whether  in 


218  CONSTITUTIONAL  DISEASES. 

infancy  or  childhood,  when  inflammation  and  more  or  less  destruction  of  the 
lung-substance  have  occurred,  the  physical  signs,  so  far  from  being  obscure, 
enable  us,  in  most  cases,  in  connection  with  the  history,  to  make  an  immediate 
and  positive  diagnosis. 

In  young  children  affected  with  pulmonary  tuberculosis  the  irregular  and 
imperfect  expansion  of  the  lungs  produces  by  degrees  changes  in  the  shape 
of  the  thorax  which  are  apparent  on  inspection.  In  some,  the  lungs  being 
habitually  imperfectly  inflated,  the  obliquity  of  the  ribs  is  increased,  and  the 
thorax  consequently  elongated,  while  its  antero-posterior  and  transverse  diam- 
eters are  diminished.  This  obviously  increases  the  convexity  or  arch  of  the 
diaphragm,  so  that  this  muscle  sometimes  lies  against  the  thoracic  walls  as 
high  as  the  ninth  or  even  eighth  rib.  If  the  costal  cartilages  are  yielding, 
there  are  anterior  flattening  of  the  chest  and  depression  of  the  stei'num  ;  if 
they  are  firm  on  account  of  the  more  advanced  age,  the  chest  remains  circular. 

Another  shape  of  the  thorax  is  not  infrequent  in  feeble  tubercular  chil- 
dren, especially  infants,  who  have  suff'ered  from  repeated  attacks  of  bronchitis. 
It  occurs  also  in  the  non-tubercular  if  the  conditions  which  favor  it  are  present. 
The  conditions  are,  on  the  one  hand,  feebleness  of  the  patient,  with  diminished 
force  of  respiration  and  impaired  resiliency  of  the  ribs,  and,  on  the  other, 
obstruction  by  mucus  of  one  or  more  of  the  bronchial  tubes.  Occlusion,  more 
or  less  complete,  of  a  bronchial  tube,  and  consequent  obstruction  to  the  current 
of  air,  produce  a  corresponding  degree  of  collapse  in  the  portion  of  lung  to 
which  the  tube  leads.  The  parts  which  collapse  are,  in  most  cases,  the  lower 
lobes  and  the  thin  anterior  margins  of  the  upper  lobes.  This  causes  lateral 
depression  of  the  lower  ribs,  except  such  as  are  pressed  outward  by  the 
abdominal  viscera  and  an  anterior  projection  of  the  lower  part  of  the  sternum. 
The  shape  of  the  thorax  in  these  cases  differs  from  that  in  rachitis  in  the  fact 
that  the  lateral  depression  does  not  extend  to  the  upper  ribs,  nor  does  the 
upper  part  of  the  sternum  project. 

Certain  precautions  should  be  observed  in  examining  the  chest  by  percus- 
sion and  auscultation.  The  child  should  sit  or  recline,  with  the  arms  and 
shoulders  in  the  same  position  on  the  two  sides,  and  the  axis  of  the  trunk 
straight.  Inclination  of  the  trunk  to  either  side,  raising  or  depressing  a 
shoulder,  may  produce  an  appreciable  difference  in  the  two  sides  as  regards 
the  physical  signs.  Percussion  of  the  two  sides  should  be  practised  at  the 
same  stage  of  respiration.  A  slight  difference  in  the  degree  of  resonance 
does  not  afford  proof  of  disease  unless  it  be  observed  at  different  examina- 
tions ;  for  in  feeble  children  it  often  happens  that  all  portions  of  the  lungs  do 
not  expand  alike,  so  that  where  we  have  noticed  slight  dulness  at  one  visit, 
it  may  by  the  next  have  disappeared,  or  even  at  the  same  visit,  if  forcible 
inspirations  be  excited. 

The  physical  signs  ascertained  by  palpation,  auscultation,  and  percussion 
are,  as  in  the  adult,  vocal  fremitus,  bronchial  respiration,  bronchophony,  and 
dulness  on  pei'cussion.  In  those  cases  in  which  the  tubercles  are  mainly  at 
the  apices  of  the  lungs,  diminished  expansion  of  the  infraclavicular  region  is 
observed  during  inspiration,  and  this  part  of  the  thoracic  wall  is  permanently 
depressed,  so  that  the  clavicles  are  unusually  prominent.  If  there  be 
emphysema,  this  flattening  does  not  occur  or  is  slight.  Dulness  on  percus- 
sion, though  more  frequently  observed  in  the  infraclavicular  region  than 
■elsewhere,  may  be  present  in  different  isolated  places.  If  pneumonia  super- 
vene, the  dulness  not  infrequently  extends  over  a  considerable  part  of  one 
lung.  The  cracked-pot  sound  is  often  observed  on  percussion,  but  it  pos- 
sesses little  diagnostic  value.  It  can  be  produced  when  there  is  no  pul- 
monary disease  by  percussion  over  a  bronchus. 

Bronchial  respiration  and  bronchophony  are  important  signs,  as  indicating 


TUBERCULOSIS.  219 

solidification  of  the  lung,  but  they  do  not  show  whether  the  solidification  be 
tubercular  or  pneumonic  or  the  two  conjoined.  This  must  be  determined 
by  the  history  of  the  case,  the  extent  of  surface  over  which  these  signs  are 
heard,  and  their  persistence.  When  the  tubercles  begin  to  soften  and  the 
lung-tissue  breaks  up,  moist  rales  appear,  often  hoarse  and  gurgling,  obscur- 
ing the  bronchial  respiration.  A  cavity  in  the  lung,  or  pneumothorax,  is 
attended  by  the  same  physical  signs  as  in  the  adult. 

Pleura. — Little  need  be  said  in  reference  to  the  symptoms  and  physical 
signs  of  tuberculosis  of  the  pleui'a,  since  this  affection  is  in  most  instances 
associated  with  tuberculosis  of  the  lungs,  and  is  not  distinguishable  from  it. 
But  now  and  then  the  pleural  tubercles  are  numerous  and  large,  giving  rise 
to  symptoms,  while  those  of  the  lungs  are  small,  few,  and  without  symptoms 
or  attended  by  symptoms  which  are  quite  subordinate.  Either  the  costal 
or  visceral  portion  of  the  pleura  may  be  the  seat  of  tubercles.  They  are 
developed  directly  under  the  pleura  or  upon  its  free  surface.  They  may 
occur  in  the  newly-formed  connective  tissue  which  results  from  pleuritis. 
Those  located  upon  the  free  surface  or  under  the  costal  pleura  rarely  soften, 
while  those  under  the  visceral  pleura  sometimes  soften  and  cause  ulceration. 
Occasionally  numerous  aggregated  tubercles  form  a  firm  continuous  layer 
upon  the  surface  of  the  pleura,  preventing,  if  upon  the  visceral  pleura,  full 
expansion  of  the  lung.  This  may  give  rise  to  a  degree  of  dulness  on  per- 
cussion and  feebleness  of  the  respiratory  murmur.  Ordinarily,  however,  in 
this  form  of  tuberculosis  the  symptoms  and  physical  signs,  so  far  as  any  are 
observed,  are  due  to  the  pleuritic  inflammation  which  the  tubercles  excite. 

Stomach  and  Intestines. — The  symptoms  in  tuberculosis  of  the  stomach 
and  intestines  vary  according  to  the  seat  and  stage  of  the  tubercles. 

Tubercles,  whether  gastric  or  intestinal,  are  not  at  first  accompanied  by 
symptoms,  or  the  symptoms  are  obscure  and  ill-defined.  Symptoms  arise 
when  inflammation  occurs  in  the  tissues  in  which  the  tubercles  are  imbedded 
or  upon  which  they  lie,  and  through  their  irritating  action.  Diarrhoea  is  one 
of  the  most  common  and  persistent  of  the  symptoms.  The  alvine  discharges 
are  brown  and  thin,  and  sometimes,  in  advanced  cases,  very  ofiensive.  They 
may  be  streaked  with  blood  which  has  escaped  from  the  ulcers.  Intestinal 
tubercles,  developed  immediately  underneath  the  peritoneal  coat,  sometimes 
cause  local  peritonitis,  usually  of  little  extent.  This  gives  rise  to  circum- 
scribed pain,  tenderness,  and  more  or  less  meteorism. 

Diagnosis. — It  is  evident  from  the  foregoing  description  of  symptoms 
that  the  diagnosis  of  incipient  tuberculosis  is  much  more  difficult  in  children 
than  adults.  Before  commencing  the  examination  it  is  best  to  learn  the 
hereditary  tendencies  of  the  family  and  the  history  of  the  patient,  especially 
as  regards  antecedent  disease  or  debilitating  agencies,  and  the  duration  of 
the  symptoms. 

Early  and  accurate  diagnosis  of  tuberculosis  in  the  child,  as  well  as  in 
the  adult,  is  now  rendered  possible  by  the  discovery  of  the  tubercle  bacillus 
in  1882  by  Koch.  This  bacillus,  abounding  in  the  sputum  as  well  as  in  the 
affected  organs  of  phthisical  patients,  having  a  slender  rod-like  form,  with 
a  length  varying  from  one-fourth  to  the  entire  diameter  of  the  red  blood-cor- 
puscles, and  susceptible  of  a  peculiar  staining  by  the  aniline  colors  which 
differentiates  it  from  all  other  bacilli,  is.  as  we  have  stated  above,  believed  to 
be  uniformly  present  in  tuberculosis  and  absent  in  other  conditions. 

Children  with  tuberculosis  of  the  lungs  expectorate  comparatively  little, 
but  sufficient  sputum  can  be  obtained  in  most  instances  for  the  purpose  of 
diagnosis.  The  presence  of  the  bacillus  indicates  clearly  the  tubercular 
nature  of  the  disease. 

Tuberculosis  of  the  encephalon  is  diagnosticated  with  more  difficulty  than 


220  CONSTITUTIONAL  DISEASES. 

that  of  the  thoracic  or  abdominal  organs  ;  but  certain  of  these  organs  are  in 
most  patients  tubercular  at  the  same  time,  and  the  knowledge  of  the  fact 
that  they  are  affected  aids  in  the  diagnosis  of  the  disease  of  the  brain  or  its 
meninges.  Among  the  symptoms  of  intracranial  tuberculosis  which  possess 
diagnostic  value  may  be  mentioned  cephalalgia  and  more  or  less  fever,  with 
exacerbations  in  the  commencement  of  the  disease,  and,  at  a  more  advanced 
period,  strabismus,  inequality  or  irregular  action  of  the  pupils,  impairment 
of  vision,  retraction  of  the  head,  and  convulsive  movements  or  paralysis. 

In  certain  cases  careful  observation  and  discrimination  of  symptoms  are 
requisite  in  order  to  determine  whether  they  arise  from  intracranial  tubercles 
or  from  congestion  of  the  brain  caused  by  obstruction  in  the  venous  circu- 
lation by  the  pressure  of  enlarged  bronchial  glands. 

The  diagnosis  of  bronchial  phthisis,  when  the  glands  are  still  small,  is 
necessarily  uncertain,  on  account  of  the  absence  of  symptoms.  When  they 
have  increased  in  size  and  are  so  located  as  to  press  on  the  pneumogastric  or 
recurrent  laryngeal  nerve,  producing  the  spasmodic  cough  already  described, 
the  differential  diagnosis  between  that  disease  and  pertussis  may  be  made  by 
attention  to  the  following  facts :  Bronchial  phthisis  occurs  singly  and  is  non- 
contagious, while  pertussis  occurs  as  an  epidemic  and  with  evidences  of  con- 
tagion. There  are  no  successive  stages — to  wit,  those  of  catarrh,  paroxysmal 
cough,  and  decline — as  in  that  disease,  and  the  cough,  though  paroxysmal,  is 
short  and  without  whoop  or  vomiting. 

In  feeble  children  with  inherited  tubercular  diathesis,  emaciation,  sweats, 
a  chronic  cough,  and  the  absence  of  pulmonary  symptoms,  should  excite 
suspicions  that  the  bronchial  glands  are  involved.  The  evidence  is  almost 
conclusive  if  the  cough  become  paroxysmal  and  there  be  a  loud,  persistent 
tracheal  or  bronchial  rale. 

In  certain  patients  affected  with  this  form  of  tuberculosis  we  have  seen 
that  the  prominent  symptoms  are  due  to  compression  of  one  or  more  of  the 
large  vessels  in  the  chest.  Compression  of  these  vessels,  and  consequent 
retarded  circulation,  may  be  confidently  referred  to  enlarged  bronchial  glands, 
since  aneurism,  carcinomatous  or  other  tumors,  which  would  produce  a  sim- 
ilar result,  are  very  rare  before  puberty.  Sometimes  the  diagnosis  is  rendered 
certain  by  the  physical  signs  observed  by  auscultation  and  percussion  over 
the  sternum  and  the  interscapular  space.  The  condition  of  the  external 
glands  should  also  be  observed,  as  those  of  the  axilla,  neck,  and  groin. 

The  diagnosis  of  pulmonary,  though  more  readily  made  than  that  of 
intracranial  and  bronchial,  tuberculosis  is  often  difficult  and  uncertain.  This 
is  in  part  explained  by  the  fact  that  the  tubercles  are  so  frequently  dis- 
seminated, while  emaciation  and  a  chronic  cough  are  not  infrequent  from 
other  causes  than  tubercles.  Rachitis,  intestinal  worms,  dentition,  simple 
tracheal  or  bronchial  inflammation,  may  be  attended  both  by  a  chronic  cough 
and  emaciation.  Caution  is  therefore  requisite  in  order  to  avoid  a  grave  error 
in  diagnosis.  Precipitancy  in  the  diagnosis  of  doubtful  cases  is  worse  than 
indecision,  and  it  is  often  best  to  postpone  an  expression  of  opinion  as  to  the 
nature  of  the  disease  till  the  case  has  been  observed  a  few  days. 

The  significance  and  importance  of  the  symptoms,  physical  signs,  and 
other  facts  on  which  a  diagnosis  must  be  based  have  already  been  sufficiently 
pointed  out.  It  is  difficult — in  fact,  in  certain  cases  impossible — to  discrim- 
inate by  the  physical  signs  between  simple  cheesy  pneumonia  and  cheesy  pneu- 
monia which  has  ended  in  the  formation  of  tubercles.  The  patient  has  an 
attack  of  catarrhal  pneumonia,  but  instead  of  absorption  of  the  infiammatory 
product,  cheesy  infiltration  occurs,  and  the  lung  in  places  becomes  infiltrated 
with  pus,  softens,  and  breaks  down.  The  patient  pi-esents  the  symptoms  and 
physical  signs  of  phthisis.       He  may  recover   after  a  protracted  sickness  or 


TUBERCULOSIS.  221 

may    die.      But    cheesy    degeneration    of    the    inflammatory    product    com- 
monly ends    in  the    development  of  tubercles,  and  in  a  certain  proportion 
of   cases  tubercles  do  form  in  the   last  weeks  of  life.     Though  the  differ- 
ential diagnosis  in  such  cases  between  cheesy 
pneumonia  and  tuberculosis  supervening  on  Fig.  39. 

pneumonia  is  impossible  by  the  physical 
signs,  practically  the  discrimination  is  unim- 
portant, as  the  same  treatment  is  required. 
But  it  is  obvious,  from  the  facts  now  ascer- 
tained in  reference  to  the  tubercle  bacillus, 
that  in  all  cases  of  doubtful  diagnosis  the 
sputum,  if  it  can  be  obtained,  should  be  ex- 
amined microscopically.  If  the  bacillus  be 
present,  the  diagnosis  of  tubercular  disease 
may  be  considered  certain. 

Prognosis. — It  has  long  been  the  belief 
in  the  profession,  as  well  as  among  the  laity, 
that  tuberculosis  is  in  the  end,  with  few  ex- 
•ceptions,  fatal,   whatever  remedial  measures 

are  employed,  and  that,  therefore,  remedies 

T-        ,  .  -Uii  ii.  Bacilli  of  tubercle  from  sputum. 

may  ameliorate  symptoms,  but  do  not  change  ^  50o  (Bristowe). 

the   result.     But    since    attention    has    been 

■directed  to  this  subject  a  sufficient  number  of  observations  have  been  made 
to  show  that  tuberculosis  at  an  early  stage  can  in  a  considerable  number 
of  cases  be  cured  or  rendered  latent.  The  late  Professor  Austin  Flint,  in 
his  treatise  on  Phthisis,  published  in  1875,  stated  that  of  670  phthisical 
cases  which  came  under  his  observation,  he  ascertained  by  auscultation  and 
percussion  that  the  disease  had  been  cured  in  44  and  was  non-progressive  in 
31  others.  But  the  most  convincing  proof  of  the  curability  of  tuberculosis 
is  furnished  by  the  post-mortem  examination  of  those  who  died  of  other  dis- 
eases. A  cretaceous  or  fibroid  state  of  the  apex  of  the  lung,  without  tuber- 
cles elsewhere,  may  be  regarded  as  certain  evidence  of  arrested  tuber- 
culosis. Now,  two  of  the  curators  of  large  New  York  hospitals  inform  me 
that  they  frequently  find  cretaceous  or  fibroid  degeneration  at  the  apex  of 
the  lung,  without  tubercles  elsewhere,  in  the  autopsies  in  these  institutions. 
One  of  these  gentlemen,  whose  examinations  are  in  the  dead-house  of  Belle- 
vue  Hospital,  states  that  this  evidence  of  arrested  tuberculosis  is  present 
In  at  least  ojie-fourth  of  the  cadavers  which  he  examines.  The  Bellevue 
Hospital  patients  come  from  the  most  crowded  and  insalubrious  tenement- 
houses  of  the  city,  and  have  led  a  life  of  poverty  and  privation,  and  fre- 
quently of  dissipation.  H.  P.  Loomis  {Med.  Record,  Jan.  9,  1892)  gives  the 
following  results  of  post-mortem  examinations  made  in  the  Bellevue  dead- 
house.  Of  769  dying  of  non-tubercular  diseases,  71,  or  over  9  per  cent.,  had 
the  anatomical  characters  of  a  cured  tuberculosis.  The  London  Lancet 
(September  22,  1888)  states  that  M.  Vibert  has  examined  the  records  of 
the  necropsies  in  the  Paris  Morgue,  and  that  in  131  subjects  who  had  died 
suddenly  from  violence  or  acute  diseases,  the  lesions  of  pulmonary  tuber- 
culosis were  present  in  25,  and  in  17  of  these  the  tubercles  had  undergone 
the  cretaceous  or  fibroid  change,  and  were  practically  cured.  It  is  certain, 
therefore,  that  tuberculosis  in  its  commencement,  and  when  affecting  only 
a  small  portion  of  the  lung,  is  often  cured  or  rendered  permanently  latent. 
It  is  now  known  that  ordinary  serum  circulating  in  the  blood-vessels 
possesses  marked  germicidal  properties,  and  therefore  measures  which  benefit 
the  general  health  and  improve  the  quality  of  this  important  constituent  of 
the  blood  have  a  curative  eff"ect  as  regards  tuberculosis.     The  tubercle  bacillus 


222  CONSTITUTIONAL  DISEASES. 

is  an  irritant  to  the  tissues,  and  in  cases  which  are  cured  or  rendered  latent  it 
becomes  surrounded  by  dense  tissue  which  in  time  undergoes  the  cretaceous 
or  fibroid  degeneration.  The  bacilli  in  the  interior  of  the  mass  may  retain 
their  vitality  for  an  indefinite  time,  but.  being  encapsulated,  they  do  no  harm. 
There  can  be  no  doubt  that  many  adults  have  local  tuberculosis,  and  are  cured 
by  improvement  in  their  general  health  and  in  the  quality  of  their  blood, 
without  suspecting  that  they  have  had  this  disease.  In  young  children, 
especially  in  infants,  tubercles  are  frequently  disseminated  in  the  organs, 
and  recovery  under  such  circumstances  must  be  impossible  or  rai'e  ;  but  local 
tuberculosis  or  tuberculosis  limited  to  certain  glands,  as  the  bronchial,  is  not 
unusual  in  childhood,  and  this  form  of  the  tubercular  disease  may  be  cured 
by  measures  which  improve  the  general  health. 

Hospital  statistics  show  that  the  average  duration  of  the  disease  is  from 
three  to  seven  months.  Under  favorable  circumstances  it  is  more  protracted, 
even  to  two  or  three  years.  Those  succumb  soonest  who  inherit  a  strongly- 
marked  tubercular  diathesis,  live  in  damp,  dark,  and  ill-ventilated  apartments, 
and  whose  diet  is  scanty  or  of  poor  quality.  Therefore  in  the  poor  quarters 
of  the  city  tuberculosis  presents  a  worse  form  and  pursues  a  more  rapid  course 
than  among  families  in  better  circumstances. 

Favorable  prognostic  signs  are  absence  of  tubercular  diathesis,  good 
appetite  and  general  health,  with  little  emaciation,  infrequency  of  cough, 
with  respiration,  pulse,  and  temperature  nearly  normal.  Such  symptoms  may 
aiford  hope  of  recovery  with  judicious  regiminal  and  therapeutic  measures. 
On  the  other  hand,  if  the  symptoms  be  grave  death  is  inevitable,  unless  in 
bronchial  phthisis,  in  which,  even  when  there  is  considerable  urgency  of 
symptoms,  the  offending  gland  is  sometimes  eliminated  by  softening  and 
ulceration,  and  the  patient  improves  temporarily,  if  he  do  not  ultimately 
recover.  Complete  and  permanent  recovery  is,  however,  quite  exceptional  in 
bronchial  phthisis,  as  it  is  in  other  forms  of  the  disease.  As  Liebermeister 
has  said,  recovery  in  any  form  of  tuberculosis  is  impossible  except  in  incipient 
and  very  limited  forms  of  the  disease. 

Death  in  tuberculosis  of  children  may  occur  from  exhaustion  induced  by 
the  general  disease  or  from  the  local  effects  of  the  tubercles.  Thus,  in  intra- 
cranial tuberculosis  it  may  result  from  meningitis  ending  in  convulsions  and 
coma ;  in  pulmonary  tuberculosis,  from  dyspnoea,  though  more  frequently 
from  exhaustion ;  in  that  of  the  bronchial  glands,  from  dyspnoea  or  hemor- 
rhage ;  in  that  of  the  abdominal  organs,  from  peritonitis  or  protracted  diar- 
rhoea. - 

Prophylaxis. — Since  tuberculosis  originates  in  so  many  different  ways, 
measures  designed  to  prevent  this  disease  have  a  wide  range.  Precau- 
tionary measures  are  especially  required  in  the  nursing  of  the  tubereulovxs 
patient.  His  sputum  should  always  be  received  in  a  cup  or  spittoon  contain- 
ing a  disinfectant  liquid,  and  this  vessel  when  emptied  should  be  cleansed 
with  boiling  water  or  a  disinfectant.  Sputum  should  never  be  received  upon 
a  handkerchief  or  cloth  and  allowed  to  dry.  Towels  and  handkerchiefs  should 
be  moist  when  used,  and  immediately  afterward  placed  in  boiling  water  or  a 
disinfectant.  We  have  seen  what  disastrous  results  occur  from  the  dried 
sputum.  Whatever  may  be  said  of  the  innocuousness  of  the  breath  of  the 
phthisical  patient,  based  on  the  supposition  that  the  tubercle  bacillus  has  so 
great  a  specific  gravity  in  its  moist  state  that  it  is  not  exhaled  in  ordinary 
respiration,  nevertheless  the  sad  experience  of  the  midwife  related  in  a  fore- 
going page  should  teach  us  to  avoid  the  breath  of  a  consumptive  so  far  as  is 
compatible  with  proper  ministrations  to  him.  The  floors  and  walls  of  his 
apartment  should  occasionally  be  washed  with  a  disinfectant  fluid,  and  the 
bedding,  clothing,  rugs,  and  mats  should  never  be  shaken  in  the  apartment, 


TUBERCULOSIS.  223 

but  outside  the  house.  Ventilation  of  the  apartment  should  be  allowed  to 
the  full  extent  compatible  with  the  safety  of  the  patient.  The  remedies 
which  we  will  hereafter  recommend  in  the  treatment  of  the  patient  are 
destructive  to  the  bacillus,  and  therefore  whenever  employed  have  also  a 
prophylactic  action. 

No  physician  who  has  read  in  the  medical  journals  of  the  last  decade  the 
many  reports  of  cases  in  which  milk  has  been  the  vehicle  of  pathogenic 
organisms  has  failed  to  see  the  urgent  need  of  obtaining  this  indispensable 
article  from  healthy  dairies.  Families  should  insist  on  the  inspection  at 
regular  intervals  of  the  dairies  that  furnish  them  milk,  and  the  exclusion  of 
such  animals  as  exhibit  the  least  sickness.  Moreover,  no  one  with  a  chronic 
cough  should  be  employed  in  milking  or  in  the  subsequent  handling  of  the 
milk.  To  this  matter  we  have  already  called  attention.  But  with  the  utmost 
endeavor,  on  the  part  of  families  living  at  a  distance,  to  obtain  milk  free  from 
impurities,  no  one  can  state  positively  that  it  will  not  sooner  or  later  contain 
pathogenic  organisms,  as  those  of  diphtheria,  scarlet  fever,  typhoid  fever,  or 
tuberculosis,  so  many  and  unsuspected  are  the  modes  of  infection.  Fortu- 
nately, heat  at  or  near  the  boiling-point  is  an  effectual  sterilizing  agent,  and 
it  can  be  employed  without  diminishing  the  nutritive  properties  of  milk  or 
rendering  it  more  indigestible.  I  do  not  forget  the  interesting  experiments 
which  have  been  made  to  determine  the  tenacity  of  life  of  the  tubercle 
bacillus  when  subjected  to  heat  and  cold.  In  experiments  made  it  is  said 
to  outlive  most  of  the  microbes  associated  with  it.  Schill  and  Fischer  state 
that  dried  and  pulverized  tubercular  matter  not  subjected  to  treatment 
retains  its  virulence  six  months,  and  Pietro  states  that  tubercular  sputum 
well  dried  and  maintained  at  77°  retains  its  virulence  nine  or  ten  months. 
But  what  concerns  us  most  at  present  is  the  remai'kable  statement  made  by 
Max  Voelsch  (^Centralb.  fur  kUn.  Med.,  June  30,  1888),  that  twice  boiling, 
does  not  entirely  destroy  the  virulence  of  the  tubercle  bacillus.  I  habitually 
direct  that  the  morning  supply  of  milk  designed  for  children  shall  be  imme- 
diately placed  in  a  steamer  and  subjected  for  fifteen  minutes  to  a  temperature 
of  167°,  the  temperature  which,  according  to  Pasteur,  is  sufficient  to  destroy 
the  pathogenic  germs.  No  pathogenic  microbe  can  probably  survive  if  sub- 
jected so  long  a  time  to  this  degree  of  heat.  The  flesh  of  the  tubercular 
animal,  which  it  is  believed  is  often  purchased  by  unsuspecting  families, 
evidently  requires  siiuilar  treatment — that  is,  thorough  cooking — in  order  t» 
be  rendered  innocuous.  A  competent  meat  inspector  should  be  employed  at 
each  slaughter-house,  and  all  diseased  meats  be  rejected ;  but  in  the  present 
management  of  the  meat  market  the  only  sure  method  of  preventing  the 
presence  of  living  and  active  bacilli  in  the  meat  foods  appears  to  be  by 
thorough  cooking. 

Outdoor  life,  residence  in  elevated  localities,  where  the  air  is  not  only 
pure  but  rarefied,  the  occupancy  of  sunlit  and  well-ventilated  rooms,  the 
avoidance  of  rooms  or  localities  where  the  air  is  contaminated  by  the  pres- 
ence of  others,  as  in  crowded  schools  or  factories,  or  by  unwholesome  occu- 
pations, and  all  measures  which  promote  the  appetite  and  general  health,  are 
prophylactic,  as  they  are  also  to  a  certain  extent  curative,  of  tuberculosis. 
It  is  evident,  from  what  has  been  stated  above,  that  caseous  substance  occur- 
ring in  any  part  of  the  system,  inasmuch  as  it  sustains  a  close  causal  relatioji 
to  tuberculosis,  should,  if  practicable,  be  removed  by  surgical  measures. 
Moreover,  since  cheesy  degeneration  results  for  the  most  part  from  inflam- 
mations occurring  in  the  scrofulous,  measures  designed  to  prevent  or  cure 
such  inflammations  or  to  cure  scrofula  have  a  prophylactic  effect  as  regards 
tuberculosis.  The  strumous  child  should  be  watched  with  great  care,  and 
such  measures  be  employed  as  are  calculated  to  invigorate  his  system.     He 


224  CONSTITUTIONAL  DISEASES. 

should  receive  antistrumous  treatment,  both  hygienic  and  medicinal.  Espe- 
cially should  glandular  hyperplasia  and  the  products  of  inflammation,  whether 
occurring  in  the  lungs  or  elsewhere,  be,  if  possible,  removed  before  caseation 
occurs.  For  this  purpose  the  old  remedies,  like  cod-liver  oil  and  syrup  of 
the  iodide  of  iron,  given  internally,  and  for  hyperplasia  of  the  subcutaneous 
glands  ointments  like  iodide  of  potassium  in  lanolin,  may  be  advantageously 
employed.  Finally,  one  having  an  abrasion  or  sore  of  the  cutaneous  or 
mucous  surface,  or  catarrh  of  the  air-passages,  as  indicated  by  discharge 
from  the  nostrils,  sore  throat,  or  a  cough,  should  not  attend  as  nurse  or 
otherwise  a  phthisical  patient  until  his  local  ailment  is  cured,  since  the  tuber- 
cle bacillus  is  believed  to  enter  the  system  more  readily  through  a  diseased 
than  a  healthy  surface. 

Treatment. — The  indications  of  treatment  are  twofold  :  first,  to  invigorate 
the  system  in  every  possible  way,  so  that  the  organs  and  tissues  are  in  a  better 
condition  to  resist  the  bacillus  and  the  serum  to  antagonize  and  destroy  it ; 
and,  secondly,  the  employment  of  medicinal  agents,  if  such  can  be  found, 
which  are  destructive  to  the  bacillus  and  safe  to  the  patient. 

Measures  designed  to  improve  the  general  health  must  be  chiefly  hygienic, 
and  are  described  in  the  text-books.  The  diet  should  consist  of  sterilized 
milk,  the  meat  preparations,  and  farinaceous  substances,  prepared  in  such 
a  way  that  they  afford  the  maximum  amount  of  nutriment  and  are  easily 
digested.  If  the  digestion  be  poor,  peptonized  food  may  be  advantageously 
employed,  and  pepsin  may  be  taken  with  the  food.  In  1881-82,  Debove 
recommended  gavage  or  forced  feeding  of  consumptives  through  a  flexible 
rubber  tube  having  a  funnel  attachment,  the  tube  being  introduced  into  the 
stomach.  He  employed  meat  preparations,  with  pepsin.  In  the  Medical 
Neios,  October  1,  1887,  Dr.  S.  Solis-Cohen  of  Philadelphia  also  recommended 
gavage  in  the  treatment  of  phthisis.  A  quart  of  milk,  two  tablespoonfuls 
of  beef  powder,  three  eggs,  fifteen  grains  of  scale  pepsin,  and  thirty  drops 
of  dilute  muriatic  acid  were  warmed  and  administered  twice  daily  through 
a  stomach-tube,  a  patient  eating  what  he  wished  in  the  interval.  Gavage 
has  been  employed  by  certain  European  physicians  in  the  treatment  of  chil- 
dren suffering  from  various  forms  of  innutrition,  and  it  seems  probable  that 
tubercular  patients  may  be  benefited  by  it  in  some  instances.  In  the  ordi- 
nary mode  of  feeding,  the  pi-edigested  foods  can  often  be  used  with  benefit 
by  consumptives,  inasmuch  as  they  have,  for  the  most  part,  feeble  digestion. 

As  regards  the  hygienic  measures  designed  to  arrest  tuberculosis,  the 
most  important,  next  to  the  use  of  proper  food  and  the  employment  of  such 
aids  to  nutrition  as  cod-liver  oil  and  the  alcoholic  preparations,  is  outdoor  life, 
and,  if  possible,  in  localities  having  a  high  altitude.  The  late  Professor  Flint, 
in  examining  the  records  of  62  eases  of  arrested  phthisis  which  came  under 
his  observation,  ascertained  that  the  principal  agent  in  effecting  this  result 
was  exercise  in  the  open  air.  He  therefore  strongly  recommended  this  mode 
of  life  to  consumptives,  and  also  constant  ventilation  of  their  sleeping  apart- 
ments, even  in  the  winter  season,  the  danger  of  taking  cold  being  averted  by 
maintaining  sufficient  warmth  of  air  by  a  fire.  Dr.  James  Blake  has  also 
reported  instances  of  recovery  of  phthisical  patients  who  lived  during  the 
five  or  six  months  of  the  dry  season  in  the  open  air  upon  the  Coast  Range 
of  mountains  in  California  at  an  altitude  of  3000  to  5000  feet.  These 
patients  were  in  the  open  air  night  and  day,  without  even  the  protection 
of  tents. 

Residence  at  a  High  Altitude. — The  London  Lancet,  May  26,  1888,  contains 
the  abstract  of  a  paper  read  before  the  Medico-Chirurgical  Society  of  London 
by  Dr.  Williams,  recommending  residence  at  a  high  altitude  as  an  efficient 
means   of   checking  the   progress   of  tuberculosis.     He   states  that   of   141 


TUBERCULOSIS.  225 

patients  who  had  employed  the  high-altitude  treatment,  14.13  per  cent,  were 
completely  cured,  29.78  per  cent,  were  much  benefited,  11.34  per  cent,  were 
more  or  less  benefited,  and  17.02  per  cent.,  including  13.47  per  cent,  who  died, 
continued  to  grow  worse.  Drs.  Quain  and  Pollock,  in  discussing  this  paper, 
expressed  the  opinion  that  consumptives  who  improve  at  a  high  altitude 
improve  equally  with  the  same  treatment  at  lower  elevations  ;  in  other  words, 
that  residence  at  a  high  altitude  does  not  influence  the  result.  Brehmer, 
on  the  other  hand,  believes  that  the  inhabitants  have  immunity  from 
tuberculosis  at  an  altitude  of  1500  feet  in  Germany,  of  4500  to  5000  feet 
in  Switzerland,  and  10,000  to  15,000  feet  at  the  equator  (^Die  Therapie 
Chronische  Lungenbescliwerden.,  Wiesb.,  1887).  The  most  apparent  and  notable 
peculiarity  in  the  air  at  high  elevations,  apart  from  its  purity,  is  its  rarefac- 
tion. At  an  altitude  of  9000  feet  above  the  level  of  the  sea  it  is  said,  from 
observations  made,  that  the  air  is  so  rarefied  that  three  times  the  usual 
exercise  of  the  lungs  is  required  to  meet  the  demands  of  the  system.  Dr. 
Mays  states  in  a  paper  published  in  the  Medical  Neics,  November  27,  1886, 
that  the  Quichua  Indians,  on  the  lofty  plateaus  of  Peru,  constantly  breath- 
ing a  rarefied  air,  "  acquire  enormous  dimensions  "  of  the  chest,  due  to  an 
increase  in  the  size,  and  perhaps  number,  of  the  air-cells.  More  numerous 
and  more  exact  observations  are  required  in  order  to  determine  whether  or  to 
what  extent  residence  at  a  high  altitude  is  beneficial  to  consumptives,  and, 
if  it  exerts  a  controlling  effect  on  the  disease,  whether  this  result  is  due  to 
the  increased  pulmonary  expansion  and  activity  or  to  other  causes.  Certainly, 
from  observations  already  made,  we  are  justified  in  recommending  outdoor 
life  in  a  mild  and  equable  climate,  and  also  residence  at  high  elevations  if  the 
cold  is  not  too  severe. 

Residence  in  the  Evergreen.  Forests  and  the  Use  of  Turpentine. — In  a  paper 
read  before  one  of  the  societies,  and  subsequently  published,  the  late  Dr.  K. 
L.  Loomis  stated  his  belief  that  the  terebinthinate  vapors  in  the  evergreen 
forests  possess  healing  properties  for  consumptives..  He  quotes  the  state- 
ment of  Ringer,  that  turpentine  employed  as  a  medicine  enters  the  blood, 
and  may  be  detected  in  the  breath,  the  perspiration,  and  in  an  altered  form 
in  the  urine  of  the  patient.  The  presence  of  the  vapor  of  turpentine  in  the 
pine  forest,  Dr.  Loomis  remarks,  cannot  be  doubted,  and  its  "  local  and  con- 
stitutional effects,"  he  adds,  "  are  those  of  a  powerful  germicide  as  well  as 
stimulant."  Dr.  Loomis  quotes  the  opinion  of  Mr.  Kingsett  that  turpentine, 
during  its  oxidation,  evolves  the  peroxide  of  hydrogen,  and  therefore  by  the 
"  oxidation  of  the  terebinthinates  there  is  produced  in  extensive  pine  forests 
an  almost  illimitable  amount  of  peroxide  of  hydrogen,  which  renders  the 
atmospheres  of  such  forests  antiseptic."  He  believes  that  the  peroxide  of 
hydrogen  so  abundantly  produced  in  pine  forests  "  successfully  an-ests  putre- 
factive processes  and  septic  poisoning,"  and  therefore  he  recommends  resi- 
dence in  the  pine  forests  as  one  of  the  most  efficient  means  of  relieving  the 
symptoms  of  tuberculosis  and  retarding  the  progress  of  this  fatal  malady. 
At  high  altitudes  the  coniferous  or  evergreen  trees  usually  predominate,  and 
if  the  views  of  Professor  Loomis  be  substantiated  by  future  investigations, 
it  may  be  that  the  benefit  believed  to  be  obtained  by  consumptives  at  high 
elevations  is  partly  due  to  the  exhalations  from  these  trees. 

The  bacteriologists  who  have  cultivated  the  tubercle  bacillus,  and 
observed  the  action  upon  it  of  the  various  agents  which  have  been  employed 
and  extolled  by  clinical  observers,  state  that  most  of  these  agents  do  not 
penetrate  the  tubercular  mass — that  while  they  may  destroy  the  superficial 
bacilli,  they  do  not  affect  those  more  deeply  seated,  and  therefore  fail  to 
arrest  the  disease.  But  turpentine  and  its  derivatives  appear  to  penetrate 
the  tissues  as  deeply  as  almost  any  other  agent,  and  therefore,  if  they  are 
15 


226  CONSTITUTIONAL  DISEASES. 

sufficiently  antiseptic  and  not  too  irritating,  we  may  expect  good  results 
from  their  judicious  use.  But  it  is  probable  that  they  are  less  efficient  as 
germicides  than  some  of  the  other  agents  which  can  be  safely  employed,  and 
therefore  should  be  recommended  only  as  adjuvants,  or  as  remedies  which 
may  give  some  relief  to  the  catarrhal  and  other  symptoms  without  exerting 
any  marked  antiseptic  action.  Hohnfeld  states  that  he  applied  oil  of  turpen- 
tine to  fresh  colonies  of  the  micrococcus  prodigiosus  and  staphylococcus 
aureus,  and  that  it  exerted  little  destructive  or  retarding  effect  on  these 
micro-organisms.^  These  experiments  would  lead  us  to  distrust  the  germi- 
cide action  of  turpentine  and  the  terebinthinate  preparations  in  tuberculosis, 
for  the  tubercle  bacillus  is  tenacious  of  life  beyond  most  other  microbes. 

Dr.  Trudeau  of  Saranac  Lake  prescribed  the  hot-air  treatment  in  four  cases 
four  hours  each  day,  the  temperature  of  the  inhaled  air  being  392°  F.  The 
first  and  second  patients  improved  slightly  at  first,  but  refused  the  treatment, 
the  one  after  one  month,  and  the  other  after  six  weeks.  The  third  patient 
was  treated  three  months  without  the  least  appreciable  effect.  The  fourth 
patient  was  treated  four  months,  with  manifest  improvement  in  her  physical 
signs  and  general  health,  but  no  more  improvement  than  frequently  occurs 
from  any  new  mode  of  treatment.  In  all  the  cases  the  sputum  was  examined 
before,  during,  and  after  the  treatment,  and  in  every  examination  the  tuber- 
cle bacillus  was  present.  The  result  claimed  for  the  hot-air  treatment  had 
not  been  obtained — that  is,  the  destruction  of  the  bacilli ;  and  if  they  are 
not  destroyed  in  the  sputum,  certainly  they  are  not  in  the  tissue  of  the  lung. 
Therefore  there  can  be  little  doubt  that  the  hot-air  inhalations,  so  far  from 
coming  into  general  use,  will  be  discarded,  not  only  because  they  are 
unpleasant  to  the  patient,  but  are  inefficient.  There  is  always  a  large  amount 
of  residual  air  in  the  alveoli,  and  there  can  be  little  doubt  that  in  the  hot-air 
inhalations  the  air  in  the  alveoli  and  terminal  bronchial  tubes  never  attains 
the  elevation  of  temperature  of  the  air  that  is  inhaled,  nor  of  that  which 
is  exhaled.  Moreover,  as  we  have  seen,  the  tubercle  bacillus  resists  the 
destructive  action  of  high  temperature.  It  is  said  to  retain  its  vitality 
in  liquids  which  have  been  twice  heated  to  the  boiling-point. 

Creasote. — Of  the  many  medicines  which  have  been  recently  employed 
in  the  treatment  of  tuberculosis,  creasote  appears  to  have  given  more  general 
satisfaction  than  any  other.  It  has  to  a  great  extent  taken  the  place  of  cod- 
liver  oil,  which  was  formerly  employed  in  the  treatment  of  tuberculosis  in 
want  of  a  better  agent.  I  am  informed  that  the  late  Dr.  Cammann,  the  in- 
ventor of  the  binaural  stethoscope,  employed  it  twenty  years  ago  in  the  treat- 
ment of  tuberculosis,  but  it  was  seldom  prescribed  for  this  disease  until 
within  the  last  decade.  In  the  Berliner  klimsche  Wochensclirift,  July  20, 
1886,  Von  Brunn  stated  that  he  had  treated  1700  phthisical  patients  in  the 
preceding  eight  years  with  creasote,  giving  to  adults  not  less  than  six  to  eight 
drops  in  twenty-four  hours.  He  employed  it  in  solution  with  tincture  of 
gentian  and  wine,  and  believed  that  he  obtained  good  results,  especially  in 
acute  unilateral  cases.  Professor  Sommerbrodt  stated  in  1887  that  he  em- 
ployed creasote  in  about  5000  phthisical  cases  during  the  preceding  nine 
years.  At  first  he  used  Bouchard's  solution  of  creasote,  and  afterward  gel- 
atin capsules,  each  containing  three-fourths  of  a  grain  of  creasote  and  three 
minims  of  the  balsam  of  Tolu.  The  amount  of  creasote  administered  daily 
to  the  patients  who  were  adults  was  increased  gradually  from  one  capsule  to 
not  less  than  nine.  x\s  many  as  600  to  2000  capsules  were  given  to  each 
patient  without  a  break.  In  many  cases  the  improvement  was  marked,  not 
only  in  the  symptoms  and  in  the  general  health,  but  also  in  the  physical 
signs.     He  believes  that  he  has  cured  cases  by  insisting  on  a  continuance  of 

^  Fortschritte  der  Medicin,  October  1,  1887. 


TUBERCULOSIS.  227 

the  treatment.  To  show  the  good  effect  of  creasote,  he  cites  the  case  of  a 
student  of  sixteen  years,  with  tuberculosis  of  the  right  lung,  who  took  three 
capsules  three  times  daily,  or  about  seven  and  a  half  grains  per  diem.  His 
cough  abated,  his  weight  increased  six  pounds  in  two  months,  his  expectora- 
tion had  ceased.  Instead  of  the  dull  percussion  sound  over  the  apex  of  the 
right  lung,  only  a  slight  rhonchus  was  observed,  and  his  general  health  had 
greatly  improved. 

Many  others  who  have  employed  creasote  during  the  last  two  or  three 
years,  both  in  this  country  and  in  Europe,  report  favorable  results.  Striim- 
pell  says  that  it  produces  no  ill  effects,  and  in  large  doses  it  frequently  causes 
improvement  in  such  symptoms  as  the  cough,  expectoration,  and  appetite,  but 
he  doubts  whether  it  exerts  any  marked  curative  effect  upon  the  disease.  It 
has  been  employed  largely  in  the  New  York  Hospitals  and  in  family  practice 
in  various  combinations,  and  the  general  opinion  expressed  is  very  favorable 
to  its  use. 

I  have  prescribed  creasote  for  internal  use  in  the  following  formula : 

R.  Creasoti  (Morson's), 
Spirit!  chloroformi, 
Alcoholis,  da.  ^ss. — M. 

Dose  for  an  adult,  nine  drops  three  times  daily  in  half  a  teacupful  of  water  con- 
taining a  tablespoonful  of  brandy  or  two  tablespoonfuls  of  wine. 

The  nine  drops  of  the  mixture,  containing  three  of  the  creasote,  have  been 
increased  to  twelve  drops,  or  four  of  creasote,  and  thus  far  in  my  practice 
patients  believe  that  they  have  been  benefited  by  this  remedy,  and  have 
desired  to  continue  it.  At  the  same  time,  in  some  instances  I  have  recom- 
mended the  inhalation  of  ten  or  fifteen  drops  of  the  same  mixture  from 
Robinson's  inhaler.  This  dose  of  creasote,  three  or  four  drops,  may  seem 
large,  btit  it  is  tolerated  when  sufiiciently  diluted,  though  it  may  be  best  to 
commence  with  a  smaller  quantity.  Children  should  of  course  take  doses 
proportionate  to  the  age.  the  fractional  part  of  a  drop  being  sufficient  for  in- 
fants. Creasote  has  also  been  injected  into  the  tubercular  lung  through  the 
chest-walls  by  several  physicians,  a  syringe  provided  with  a  long  and  delicate 
needle  being  used.  Rosenbusch  injected  eight  drops  of  a  3  per  cent,  solu- 
tion of  creasote  in  almond  oil  in  two  places  at  the  seat  of  the  disease,  or  six- 
teen drops  in  all.  The  result  was  a  marked  diminution  of  the  cough,  the 
sweats,  the  amount  of  sputum,  and,  in  recent  cases,  an  increase  in  weight. 
The  beech  creasote  was  used,  and  the  skin  and  apparatus  were  first  sterilized 
by  an  antiseptic  lotion.  When  the  instrument  was  not  introduced  deeply 
enough,  a  sharp,  pleuritic  pain  sometimes  occurred,  but  it  soon  abated. 
Creasote  appears  to  be  the  most  valuable  of  the  recent  remedies  recommended 
for  tuberculosis,  but  in  order  to  determine  its  exact  value,  the  proper  mode 
of  employing  it,  and  the  size  and  frequency  of  the  dose,  more  extended 
observations  are  required.  Frantzel  says  that  experiments  have  shown  that 
this  substance  is  inimical  to  the  growth  of  the  bacillus  when  mingled  in 
minute  quantity  with  a  gelatin  culture-medium,  and  on  this  fact  is  based  its 
internal  administration.  When  it  is  injected  into  the  lungs  through  the 
chest-walls.  Dr.  E.  Gr.  Janeway  of  New  York  believes  that  it  is  very  import- 
ant that  the  almond  oil  or  other  vehicle  employed  should  be  first  sterilized. 

In  the  present  state  of  our  knowledge  of  the  use  of  antiseptics  in  the 
treatment  of  ttiberculosis,  creasote  is  the  one  which  is  most  deserving  of  con- 
fidence and  employment.  In  New  York  City,  in  cases  of  protracted  broncho- 
pneumonia with  emaciation,  the  symptoms  indicating  the  probability  of 
cheesy  degeneration  and  commencing  tuberculosis,  I  am  prescribing  the 
hourly  inhalation  of  the  vapor  of  creasote,  one  part  to  ten  or  fifteen  of  tere- 


228  CONSTITUTIONAL  DISEASES. 

bene,  fifteen  to  twenty-five  minims,  or  more  of  the  mixture  being  dropped 
on  the  sponge  in  Robinson's  perforated  zinc  inhaler.  Children  willingly  in- 
hale this  vapor  five  or  ten  minutes  at  a  time,  with  some  apparent  relief  of 
symptoms. 

Dr.  Robinson  (Amer.  Journ.  of  Med.  Sci.')  writes :  "  I  am  convinced  from 
what  I  have  seen  ....  that  we  have  in  beechwood  creasote  a  remedy  of 
great  value  in  the  treatment  of  pulmonary  phthisis,  particularly  during  the 
first  stage.  Not  only  does  it  lessen  or  cure  cough,  diminish,  favorably  change, 
and  occasionally  stop  sputa,  and  relieve  dyspnoea  in  very  many  instances,  but 
it  also  often  increases  appetite,  promotes  nutrition,  and  arrests  night-sweats." 
Von  Brunn  obtained  favorable  results  from  the  use  of  creasote  in  1700  cases. 
The  gastric  digestion,  and  later  the  respiratory  symptoms,  were  improved.  A 
diminution,  and  even  disappearance,  of  bacilli  occurred.  The  creasote  was 
given  in  wine  and  by  inhalation. 

The  experiments  of  Guttmann  show  that  the  tubercular  bacillus  will  not 
grow  in  solutions  of  the  strength  of  1  :  2000,  and  only  feebly  in  solutions  of 
the  strength  of  1  :  4000.  The  medical  journals  during  the  last  five  years 
contain  numerous  communications  recommending  creasote  as  the  most  effi- 
cient remedy  in  tuberculosis  and  chronic  catarrhs.  For  such  maladies  it  has 
to  a  great  extent  taken  the  place  of  the  old  remedy,  cod-liver  oil.  Seitz  pre- 
scribes it  for  these  affections  with  cod-liver  oil,  in  the  following  formula: 

R.  Creasoti,  38     grains   (2.5  grammes); 

Olei  morrhuse      6 j  ounces  (200        "       ); 
Sacchari,  2    grains  (0.13  gramme). 

Dose  :  One  to  four  teaspoonfuls  two  or  three  times  daily. 
For  children  smaller  doses. 

Creasote  has  also  been  given  in  two  or  three  teaspoonfuls  of  orange  juice, 
to  which  the  same  quantity  of  Tokay  or  Malaga  wine  is  added,  and  it  should, 
in  my  opinion,  always  be  given,  especially  to  children,  in  smaller  and  more 
frequent  doses  than  most  formulae  state,  and  after  the  feeding,  so  as  not  to 
irritate  the  stomach.  It  is  the  common  and,  I  believe,  correct  practice  to  pre- 
scribe the  minimum  dose  at  first  and  gradually  increase  the  quantity  given  if 
tolerance  is  manifested.  A  half-drop  to  one  drop  after  taking  food  would 
be  considered  a  proper  dose  for  a  child  of  five  years.  But  the  dose  can  be 
doubled  if  sufficiently  diluted  so  as  not  to  be  irritating,  and  given  more  times 
daily. 

Every  year  since  the  introduction  into  practice  of  creasote  as  a  remedy 
for  tuberculosis  its  use  has  extended  and  it  has  been  more  and  more  extolled. 
It  is  commonly  stated  by  those  who  have  most  employed  it,  that  creasote 
properly  administered  does  no  harm,  but  improves  the  digestion  and  general 
health  ;  therefore  it  has  been  useful  when  its  vapor  is  employed  in  protracted 
catarrhal  affections  and  tuberculosis  of  the  lungs  and  air-passages.  By  my 
own  experience  I  can  highly  recommend  the  following  formula : 

Creasoti  (Morson's  beechwood),  .^ij  ; 

Terebene,  giv. — Misce. 

Add  one  teaspoonful  to  three  or  four  tablespoonfuls  of  boiling  water,  and 
inhale  the  vapor  from  three  to  five  minutes,  or  employ  the  same  upon  the 
sponge  of  Robinson's  perforated  zinc  inhaler.  It  may  be  used  once  in  three 
or  four  hours  or  oftener. 

Gnaiacol. — This  is  described  in  the  books  as  a  liquid  compound  consisting 
of  60  to  90  per  cent,  of  creasote.  In  1891-92  a  carbonate  of  guaiacol  was 
produced,  which   promises  to   be  a  medicine   of  great  value,  and  in   some 


TUBERCULOSIS.  229 

instances  a  substitute  for  creasote.  It  occurs  in  the  form  of  neutral  crystals 
without  taste  or  odor,  insoluble  in  water,  but  dissolving  at  86°  to  90°.  The 
combination  with  the  carbonate  appears  to  remove  all  irritating  properties 
from  the  medicine,  and  I  have  several  times  allowed  five  grains  of  the  guaia- 
col  carbonate  to  dissolve  in  my  mouth  and  be  swallowed  without  experiencing 
the  least  irritation  from  it.  I  look  for  a  favorable  reception  of  this  agent  in 
chronic  catarrhs  and  in  incipient  as  well  as  in  advanced  tuberculosis. 

As  is  the  case  with  all  common  and  fatal  diseases,  many  new  drugs  for 
phthisis  have  been  recommended  each  year  since  the  appearance  of  the  last 
edition  of  this  book.  Most  of  them,  after  a  few  trials,  have  fallen  into  disuse. 
The  one  that  has  attracted  the  most  attention,  originating  from  a  high  scien- 
tific authority,  is  tuberculin. 

Tuherculia. — Koch  published  the  experiments  which  led  to  the  preparation 
of  tuberculin  in  the  Deutsch.  med.  Wochen.,  No.  46,  1890.  If  a  healthy  guinea- 
pig  be  inoculated  with  a  pure  culture  of  the  tubercle  bacillus,  the  wound 
closes  and  for  a  few  days  appears  to  be  healing.  In  about  two  weeks,  how- 
ever, a  hard  nodule  forms,  which  soon  breaks  down,  leaving  an  ulcer  until 
the  death  of  the  animal.  But  if  the  animal,  successfully  inoculated  four  to 
six  weeks  previously,  be  reinoculated,  no  nodule  is  formed,  but  on  the  second 
day  the  point  of  inoculation  becomes  hard  and  darker  to  the  extent  of  .5  to  1 
centimetre.  This  dark  necrotic  substance  is  cast  oif  and  the  wound  soon 
heals.  If  the  injection  of  a  proper  quantity  be  repeated  in  one  to  two  days, 
the  health  of  the  animal  improves  and  the  wound  becomes  smaller,  cicatrizes, 
and  the  lymphatic  nodules  diminish  in  size.  Koch  found,  however,  that 
"  the  objection  to  the  use  of  the  sterilized  cultures  lay  in  the  fact  that  the 
dead  bacilli  were  not  absorbed,  but  remained  at  the  point  of  injection,  and 
caused  more  or  less  suppuration.  The  material  which  had  a  curative  eff"ect 
was  something  which  was  soluble  and  which  entered  the  fluid  of  the  tissue 
about  the  bacilli."  Koch  then  endeavored  to  extract  from  the  cultures  of 
the  bacillus  this  soluble  substance. 

Clinical  results  are  the  test  of  the  value  of  a  medicine  given  to  check  or 
cure  disease,  and  the  result  of  the  use  of  tuberculin,  whatever  will  be  its 
future,  has  been  less  efficient  than  that  of  creasote.  Still,  already  one  im- 
portant benefit  has  resulted  from  its  use.  If  tuberculin  be  injected  under 
the  skin  of  an  animal  having  tuberculosis,  it  causes  fever,  but  none  if  the 
animal  is  healthy.  It  is  thei'efore  very  useful  as  the  means  of  excluding 
diseased  cows  from  a  dairy. 

I  have  described  in  the  foregoing  pages  the  most  important  of  the  remedies 
which  have  been  recently  recommended  by  apparently  competent  observers. 
There  are  others  which,  from  their  nature  and  the  limited  trial  which  they 
have  received,  I  have  not  thought  of  sufficient  importance  to  require  notice. 
Most  of  them  will  probably  soon  be  discarded  by  those  who  now  recommend 
them.  The  hygienic  measures — as  outdoor  life,  residence  at  a  high  altitude, 
free  ventilation  of  sleeping  apartment,  and  the  use  of  the  most  nutritious  and 
easily-digested  food — still  maintain  a  most  important  place  in  the  treatment 
of  tuberculosis.  Of  the  medicines,  creasote,  used  internally  and  by  inhala- 
tion, appears  to  be  the  most  deserving  of  recommendation. 


230  CONSTITUTIONAL  DISEASES. 

CHAPTER    IV. 
SYPHILIS. 

Syphilis  in  infancy  and  ehildliood  occurs  under  two  forms — to  wit,  the 
congenital  and  acquired.     The  former  is  the  more  frequent. 

Etiology. — Congenital  syphilis  may  be  derived  from  either  father  or 
mother.  Either  parent,  having  syphilis  in  its  first  or  second  stage,  may 
transmit  it  to  the  offspring,  although  at  the  time  free  from  syphilitic  symp- 
toms. The  mother,  healthy  at  the  time  of  conception  and  contracting  syph- 
ilis prior  to  the  eighth  month  of  gestation,  may  communicate  the  disease  to 
the  foetus.  Syphilis  contracted  by  the  mother  in  the  eighth  or  ninth  month 
of  gestation  is  less  likely  to  be  communicated  to  the  foetus.  Writers  mention 
the  case  reported  by  Zeissl,  in  which  the  wife,  previously  well,  contracted 
syphilis  from  her  husband  between  the  fifth  and  seventh  months  of  gestation, 
and  the  infant,  born  at  term,  soon  exhibited  the  characteristic  syphilitic 
lesions.  If  both  parents  have  syphilis  at  the  time  of  conception,  the  infant 
is  almost  necessarily  syphilitic ;  on  the  other  hand,  if  only  one  parent  be 
syphilitic,  the  infant  may  or  may  not  be  contaminated.  Sometimes  with  such 
parentage  a  part  of  the  children  are  syphilitic  and  a  part  healthy. 

All  syphilographers  agree  that  syphilis  in  its  third  stage  is  not  transmis- 
sible from  parent  to  child,  but  parents  in  this  stage  of  the  disease  are  likely 
to  beget  scrofulous  children.  Hutchinson  of  London  regards  syphilis  as  an 
exanthem,  with  its  periods  of  efilorescence  and  decline,  and  the  symptoms 
and  ailments  which  characterize  the  so-called  third  state  he  regards  as 
sequelae.  That  syphilis  is  no  longer  transmissible  after  the  close  of  the 
second  stage  is  shown  by  many  observations.  Thus,  M.  Mireur  relates  the 
history  of  a  man  and  wife  who  were  syphilitic  and  were  never  treated,  but 
their  children  were  without  syphilitic  symptoms. 

Acquired  syphilis  in  infancy  and  childhood  may  be  received  through 
primary  lesions — that  is,  by  reception  of  the  virus  from  a  chancre  or  bubo — 
or  it  may  be  derived  from  certain  of  the  secondary  lesions.  Inoculation  by 
primary  lesions  may  occur  at  the  birth  of  the  infant  from  a  syphilitic  sore  in 
the  vagina  or  upon  the  vulva  of  the  mother ;  inoculation  in  this  manner  is, 
however,  rare.  Children  may  also  receive  the  virus  from  primary  lesions  on 
the  persons  of  nurses  or  companions.  Infection  in  this  manner  is  sometimes 
accidental  and  sometimes  the  result  of  criminal  conduct.  A  chancre  on  the 
breast  of  the  wet-nurse  not  very  infrequently  communicates  syphilis  to  the 
nursling. 

The  contagiousness  of  "  secondary  manifestations,"  for  a  longtime  doubted, 
is  now  fully  established.  Syphilis  may  be  communicated  by  the  secretion  or 
exudation  of  a  mucous  patch  or  a  secondary  sore.  Hence  the  danger  of 
suckling  by  infected  wet-nurses,  though  they  present  no  symptoms  of  recent 
syphilis.  Excoriations  or  sores  upon  the  nipple  or  breast  of  a  syphilitic  wet- 
nurse  may  communicate  the  disease  to  the  nursling ;  and,  on  the  other  hand, 
mucous  tubercles  or  fissures  iipon  the  lips  or  tongue  of  the  infected  infant 
may  be  the  means  of  contaminating  a  healthy  wet-nurse.  Many  such  cases 
are  now  contained  in  the  records  of  medicine.  Vaccination  by  means  of  the 
scab  is  also  a  mode  by  which  syphilis  has  been  communicated.  (For  further 
particulars  in  reference  to  this  subject  the  reader  is  referred  to  our  remarks 
on  vaccination.) 

Syphilis  is  believed  to  be  a  microbic  disease,  but  further  investigations 


SYPHILIS.  231 

are  required  in  order  to  determine  positively  which  microbe  is  the  causal 
agent.  Klebs  obtained  by  cultivation  bacilli  which  he  found  in  indurated 
chancres.  With  these  bacilli  he  produced  a  local  affection  by  inoculation  of 
the  monkey  which  resembled,  in  some  respects,  that  of  syphilis  and  in  other 
respects  that  of  tuberculosis.  Ziegler  and  Von  Rinecker  obtained  negative 
results  from  similar  experiments  (Ziegler's  Path.  Anatomy).  Lustgarten 
has  described  a  bacillus  which  occurs  in  syphilitic  lesions,  and  which  he  dis- 
tinguishes from  that  of  tuberculosis  by  colorations  which  the  latter  receives 
and  this  does  not.  Alvarez  and  Tavel  in  1885,  and  later  Cornil,  describe  a 
bacillus  found  in  the  desquamation  of  the  genitals  which  closely  resembles 
Lustgarten's  bacillus  of  syphilis,  but  which  Cornil  states  can  be  distin- 
guished from  it  by  certain  differences  in  the  coloration  (^Cyclop,  of  Diseases 
of  Children,  vol.  i.  168,  Phila.,  1889). 

Dr.  "W.  H.  Welch,  the  distinguished  professor  of  pathology  in  Johns  Hop- 
kins University,  has  favored  me  with  the  following  note  relating  to  the  micro- 
organism which  causes  syphilis  : 

BaltIiMore,  Aug.  14. 

There  has  hitherto  been  no  satisfactory  demonstration  of  this  organism,  although 
there  have  been  many  claims  to  its  discovery.  The  only  organism  yet  demonstrated 
which  has  any  claims  to  being  considered  the  cause  of  this  disease  is,  in  my  opinion, 

the  bacillus  of  Lustgarten There  is  much  to  be  said  in  favor  of  the  bacillus 

discovered  by  Lustgarten,  and  first  described  by  him  in  November,  1884,  and  I 
think  this  is  the  only  micro-organism  hitherto  observed  in  syphilitic  lesions  which 
possesses  much  interest.  His  work  from  the  first  attracted  attention,  as  it  was  done 
under  the  direction  of  Prof  Weigert,  one  of  the  greatest  living  experts  in  this  line 
of  study.  The  organism  is  described  by  Lustgarten  as  a  bacillus  three  to  seven 
micro-millimetres  long,  often  slightly  wavy  in  shape,  and  found  usually  within  the 
protoplasm  of  cells  in  syphilitic  products.  It  Avas  found  by  Lustgarten  in  all 
of  the  syphilitic  products,  including  gummata,  which  he  examined.  Next  to 
Lustgarten's,  the  most  important  studies  of  this  bacillus  have  been  made  prob- 
ably by  Doutrelepont  of  Bonn,  in  co-operation  with  Schiitz  ;  by  Matterstock  of 
AViirzburg :  by  Markase  ;  and  by  Fordyce.  The  significance  of  Lustgarten's  dis- 
covery for  a  time  seemed  to  be  overthrown  by  the  detection  by  Matterstock  and  by 
Alvarez  and  Tavel  of  a  bacillus  in  smegma,  which  these  observers  believed  to  be 
identical  with  Lustgarten's  syphilitic  bacillus ;  but,  although  strikinglj^  similar, 
these  two  species  of  organism  have  now,  I  believe,  been  shown  to  be  entirely  difi'er- 
ent  species,  and  the  smegma  bacillus  has  nothing  to  do  with  the  syphilis  bacillus. 

Lustgarten's  bacillus  has  not  been  cultivated,  notwithstanding  repeated  attempts 
to  find  a  medium  suitable  for  its  growth.  It  is  certainly  often,  and  probably  con- 
stantly, present  in  syphilitic  lesions.  Still,  several  observers  have  reported  negative 
result's  in  searching  for  it.  The  reason  of  this  is  probably  the  extraordinary  difli- 
culty  in  demonstrating  this  organism.  There  is  nothing  in  all  histological  technique 
which  requires  such  an  outlay  of  time  and  patience  as  the  demonstration  of  the 
syphilis  bacillas,  so  that  so  skilled  an  histologist  as  Weigert  says  that  he  simply 
has  not  the  patience  to  work  at  this  subject :  and  this  is  probably  the  conclusion 
of  others  who  have  tackled  it. 

It  is  clear,  however,  that  the  discovery  of  a  peculiar  bacillus  with  remarkable 
staining  properties,  enclosed  within  cells  in  syphilitic  products,  is  something  of 
great  significance — far  greater  than  finding,  as  did  Aufrect,  ordinary  cocci  in  juice 
squeezed  out  of  a  flat  condyloma,  or  in  mistaking  plasma-cells  for  clumps  of  cocci, 
as  Birch-Hirschfeld  is  known  to  have  done.  When,  in  addition  to  this,  the  few 
good  observers,  who,  like  Lustgarten,  have  had  the  patience  and  skill  to  make  a 
satisfactory  study  of  the  question,  claim  to  find  this  peculiar  bacillus  so  frequently 
in  the  lesions  of  syphilis,  I  think  it  must  be  admitted  that  this  bacillus  has  special 
claims  upon  our  consideration.  It  must  be  admitted,  however,  that  a  complete 
demonstration  that  Lustgarten's  bacillus  is  the  specific  cause  of  syphilis  has  not  as 
yet  been  furnished. 

It  may  interest  you  to  know  that  within  the  last  year  or  two  some  interest  has 
attached  to  the  observation  first  made  by  Kassowitz  and  Hochsinger,  that  strepto- 
cocci are  often  present  in  congenital  syphilis  ;  but  I  do  not  think  that  there  can  be 


232  CONSTITUTIONAL  DISEASES. 

any  doubt  that  these  streptococci  have  nothing  to  do  with  the  specific  contagium 
of  syphilis  (and,  indeed,  Doutrelepont  has  found  Lustgarten's  bacillus  in  combi- 
nation with  streptococci  in  congenital  syphilis),  but  they  are  evidence  of  mixed 
infection.  They  are  probably  the  oi'dinary  streptococci  of  suppuration.  It  is,  how- 
ever, of  some  interest  to  have  this  bacteriological  evidence  of  a  clinical  fact,  that 
many  cases  of  congenital  syphilis  are  examples  of  mixed  infection.  It  is  probable 
that  some  lesions  of  congenital  syphilis  which  have  beeii  regarded  as  specific, 
particularly  those  of  a  suppurative  character,  are  due  to  the  secondary  invasion 
of  these  streptococci,  for  which  the  soil  has  been  prepared  by  the  specific  organism 
of  syphilis.  Yours  very  truly, 

W.  H.  AYelch. 

It  is  evident,  in  consequence  of  the  risk  of  begetting  syphilitic  children, 
that  one  who  has  contracted  syphilis  should  not  marry  or  sustain  conjugal 
relations  until  four  years  have  elapsed  from  the  time  of  infection  and  the 
disease  has  passed  through  its  first  and  second  stages,  and  eighteen  months 
of  treatment  have  been  employed.  We  have  seen  that  hereditary  syphilis 
may  be  inherited  from  either  parent,  although  the  parent  do  not  exhibit  at 
the  time  any  syphilitic  symptoms,  and  that  the  mother,  contracting  syphilis 
during  gestation  even  as  late  as  the  seventh  month,  may  transmit  it  to  her 
infant. 

Clinical  History. — The  effects  of  the  syphilitic  poison  upon  the  devel- 
opment of  the  foetus  and  the  development  and  health  of  the  infant  are  differ- 
ent in  different  cases.  The  foetus,  under  the  influence  of  the  poison,  often 
ceases  to  grow,  shrivels,  dies,  and  is  expelled  long  before  term  ;  or  it  may  be 
born  alive,  but  prematurely,  and  showing  clear  evidences  of  the  disease  as 
soon  as  it  comes  into  the  world ;  or,  again,  it  may  be  born  at  term,  but  dead. 
So  frequently  is  syphilis  a  cause  of  non-viability  that,  as  Trousseau  has 
remarked,  this  disease  should  be  suspected  as  the  cause  whenever  a  woman 
repeatedly  aborts.  Abortion  from  syphilis  commonly  occurs  at  or  about  the 
sixth  month  of  gestation.  In  those  cases  in  which  the  foetus  dies  from  syph- 
ilis there  is  often  placental  syphilitic  disease — to  wit,  an  undue  growth  of 
cells  in  the  villi,  which,  compressing  the  vessels,  gives  rise  to  fatty  degenera- 
tion and  prevents  the  requisite  interchange  between  the  maternal  and  foetal 
blood  (Harring,  Frankel).  Frankel  designated  the  change  "  granulation-cell 
hypertrophy  of  the  placental  villi."  Virchow  in  one  case  found  a  gummy 
tumor  in  the  maternal  portion  of  the  placenta. 

When  a  foetus  destroyed  by  syphilis  is  expelled,  it  frequently  presents  a 
macerated  appearance,  the  cuticle  being  detached  over  large  patches  of  sur- 
face, and  in  other  parts  raised  in  blebs,  with  a  thin,  purifonn,  and  offensive 
fluid  underneath  ;  the  liver  is  occasionally  indurated,  and  abscesses  with  spots 
of  inflammation  are  sometimes  observed  in  the  thymus  gland ;  the  amniotic 
fluid  is  offensive,  turbid,  and  of  a  greenish  or  greenish-brown  appearance. 

If  the  foetus  in  which  syphilitic  manifestations  have  begun  to  occur  have 
reached  a  viable  age  and  be  born  alive,  it  is  small  'and  imperfectly  developed, 
often  shrivelled  and  senile  in  appearance.  The  skin  looks  unhealthy,  and  it 
may  exhibit  a  distinct  rash.  Bouchut  saw  a  seven  and  a  half  months'  infant 
born  alive,  with  an  eruption  of  a  copper  color  upon  the  legs  and  arms  and 
onychia  upon  the  fingers  and  toes.  The  bullae  of  pemphigus  are  also  not  infre- 
quent upon  the  skin  at  birth,  or  they  appear  within  a  few  days  (two  or  three) 
after  birth.  The  smallest  are  about  the  size  of  a  split  pea,  but  many  are 
considerably  larger  ;  the  largest  consist  of  two  or  more  which  have  coalesced. 
They  contain  a  thin,  greenish,  purulent  matter,  and  appear  most  frequently 
upon  the  palms  of  the  hands  and  soles  of  the  feet,  but  also  in  severe  cases 
upon  the  face  and  over  the  surface  of  the  body.  Recently  I  was  able  to 
diagnosticate  syphilis  in  an  infant  within  a  day  after  birth  by  its  small  size 
and  feebleness   and   the   appearance  of  large  blebs  of  pemphigus  upon  its 


SYPHILIS.  233 

liands,  feet,  fingers,  and  toes,  over  which  the  skin  soon  broke  leaving  trouble- 
some and  bleeding  sores ;  coryza  commenced  about  the  twelfth  day.  The 
parents  seemed  healthy,  but  I  was  enabled  to  ti-ace  the  syphilitic  taint  to  the 
mother.  Non-syphilitic  pemphigus,  the  result  of  cachexia,  sometimes  appears 
soon  after  birth,  but  its  primary  and  usual  seat  is  around  the  neck  and  upon 
the  body.  I  have  known  it  to  appear  within  the  first  week  of  life,  and  end 
fatally  by  the  close  of  the  second  week.  I  have  not  found  it  difl&cult  to  dis- 
tinguish it  from  syphilitic  pemphigus  by  the  history  of  the  family  and  its 
absence  from  the  palmar  and  plantar  surfaces  of  the  hands  and  feet.  Con- 
dylomata, mucous  patches,  and  stains  of  a  copper  color  are  the  principal 
syphilitic  affections,  besides  pemphigus,  which  have  been  observed  at  birth 
on  the  bodies  of  contaminated  infants.  It  is  stated  that  M.  Cullerier  in  ten 
years'  attendance  at  the  Hopital  de  Lorraine  met  only  two  cases  of  syphilitic 
manifestations  at  birth,  and  Victor  de  Meric  only  two  cases  in  forty-six 
infants,  who  were  affected  with  congenital  syphilis  (Bumstead)  ;  but  in  the 
.practice  of  others  a  larger  proportion  have  exhibited  symptoms  at  birth. 
Ordinarily,  the  period  in  which  congenital  syphilis  is  first  revealed  by  symp- 
toms is  between  the  fifteenth  and  fortieth  days.  Rarely  the  manifestations 
of  the  disease  are  delayed  several  months.  M.  Diday  ascertained  the  time  of 
the  commencement  of  symptoms  in  158  cases,  as  follows: 

Before  the  completion  of  one  montli  after  birth,  in 86 

Before  the  completion  of  two  months  after  birth,  in 45 

Before  the  completion  of  three  months  after  birth,  in 15 

At  four  montlis 7 

At  five  months 1 

At  six  months 1 

At  eight  months 1 

At  one  year 1 

At  two  years 1 

When  the  symptoms  do  not  occur  until  several  weeks  have  elapsed,  it  is 
probable  that  the  poison  has  been  partially  eradicated  from  the  affected 
parents  by  appropriate  treatment. 

The  nutrition  of  the  infant  who  has  inherited  the  syphilitic  taint,  but 
does  not  exhibit  it  at  birth,  is  for  a  time  good,  but  it  begins  to  be  impaired 
when  the  local  manifestations  of  syphilis  appear  or  soon  after.  The  system 
gradually  wastes  ;  the  skin  loses  its  fresh  and  healthy  appearance  and  becomes 
sallow,  and  after  a  time  more  or  less  wrinkled ;  the  features  become  pinched 
and  contracted  and  wear  a  sad  expression.  M.  Diday  says :  "  Next  to  this 
look  of  little  old  men,  so  common  in  new-born  children  doomed  to  syphilis, 
the  most  characteristic  sign  is  the  color  of  the  skin."  Trousseau  thus  described 
this  discoloration  of  the  surface :  "  Before  the  health  becomes  affected  the 
child  has  already  a  peculiar  appearance  ;  the  skin,  especially  that  of  the  face, 
loses  its  transparency ;  it  becomes  dull,  even  when  there  is  neither  pufiiness 
nor  emaciation  ;  its  rosy  color  disappears,  and  is  replaced  by  a  sooty  tint, 
which  resembles  that  of  Asiatics.  It  is  yellow  or  like  coffee  mixed  with 
milk,  or  looks  as  if  it  had  been  exposed  to  smoke ;  it  has  an  empyreumatic 
color,  similar  to  that  which  exists  on  the  fingers  of  persons  who  are  in  the 
habit  of  smoking  cigarettes.  It  appears  as  if  a  layer  of  coloring  had  been 
laid  on  unequally  ;  it  sometimes  occupies  the  whole  of  the  skin,  but  is  more 
marked  in  certain  favorite  spots,  as  the  forehead,  eyebrows,  chin,  nose,  eye- 
lids— in  short,  the  most  prominent  parts  of  the  face  ;  the  deeper  parts,  such 
as  the  internal  angle  of  the  orbit,  the  hollow  of  the  cheek,  and  that  which 
separates  the  lower  lip  from  the  chin,  almost  always  remain  free  from  it. 
Although  the  face  is  commonly  the  part  most  affected,  the  rest  of  the  body 


234  COXSTITUTIOXAL  DISEASES. 

always  participates  more  or  less  in  this  tint.  The  infant  becomes  pale 
and  wan." 

The  infant  whose  system  is  profoundly  affected  by  syphilis  rarely  smiles- 
and  its  voice  is  feeble  and  plaintive ;  its  frequent,  whimpering  cry  is  quite 
characteristic. 

Coryza  is  one  of  the  earliest  and  most  constant  of  the  local  affections  in 
infantile  syphilis.  It  is  slight  at  first,  attracting  little  attention  on  the  part 
of  the  parents,  who  are  not  aware  of  its  significance  and  usually  attribute  it 
to  a  slight  cold  ;  but  it  gradually  increases.  It  gives  rise  to  a  secretion  fi'om 
the  Schneiderian  membrane,  at  first  thin,  but  which  becomes  more  consistent 
and  is  attended  by  the  formation  of  scabs.  The  thickening  of  the  mucous 
membrane  in  consequence  of  the  inflammation  and  the  presence  of  crusts 
narrows  the  passage  through  the  nostrils,  so  as  to  produce  snuffling  respira- 
tion and  sometimes  render  nursing  difiicult.  In  severe  cases  respiration 
through  the  nostrils  is  almost  wholly  prevented,  so  that  death  may  occur 
from  inanition,  unless  the  breast  be  milked  into  the  infant's  mouth  or  it  be 
fed  with  a  spoon ;  but  ordinarily,  even  in  grave  coryza,  it  continues  to  nurse, 
though  obliged  often  to  release  its  hold  of  the  nipple  to  obtain  breath.  It  is 
when  the  coryza  interferes  with  drawing  the  nipple  that  it  first  alarms  the 
parents.  The  infiammation  at  the  same  time  may  affect  the  throat  and 
larynx,  causing  hoarseness  of  the  voice.  Ulceration  of  the  Schneiderian  mem- 
brane and  the  adjacent  cartilage  or  bone  is  rare  in  infancy  or  childhood, 
although  cases  occur  which  are  even  attended  with  more  or  less  flattening 
of  the  nose.  Diday  believes  that  the  discharge  which  accompanies  coryza 
is  in  great  part  due  to  mucous  patches  developed  on  the  Schneiderian  mem- 
brane. The  upper  lip,  over  which  the  discharge  flows,  becomes  red,  excoriated, 
and  more  or  less  incrusted.  The  coryza  in  most  cases  coexists  with  other 
local  syphilitic  affections.  Occasionally  it  occurs  alone,  and  is  the  only  evi- 
dence of  the  presence  of  the  specific  taint,  except  such  as  is  afforded  by  the 
malnutrition  and  general  appearance  of  the  patient. 

Mucous  patches  occur  in  most  patients.  They  are  developed  either  upon 
the  mucous  surfaces  or  upon  parts  of  the  skin  which  are  thin  and  exposed 
to  friction,  and  such  as  are  moistened  by  secretion  or  transudation  from  the 
vessels  underneath.  The  most  common  seat  of  mucous  patches  is  at  the  ter- 
mination of  mucous  canals ;  but  in  infancy,  on  account  of  the  peculiar  deli- 
cacy of  the  skin,  they  may  occur  upon  almost  any  part  of  the  cutaneous 
surface.  They  are  most  common,  however,  around  the  anus,  upon  the  vulva, 
scrotum,  umbilicus,  labial  commissures,  in  the  axillje,  and  behind  the  ears. 

Mucous  patches  upon  the  skin  present  a  rounded  border  and  are  slightly- 
elevated.  Their  color  has  been  compared  to  that  of  skin  which  has  been 
softened  by  the  prolonged  application  of  a  poultice.  Erosions  and  cracks 
sometimes  occur  in  the  patches,  from  which  a  thin  liquid  exudes. 

Upon  mucous  surfaces  they  are  less  elevated  than  upon  the  skin,  and  are 
prone  to  ulcerate.  These  ulcerations,  commencing  at  the  centre,  extend,  and 
soon  the  mucous  patch  disappears  and  its  site  is  occupied  by  an  ulcer.  The 
ulcer  may  be  circular,  oval,  elliptical,  crescentic.  or  irregular.  The  arches 
of  the  fauces  are  a  common  seat  of  mucous  patches. 

Roseola  is  an  occasional  symptom  of  infantile  syphilis.  "  It  is  distin- 
guished," says  Diday,  "  by  patches  of  a  bright  rose  color,  circumscribed, 
irregularly  rounded,  of  various  sizes  (most  frequently  about  as  large  as  one 
of  the  nails)  ;  appearing  by  preference  on  the  belly,  lower  part  of  the  chest, 
neck,  and  inner  surface  of  the  extremities."  The  spots  do  not  readily  and 
fully  disappear  by  pressure. 

Pemphigus,  appearing  soon  after  birth,  has  already  been  alluded  to.  Its 
most  frequent  seat,  whether  occurring  at  birth  or  as  a  subsequent  manifesta- 


SYPHILIS.  235 

tion,  is  as  we  have  stated,  tlie  palms  of  the  hands,  soles  of  the  feet,  the  fingers, 
and  the  toes.  This  eruption  commences  by  a  violet  tint  of  the  skin,  and  in 
the  course  of  twenty-four  to  forty-eight  hours  a  watery  fluid  collects  under- 
neath, which  soon  becomes  turbid.  The  skin  peels  off,  and  sometimes  an 
angry  sore  results,  which  bleeds  readily  when  rubbed  or  pressed.  In  other 
and  more  favorable  cases  new  skin  takes  the  place  of  that  which  is  lost. 
Pemphigus  at  birth  is  a  precursor  of  death,  but  when  it  appears  for  the 
first  time  some  weeks  after  birth,  it  is  a  less  unfavorable  prognostic  sign.  In 
cases  of  recovery  it  disappears,  with  proper  treatment,  in  two  or  three  weeks. 

Acne.  Impetigo,  and  Ecthyma  are  occasionally  observed  in  children  aiflicted 
with  syphilis.  The  indurated  pustules  of  acne  occur  most  frequently  upon 
the  shoulders,  back,  chest,  and  buttocks.  The  pus  is  sometimes  absorbed  and 
in  other  cases  discharged,  leaving  a  small  cicatrix,  which  after  a  time  dis- 
appears. Impetigo  appears  most  frequently  upon  the  face,  and  occasionally 
upon  the  chest,  neck,  axillae,  and  groin.  Unlike  simple  impetigo,  the  syphi- 
litic impetiginous  eruption  is  surrounded  by  a  copper-colored  areola.  Ecthyma 
occurs  upon  the  legs  and  buttocks  chiefly.  It  commences  as  violet-colored 
spots,  which  are  soon  transformed  into  pustules.  Ulcers  succeed,  which  in 
reduced  states  of  the  system  sometimes  enlarge  and  endanger  the  safety  of 
the  child.  Of  the  three  pustular  eruptions,  acne,  according  to  Diday,  is  the 
least  serious,  indicating  a  "  less  confirmed  diathesis."  Ecthyma  is  the  most 
serious,  on  account  of  the  reduced  state  of  the  system  with  which  it  is  usually 
associated.  Syphilitic  papulae  and  squamae  are  rare  in  infants,  but  cases  have 
been  observed.  Onychia  occasionally  occurs,  though  less  frequently  than  in 
syphilis  of  the  adult. 

In  an  interesting  lecture  on  hereditary  syphilis  Dr.  Miller  remarks  that 
polymorphism  of  its  cutaneous  eruptions  characterizes  hereditary  syphilis.  In 
1000  cases  of  the  inherited  disease  the  local  affections  referable  to  syphilis, 
and  seated  upon  or  in  immediate  relation  with  the  cutaneous  and  mucous 
surfaces,  were  as  follows  :  ^ 

Papules 74  per  cent,  of  the  cases. 

Ehas;ades  of  the  lips  and  anus 70  "  "  "  " 

Khinitis 58  "  "  "  " 

Ulcers  of  hard  palate 52  "  "  "  " 

Erj'thematous  eruptions 45  "  "  "  " 

Lymphadenitis  chronica 20  ','  "  "  " 

Ulcers  of  tongue  (glossitis  ulcerosa) 27  "  "  "  " 

Bullous  eruptions  ( pemphigus )      25  "  "  "  " 

Onychia  and  paronychia 23  "  "  "  " 

Laryngitis 17  "  "  "  " 

Pseudo-paralvsis  of  extremities 7  "  "  "  " 

Ulcers     .    .  ■ 4  "  " 

Ulcerative  gingivitis 4  "  "  "  " 

Visceral  Lesions. — -The  visceral  lesions  which  result  from  the  syphilis  of 
infancy  and  childhood  are  sixppuration  in  the  thymus  gland ;  gummy  tumors 
in  certain  organs,  most  frequently  the  lungs  and  liver ;  increase  of  the  con- 
nective tissue  of  the  liver,  known  as  syphilitic  cirrhosis  ;  partial  perihepatitis, 
with  depressions  resembling  cicatrices  on  the  surface  of  the  liver ;  periostitis, 
with  thicking  of  the  bone  ;  and  exostosis. 

Suppurative  inflammation  in  the  thymus  gland  is  not  common  or  has  not 
been  frequently  observed.  When  it  is  present  the  gland  sometimes  presents 
its  normal  appearance  externally,  and  the  abscess  is  only  discovered  by  incis- 
ions. Gummy  tumors  are  white  and  spheroidal ;  some  are  as  small  or  smaller 
than  a  pin's  head,  while  others  are  as  large  as  a  pea  or  even  a  hazel-nut.     I 

^  Pacific  Med.  Surg.  Journ. ,  1888. 


236  COXSTITUTIOXAL  DISEASES. 

have  seen  a  considerable  number  of  them  not  as  large  as  a  pin's  head  in  the 
liver  of  an  infant.  Grummy  tumors,  according  to  Lebert,  consist  "  of  loose 
fibrous  tissue  made  up  of  pale,  elastic  fibres,  enclosing  in  their  large  inter- 
spaces a  homogeneous  granular  substance,  the  elements  of  which  are  less  adhe- 
rent to  each  other  than  in  deposits  of  true  tubercle."  Lebert  also,  with  other 
microscopists,  discovered  round  granular  cells  in  these  tumors.  According  to 
Robin,  gummy  tumors  "  are  made  up  of  rounded  nuclei  belonging  to  fibro- 
plastic cells,  or  cytohlastions;  of  a  finely  granular,  semi-transparent,  and  amor- 
phous substance ;  and,  finally,  of  isolated  fibres  of  cellular  tissue,  a  small 
number  of  elastic  fibres,  and  a  few  capillary  blood-vessels." 

Constitutional  syphilis  is  one  of  the  principal  causes  of  waxy  degenera- 
tion, and  the  spleen  and  liver  of  infants  may  be  enlarged  from  this  cause. 
Dr.  Samuel  Gee  has  expressed  the  opinion  that  in  half  the  cases  of  hereditary 
syphilis  the  spleen  is  enlarged  (^London  Lancet,  April  13,  1867). 

Infiltration  of  the  liver  by  fibrous  substance  was  first  noticed  by  Giibler. 
It  is  not  common  in  the  infant.  A  specimen,  showing  this  lesion,  was  pre- 
sented to  the  London  Pathological  Society  in  1866  by  Dr.  Samuel  Wilks. 
The  following  remarks  by  Dr.  Wilks  convey  a  good  idea  of  the  appearance 
and  state  of  the  liver  in  syphilitic  cirrhosis :  "  Having  dissected  the  bodies 
of  several  infants  who  have  died  of  congenital  syphilis,  I  have  found  fatty 
livei's  and  an  inflammation  of  the  capsule,  but  in  only  two  have  I  discovered 
adventitious  products  of  a  fibrous  character.  The  present  example,  however, 
corresponds  in  every  particular  with  the  disease  described  by  Giibler.  It 
must  be  distinguished  (at  least  as  far  as  the  naked-eye  appearance  reaches) 
from  syphilitic  disease  of  adults,  of  which  many  specimens  have  been  before 
the  society.  In  these  the  oi'gan  is  cicatrized  on  the  surface  and  contains  dis- 
tinct nodules  of  fibrous  tissue ;  while  in  the  disease  of  children,  as  in  the 
present  specimen,  the  whole  organ  is  infiltrated  by  a  new  material,  and  it 
consequently  becomes,  as  described  by  Giibler,  hypertrophied,  globular,  and 
hard,  resistant  to  pressure,  and  even  when  torn  by  the  fingers  its  surface 
receives  no  indentation  from  them  ;  it  is  also  elastic,  and  when  cut  creaks 
slightly  under  the  scalpel.  This  was  the  form  of  disease  in  the  present 
specimen.  It  came  from  a  syphilitic  child  a  month  old,  in  whom  the  liver 
could  be  felt  enlarged  during  life,  and  when  removed  weighed  a  pound  and  a 
half.  It  was  smooth  on  the  surface,  and  so  hard  that  it  resembled  rather  a 
fibrous  tumor  than  a  liver.  It  is  seen  that  the  liver  in  the  syphilitic  child  is 
liable  to  three  distinct  pathological  processes — namely,  gummy  tumors,  cir- 
rhosis or  fibroid  degeneration,  and  waxy  degeneration." 

Syphilitic  perihepatitis  and  periostitis  are  more  rare  in  infancy  and  child- 
hood than  in  adult  life,  but  they  occasionally  occur.  The  late  Sir  James  Y. 
Simpson  considered  peritonitis  in  the  foetus  one  of  the  results  of  syphilis,  and 
a  cause  of  its  death. 

Osseous  Lesions. — "Within  the  last  few  years  important  discoveries  have 
been  made  in  regard  to  the  efi"ect  of  syphilis  upon  the  nutrition  of  the  bones 
in  children.  In  1870,  Dr.  Wegner  of  Bei'lin  published  his  observations  of  the 
state  of  the  skeleton  in  twelve  syphilitic  children  who  were  either  stillborn 
or  who  died  within  a  few  days  or  weeks  after  birth.  He  found  clear  proof 
that  the  syphilitic  dyscrasia  frequently  disturbs  the  nutrition  and  produces 
anatomical  changes  in  the  skeleton  of  the  foetus.  The  following  are  the 
lesions  clearly  referable  to  syphilis  which  he  observed :  Periostitis  of  long 
bones,  including  the  ribs ;  softening,  separation,  and  sometimes  crepitation  at 
the  point  of  union  of  diaphysis  and  epiphysis  ;  chalky  concretions  and  infil- 
trations along  the  line  of  ossification  ;  fatty  degeneration  of  marrow  ;  irreg- 
ular formation  and  distribution  of  spongy  substance  in  the  epiphysis.  These 
lesions  were  not  all  observed  in  each  case,  but  they  occurred  with  such  fre- 


SYPHILIS. 


237 


quency  that  there  could  be  no  doubt  that  they  were  due  to  the  syphilitic  taint 
of  system.  Confirmatory  observations  also  in  twelve  cases  have  since  been 
made  by  Waldeyer  and  Kobner.^ 

Again,  there  is  a  syphilitic  lesion  of  the  bone  in  children  which  is  not 
usually  present  or  has  not  usually  been  observed  at  birth,  but  is  developed 
in  the  first  weeks  or  months  of  infancy.  The  lesion  alluded  to  is  a  circum- 
scribed enlargement  of  one  or  more  bones.  This  has  been  most  frequently 
observed  upon  the  long  bones,  including  the  clavicle  and  ribs,  but  in  certain 
children  it  occurs  upon  other  bones  in  addition.  In  some  cases  it  is  one  of 
the  first  manifestations  of  hereditary  syphilis,  occurring  even  sooner  than  the 
coryza,  while  in  others  several  months  elapse  before  it  appears.  In  one  case 
reported  by  Dr.  Bulkley  ^  of  this  cit}-  it  was  first  seen  only  a  few  days  after 
birth,  being  perhaps  congenital ;  while  in  another  case,  in  which  the  enlarge- 
ment was  upon  certain  phalanges,  and  which  is  represented  in  the  accompany- 

FiG.  40. 


ing  figure,  it  appeared  at  the  age  of  twelve  months.  When  it  occurs  upon  a 
phalangeal  bone  it  is  designated  dactylitis  syphilitica. 

The  enlargement,  if  upon  a  long  bone,  ordinarily  begins  at  or  near  the 
point  of  union  of  the  diaphysis  with  the  epiphysis.  It  is  located  upon  the 
extremity  of  the  shaft,  which  it  encircles,  and  it  extends  over  a  part  or  nearly 
the  whole  of  the  epiphysis.  It  has  an  elevation  of  perhaps  one-half  or  three- 
quarters  of  an  inch  in  typical  cases :  its  surface  is  smooth  or  slightly  undu- 
lating, and  the  skin  over  it,  though  distended,  has  its  normal  appearance  and 
is  easily  movable,  unless  ulcerations  have  occurred. 

These  enlargements,  which  result  from  the  specific  inflammation  occurring 
in  the  periosteum  and  the  bone,  may  resolve  under  proper  treatment ;  but  if 
neglected  and  the  antihygienic  conditions  are  bad,  degenerative  changes  may 
occur,  ending  in  ulceration  and  destruction  of  the  diseased  part  to  a  greater 
or  less  extent. 

^  See  paper  by  K.  W.  Taylor,  M.  D.,  New  York  Journal  of  Obstetrics,  etc.,  July, 
1874. 

-  "Eare  Cases  of  Congenital  Syphilis,"  New  York  Med.  Journal,  May,  1874. 


238  CONSTITUTIONAL  DISEASES. 

Though  these  bone-enlargements,  whenever  observed,  should  excite  suspi- 
cions of  syphilis  as  the  cause,  enlargements  which  present  the  same  general 
appearance  do  occur  from  other  causes.  Such  a  case  was  observed  by  me  in 
the  children's  class  in  the  Out-door  Department  of  Bellevue,  and  Dr.  Bulkley 
details  another  case  in  his  paper.  In  the  case  observed  by  me  the  inflamma- 
tion and  enlargement  seemed  to  be  strumous.  Baumler  says :  "  Dactylitis 
syphilitica  does  not  always  originate  in  the  bone ;  similar  appearances  may 
be  produced  through  gummous  formation  in  the  sheaths  of  the  tendons  and 
in  the  fibrous  structure  of  the  finger ;"  and  again,  "  Its  outward  appearance 
may  be  produced  also  by  tuberculosis,  enchondroma,  or  sarcoma  of  the  bone- 
marrow  "  (art.  "  Syphilis,"  Ziemssen's  Encycl}). 

Mr.  J.  Hutchinson  of  London  has  called  attention  to  the  fact  that  hered- 
itary syphilis,  having  perhaps  been  manifested  by  the  usual  symptoms  during 

infancy  and  then  becoming   latent,  may  give 
-'^^'^-  ^^-  rise  to  new  symptoms   after  the  fourth  year. 

The  most  noticeable  of  these  symptoms  is  a 
dwarfing  of  the  permanent  incisor  teeth,  which 
are  rounded  and  peg-like  and  their  enamel 
notched  at  the  free  ends  of  the  teeth.  On 
account  of  the  small  size  and  shape  of  the 
teeth  there  are  interspaces ,  between  them. 
This  abnormal  development  is  most  marked 
in  the  central  incisors  of  the  upper  jaw,  and  in  certain  cases  it  is  limited  to 
them,  and  it  never  appears  in  the  other  incisors  unless  it  does  also  in  them. 
Another  symptom,  which  only  appears  in  hereditary  syphilis,  is  an  interstitial 
keratitis  occurring  on  both  sides  and  attended  by  the  deposition  of  fibrin  in 
the  substance  of  the  cornea.  In  a  few  weeks  the  inflammation  declines,  but 
a  slight  opacity  of  the  cornea  remains.  The  cerebral  nerves  may  become 
affected,  usually  a  single  pair — if  the  auditory,  deafness  resulting ;  if  the 
optic,  dimness  of  sight.  Occasionally  there  are  other  manifestations  of 
syphilis  in  this  period,  as  enlargement  of  spleen  and  liver  and  nodes  upon 
the  long  bones. 

Prognosis. — This  depends  in  great  part  on  the  general  condition  of  the 
patient.  If  there  be  much  emaciation  and  the  symptoms  indicate  a  deeply- 
seated  cachexia,  a  considerable  proportion  of  the  patients  perish.  On  the 
other  hand,  if  the  general  health  be  not  greatly  impaired,  although  the  local 
affections  are  pretty  severe,  the  prognosis  with  correct  treatment  is  good. 
The  younger  the  infant  when  the  symptoms  of  syphilis  appear,  the  more 
unfavorable,  as  a  rule,  is  the  prognosis. 

Treatment. — Parents  who  beget  syphilitic  children  ought,  from  a  due 
regard  for  their  offspring  to  make  use  of  antisyphilitic  remedies,  although 
they  present  in  their  persons  no  evidences  of  syphilitic  taint.  A  good  pre- 
scription for  the  parents  is  one-sixtieth  of  a  grain  of  corrosive  sublimate  in 
the  compound  tincture  of  bark,  given  twice  or  three  times  daily  for  several 
months.  If  the  father  have  had  syphilis,  both  parents  should  be  subjected  to 
this  treatment,  and  it  may  be  continued,  at  least  on  the  part  of  the  mother, 
during  the  first  months  of  her  gestation.  So  small  a  dose  of  the  mercurial 
does  not,  in  my  opinion,  materially  increase  the  liability  to  miscarry.  There 
is  much  more  danger  of  miscarrying  from  allowing  the  syphilitic  taint  to 
remain  uncontrolled.  Some  prefer  the  use  of  mercurial  ointment  in  the 
treatment  of  pregnant  women  having  syphilis,  in  the  belief  that  it  is  less 
likely  to  produce  abortion.  It  is  used  for  this  purpose  in  the  proportion 
of  one  drachm  to  the  ounce.  It  is  equally  effectual  in  the  eradication  of  the 
syphilitic  taint  with  the  small  dose  of  corrosive  sublimate  recommended  above 
for  internal  administration ;  but  it  is  impossible  to  determine  the  quantity  of 


SYPHILIS.  239 

mercury  whicli  enters  the  circulation  when  inunction  is  employed  and  saliva- 
tion is  more  likely  to  occur.  The  following  is,  however,  probably  the  best 
prescription  for  the  treatment  of  parents  infected  by  the  syphilitic  virus.  It 
should  be  given  for  several  months : 

R.  Hydrarg.  biniodidi,  gr.  j  ; 

Liq.  potassii  arsenit.,  5J  ; 

Tine,  belladonnse,  3ij  ; 

Potassii  iodidi,  .^ss  ; 

Aquse,  q.  s.  ad  ^^iv. — M. 

Dose  :  One  teaspoonful  three  times  daily  after  the  meals. 

Or 

R-   Vini,  _  _  Svj  ; 

Pepsini  puri  in  lamellis,  ^ij  ; 

Potassii  iodidi,  ^ij  ; 

Liq.  potassii  arsenit.,  3ij  ; 

Hydrarg.  biniodidi,  gr.  j  ; 

Qui.  at  ferri  citratis,  ,5ij  ; 

Syr.  simplic,  ^ij  L. 

01.  anisi,  gtt.  iij. — Misce. 
Dose :  One  dessertspoonful  three  times  daily. 

The  nutrition  of  the  infant  that  has  unfortunately  inherited  the  syphilitic 
taint  requires  special  attention.  Besides  exhibiting  the  characteristic  symp- 
toms of  the  disease,  it  usually  suffers  from  innutrition,  and  sometimes  passes 
into  a  state  of  decided  marasmus.  The  mother  who  has  given  birth  to  a 
syphilitic  infant  should,  if  possible,  wet-nurse  it.  Even  if  she  never  has 
exhibited  any  symptoms  of  the  disease  in  her  own  person,  she  cannot  contract 
syphilis  from  her  infant.  Colles  wrote  as  follows  in  1837  :  "  One  fact  well 
deserving  our  attention  is  this :  that  a  child  born  of  a  mother  who  is  with- 
out obvious  venereal  symptoms,  and  which,  without  being  exposed  to  any 
infection  subsequent  to  its  birth,  shows  this  disease  when  a  few  weeks  old, — 
this  child  will  infect  the  most  healthy  nurse,  whether  she  suckle  it  or  merely 
handle  and  dress  it ;  and  yet  this  child  is  never  known  to  infect  its  own 
mother,  even  though  she  suckle  it  while  it  has  venereal  ulcers  of  the  lips  and 
tongue."  This  remarkable  law  relating  to  the  immunity  of  mothers  has  been 
fully  accepted  by  all  subsequent  syphilographers.  On  the  other  hand,  a  wet- 
nurse  employed  to  suckle  a  syphilitic  infant  is  very  liable  to  contract  the  dis- 
ease, through  her  nipples,  from  the  infected  lips  of  the  infant.  If  a  wet-nurse 
be  employed  for  such  an  infant,  she  should  be  aware  of  the  risk  she  incurs, 
and  should  protect  herself  by  the  use  of  an  artificial  nipple.  At  the  same 
time,  the  infant  should  be  placed  fully  under  antisyphilitic  treatment.  Arti- 
ficial feeding,  though  usually  disastrous,  is  preferable  to  the  propagation  of 
the  disease  to  a  healthy  wet-nurse. 

Syphilis  in  the  infant  requires  mercurial  treatment  as  in  the  adult.  Mer- 
cury may  be  employed  internally  or  by  inunction.  Some  prefer  inunction  in 
the  treatment  of  ordinary  cases  in  the  manner  recommended  by  Sir  Benjamin 
Brodie.  "  I  have  spread,"  says  he,  "  mercurial  ointment,  made  in  the  pro- 
portion of  a  drachm  to  an  ounce,  over  a  flannel  roller,  and  bound  it  round 
the  child  once  a  day.  The  child  kicks  about,  and,  the  cuticle  being  thin,  the 
mercury  is  absorbed.  It  does  not  either  gripe  or  purge,  nor  does  it  make  the 
gums  sore,  but  it  cures  the  disease.  I  have  adopted  this  practice  in  a  great 
many  cases  with  the  most  signal  success."  The  oleate  of  mercury,  10  per 
cent.,  is  a  better  preparation  for  inunction.  Five  drops  may  be  rubbed  in 
three  times  daily.  Trousseau,  on  the  other  hand,  discountenances  the  use 
of  inunction,  since  mercurial  ointment  applied  to  the  skin  produces  irritation 


240  CONSTITUTIONAL  DISEASES. 

and  increases  the  sufFering  and  restlessness  of  the  child.     He  prefers  the  fol- 
lowing solution,  which  is  known  as  Van  Swieten's,  for  internal  treatment : 

R.  Hydrarg.  biclilorid.,  1  part  ; 

Aquae,  950  parts  ; 

Spts.  rectific,  100  parts. — Misce. 

Dose  :  One  or  at  most  two  grammes  (15.434  to  30.868  grains),  in  milk,  daily. 

In  order  to  avoid  the  risk  of  establishing  a  diarrhoea,  and  to  leave  the 
stomach  free  for  the  employment  of  other  medicines,  as  cod-liver  oil  and  the 
iodide  of  iron,  I  prefer  and  commonly  prescribe  for  infants  inunction  with 
the  mercurial  ointment  diluted  with  eight  times  its  quantity  of  lard,  cold 
cream,  or  vaseline.  It  should  not  be  applied  as  a  plaster,  but  a  quantity  of 
the  size  of  a  large  chestnut  should  be  rubbed  three  times  daily  upon  the 
neck  or  breast  of  an  infant  of  three  or  four  months.  For  children  over  the 
age  of  eight  or  ten  months,  Van  Swieten's  or  one  of  the  following  formulae 
may  be  employed : 

R.  Hydrarg.  cum  creta,  gr.  iij-vj  ; 

Sach.  alb.,  9j. — Misce. 

Divid.  in  chart.  No.  xii.     One  powder  three  times  daily. 

R.  Hydrarg.  chlor.  corros.,  gr.  ss-j  ; 

Syr.  sarsEe.  comp.,  5ij  ; 

Aqufe,  o^^ij- — Misce. 
Dose :  One  teaspoonful  three  times  daily. 

R.  Hyd.  chlor.  corros.,  gr.  ss  ; 

Potas.  iodid.,  5J  ; 

Ferri  et  ammon.  citrat.,  5j  ; 

Syr.  simplic,  5vj. — Misce. 

Dose  :  One  teaspoonful  three  times  daily  for  a  child  of  three  to  five  years. 

R.  Hj-d.  chlor.  corros.,  gr.  j  ; 

Potas.  iodid. ,  3ij  ; 

Syrup,  simplic, 

Aqupe,  da.  ,^ij. — Misce. 

Dose  :  Six  drops  three  times  daily  for  a  child  of  three  months. 

Prof.  A.  Jacobi  recommends,  in  the  treatment  of  syphilis  of  the  newly- 
born,  one-twentieth  of  a  grain  of  calomel,  to  be  given  three  times  daily.  An 
important  advantage  of  its  use  is  the  rapidity  and  certainty  of  its  action. 

Mercury,  in  whatever  way  employed,  should  not  be  discontinued  entirely 
till  several  weeks  after  the  syphilitic  symptoms  have  disappeared  ;  it  is  proper 
to  continue  it  for  a  time,  in  diminished  quantity  and  fewer  doses,  after  the 
health  seems  fully  restored. 

When  the  mercurial  treatment  is  omitted  tonics  are  often  required.  The 
preparations  of  cinchona  are  useful  in  certain  cases,  as  are  also  those  of  iron. 
If  the  patient  remain  feeble  and  pallid,  presenting  evidences  of  struma,  cod- 
liver  oil  and  syrup  of  the  iodide  of  iron  will  be  found  beneficial,  continued  for 
some  weeks  or  months  after  the  mercury  is  discontinued.  Attention  should 
always  be  given  to  cleanliness  and  the  hygienic  management  of  the  patient. 
In  some  instances  direct  treatment  of  the  local  affection  is  serviceable.  To 
aid  in  the  cure  of  syphilitic  coryza  the  following  ointment  should  be  applied 
within  the  nostrils  hj  a  nasal  sponge  three  times  daily : 

R.  Ung.  hydrai'g.  nitratis,  ^^ij  ; 

Ung.  zinci  oxidi,  %\]. — Misce. 


SYPHILIS.  241 

Recently  I  have  been  in  the  habit  of  employing  Squibb's  oleate  of  mer- 
cury, 2  per  cent.,  for  syphilitic  coryza  of  infants,  and  the  effect  has  been 
satisfaetoi'y.  It  may  also  be  employed  by  cutaneous  inunction  in  the  treat- 
ment of  the  general  disease. 

Condylomata  or  mucous  patches  seated  upon  the  cutaneous  surface  should 
be  dusted  with  calomel.  At  my  clinique  in  April,  1871,  a  child  two  years 
and  ten  months  old  was  presented,  with  a  large  condylomatous  outgrowth 
near  the  anus.  The  history  of  the  child  showed  that  in  all  probability  the 
disease  had  been  contracted  within  a  year  from  syphilitic  children  in  one  of 
the  public  institutions.  Within  three  weeks  this  affection  disappeared  by 
dusting  upon  it  calomel  once  daily,  with  appropriate  internal  treatment. 

The  infant  should  be  kept  clean  by  bathing  it  in  tepid  water  twice  daily, 
and  excoriations  upon  its  lips  or  mucous  patches  should  be  bathed  before  the 
nursing  with  some  mild  disinfectant  solution,  as  boric  acid.  The  best  pos- 
sible hygienic  conditions  should  be  provided  for  the  infant,  since  cachexia  is 
commonly  present.  It  should  be  taken  outdoors  frequently  in  suitable  weather, 
and  its  removal  from  the  city  to  the  country,  especially  in  hot  weather,  may 
be  advisable.  The  cachexia  which  remains  after  the  disappearance  of  the 
syphilitic  manifestations  requires  the  use  of  tonics,  as  cod-liver  oil  and  syrup 
of  the  iodide  of  iron. 

Syphilitic  symptoms  may  reappear  during  childhood.  The  exanthemata 
rarely  appear  at  this  age  when  the  proper  treatment  has  been  employed  in 
infancy,  but  condylomata  and  gummy  tumors  may,  and  they  require  a  return 
to  the  mercurial  treatment.  If  the  bones  are  affected  the  iodide  of  potassium 
is  the  proper  remedy.  It  causes  the  disappearance  of  the  periosteal  pains 
and  swelling,  and  manifest  improvement  in  the  symptoms  generally. 
16 


SECTION   II. 
ERUPTIVE   FEVERS. 


CHAPTER   I. 

MEASLES. 


The  disease  known  in  the  vernacular  as  measles  has  also  the  names 
rubeola  and  morbilli.  It  is  a  common  exanthematic  affection  occurring  at 
any  age,  but  most  frequently  in  childhood.  It  affects  once  the  majority 
of  mankind.  Writers  recognize  three  stages  of  measles:  first,  that  of  inva- 
sion, which  ends  with  the  appearance  of  the  eruption  ;  secondly,  the  eruptive 
stage ;  and,  thirdly,  the  stage  of  decline  or  desquamation. 

Etiology. — Micrococci  have  been  found  in  the  blood  of  rubeolar  patients 
by  Coze  and  Feltz.  Keating  also  discovered  them  during  an  epidemic  of  malig- 
nant measles  (^Phila.  Med.  Times,  Aug.  12,  1882),  and  Ransome,  Braidwood, 
and  A^aeher  found  them  in  the  breath  of  patients  as  well  as  in  their  tissues 
{Brit.  Med.  Jouni.,  Jan.  21,  1882).  It  seems  probable  that  they  are  the  specific 
principle  ;  if  so,  they  remain  dormant  in  the  system  about  twelve  days,  which 
is  the  incubative  period.  Additional  observations  are  required  in  order  to 
determine  positively  whether  this  micrococcus  be  the  causal  agent  in  measles, 
or  whether  it  may  not  be  some  other  microbe. 

Symptoms. — This  disease  commences  with  such  symptoms  as  usually 
occur  in  mild  but  pretty  general  inflammation  of  the  air-passages — to  wit, 
cough,  fever,  anorexia,  and  thirst.  The  eyes  present  a  suffused,  moderately 
injected,  and  brilliant  appearance,  and  the  buccal  and  faucial  surfaces  are 
injected.  The  Schneiderian  membrane  and  that  lining  the  larynx,  trachea, 
and  bronchial  tubes  participate  in  the  increased  vascularity.  The  cough  at 
first  is  dry,  and  sometimes  distinctly  croupy.  Catarrhal  or  false  croup,  indeed, 
is  not  infrequent  in  the  initial  period  of  measles.  The  cough  is  attended  with 
slight  acceleration  of  respiration  and  by  little  or  no  pain  in  the  respiratory 
movements.  If  auscultation  be  practised  at  this  early  stage,  we  observe  the 
vesicular  murmur,  somewhat  harsh  in  character,  and  sometimes  sonorous  and 
sibilant  rales.     A  little  later  rales  of  a  moist  character  appear. 

The  patient,  if  old  enough,  commonly  complains  of  headache  and  of  dull 
pain  in  the  epigastric  region  or  the  centre  of  the  sternum,  due  to  the  bron- 
chitis. With  these  local  symptoms  febrile  reaction  occurs.  The  temperature 
rises  to  about  102°  or  103°,  as  indicated  by  the  thermometer  in  the  axilla. 
The  pulse  numbers  from  110  to  130  per  minute.  The  febrile  movement  is 
greater  than  in  primary  tracheo-bronchitis,  except  when  the  bronchitis  extends 
to  the  bronchioles,  but  it  is  less  than  in  most  cases  of  scarlet  fever. 

The  fever  in  the  premonitory  stage  of  measles  after  the  first  day  is  not 
uniform.  It  is  attended  by  remissions  and  exacerbations,  the  former  occur- 
242 


MEASLES.  243 

ring  in  the  first  part  of  the  day,  the  hitter  in  the  evening.  Sometimes  two 
exacerbations  occur  in  the  day.  The  face  is  flushed  and  somewhat  swollen, 
especially  during  the  times  of  increase  in  the  fever,  and  the  child  is  drowsy 
or  restless.  Vomiting,  so  common  a  symptom  in  the  commencement  of  scarlet 
fever,  occasionally  occurs  in  measles.  While  in  scarlet  fever  this  takes  place 
in  the  first  twenty-four  houi's,  in  measles  it  takes  place  with  about  equal  fre- 
■quency  at  any  period  previously  to  the  eruption.  It  was  present  during  the 
first  stage,  sometimes  almost  as  late  as  the  eruptive  period,  in  13.  and  was 
absent  in  23  cases  in  which  I  preserved  records  in  reference  to  this  symptom. 

The  duration  of  the  first  stage  varies  in  different  cases.  It  is  usually  from 
two  to  five  days,  with  an  average  of  about  four.  Occasionally  it  is  more  pro- 
tracted on  account  of  some  disturbance  in  the  economy,  either  from  exposure 
to  cold  or  other  cause,  which  prevents  the  necessary  afilux  of  blood  toward 
the  surface  and  retards  the  eruption.  In  18  cases  in  my  practice  in  which 
the  duration  of  the  cough  previously  to  the  appearance  of  the  rash  was  accu- 
rately ascertained,  the  time  varied  from  one  to  five  days,  with  an  average  of 
three  and  one-third;  in  10  other  cases  it  had  continued,  the  parents  stated, 
about  a  week ;  and  in  5,  from  one  to  two  weeks  previously  to  the  eruption. 

The  eruption  commences,  when  the  disease  pursues  its  normal  course,  upon 
the  forehead  and  neck,  then  the  face,  and  gradually  extends  downward,  occu- 
pying from  twenty-four  to  thirty-six  hours  in  passing  over  the  trunk  and 
limbs.  It  appears  first  as  indistinct  red  points,  not  more  than  a  line  in  diam- 
eter, which  increase  in  size  and  become  more  distinct.  Their  borders  are 
uneven  or  irregular  or  they  are  finely  notched ;  their  general  shape  is,  how- 
ever, circular,  except  as  two  or  more  unite,  when  they  may  assume  any  form. 
The  crescentic  form  which  writers  describe  is  due  to  the  union  of  two  points 
of  eruption.  The  largest  of  these  points,  when  there  is  no  coalescence,  do 
not  exceed  a  quarter  of  an  inch  in  diameter,  and  many  are  much  smaller. 
Frequently  in  plethoric  children,  if  there  be  much  fever,  there  is  continuous 
redness  over  several  inches  of  surface.  The  eruption  is  then  confluent.  This 
form  is  often  observed  upon  the  parts  of  the  surface  where  the  capillary  cir- 
culation is  most  active  when  it  is  discrete  elsewhere.  In  some  of  these  cases 
diagnosis  of  measles  from  scarlet  fever  is  attended  with  difficulty. 

The  rubeolous  eruption  is  slightly  elevated,  the  elevation  not  being  appre- 
ciable to  the  sight,  but  it  can  be  ascertained  by  passing  the  finger  over  the 
skin,  when  roughness  is  felt  at  the  point  of  eruption.  Sometimes  the  eleva- 
tion, especially  in  the  commencement  of  the  efflorescence,  is  not  appreciable, 
even  to  the  touch.  The  eruption  is  broad  and  flat,  never  acuminate,  never 
changing  its  form  to  the  vesicular  or  pustular.  It  disappears  by  pressure, 
and  immediately  reappears  when  the  pressure  is  removed.  It  has  been  com- 
pared in  appearance  to  flea-bites.  Small,  pointed,  papular,  vesicular,  or  pustu- 
lar eruptions  are  sometimes  seen  in  connection  with  those  of  measles,  but  they 
are  accidental,  occurring  in  other  states  of  the  system  as  well  as  in  measles, 
if  there  be  the  same  augmented  temperature. 

In  the  commencement  of  the  eruptive  period  the  severity  of  the  consti- 
tutional and  local  symptoms  increases.  The  pulse  and  temperature  corre- 
spond with  the  character  which  they  presented  during  the  exacerbations  of 
the  first  stage.  The  features  are  slightly  swollen ;  the  eyes  still  watery  and 
sensitive  to  light ;  the  conjunctiva,  ocular  and  palpebral,  and  the  mucous 
membranes  of  the  cavity  of  the  mouth  and  of  the  air-passages,  continue 
injected.  The  tongue  is  covered  with  a  moist  thin  fur,  and  its  papillae  are 
prominent,  though  less  so  than  in  scarlet  fever.  The  cough  continues  fre- 
quent, and  is  seldom  attended  with  much  expectoration  in  uncomplicated 
cases ;  often  there  is  no  expectoration  whatever.  The  appetite  is  lost,  but 
drinks   are   readily  taken    on   account  of   the  thirst.     Diarrhoea    sometimes 


244  CONSTITUTIONAL  DISEASES. 

occurs  on  the  first  clay  of  tlie  eruption,  but  it  lasts  only  a  few  hours,  and, 
if  the  disease  pursue  its  usual  course,  abates  of  itself.  With  the  exception 
of  this  the  bowels  are  regular  or  a  little  constipated  during  the  eruptive 
period. 

On  the  second  day  of  the  eruption,  or  siith  of  the  fever,  the  symptoms 
begin  to  abate.  The  pulse  is  less  accelerated  and  the  temperature  diminishes  ; 
the  cough  is  less  frequent  and  is  easier,  and  the  flushed  and  swollen  appear- 
ance of  the  face  declines.  By  the  close  of  the  third  or  on  the  fourth  day 
the  rash  has  disappeared  in  the  order  in  which  it  extended  over  the  body. 
There  only  remain  faint  maculas,  which  in  the  course  of  a  day  or  two  fade 
completely. 

With  the  disappearance  of  the  rash  the  fever  nearly  or  quite  ceases,  but 
a  slight  and  painless  cough  continues  for  several  days. 

Occasionally  the  eruption  presents  a  livid  appearance  ;  this  is  the  rubeola 
nigra  of  writers.  From  cases  which  I  have  observed  it  is  my  opinion  that 
this  should  not  be  considered  a  distinct  species  in  the  vast  majority  of 
patients,  but  that  the  dark  color  is  due  to  internal  inflammation,  usually 
capillary  bronchitis  or  pneumonia,  which  prevents  full  decarbonization  of  the 
blood.  Rarely,  rubeola  nigra  is  due  to  the  vitiated  state  of  the  blood  or  the 
malignant  nature  of  the  disease.  The  course  of  the  eruption  in  this  form 
of  measles  is  somewhat  diff"erent ;  it  continues  longer,  fades  more  slowly,  and 
does  not  disappear  so  readily  on  pressure.  Traces  of  it  are  observed  a  week 
or  more  after  its  first  appearance ;  it  is  likely  to  be  fatal.  Measles  may  pre- 
sent this  form  from  the  beginning,  or,  commencing  as  vulgaris,  it  may  pass 
into  rubeola  nigra. 

Measles  may  be  irregular  in  form,  but  aberrations  are  less  frequent  than 
in  scarlet  fever.  Writers  describe  measles  without  catarrh,  and,  on  the  other 
hand,  with  catarrh,  but  without  the  rash.  But  positive  diagnosis  in  such 
cases  must  be  difficult.  It  is  probable  that  simple  catarrh  and  roseola  have 
sometimes  been  mistaken  for  the  two  forms  of  irregularity  mentioned ;  but 
when  a  child  in  a  family  of  children  aff"ected  with  measles  presents  all  the 
symptoms  of  that  disease  except  the  catarrh  or  except  the  eruption,  the 
diagnosis  of  irregular  measles  would,  as  a  rule,  be  correct. 

Occasionally  the  stage  of  invasion  is  very  short  or  even  ab.sent.  In  one 
case  the  parents  informed  me  that  the  catarrhal  symptoms  began  on  the  day 
when  the  eruption  appeared.  Convulsions  sometimes  occur  at  the  commence- 
ment of  measles,  as  well  as  during  its  progress.  A  single  convulsive  attack 
at  the  commencement  is  usually  not  dangerous ;  when  repeated  it  is  more 
serious ;  it  is  also  more  serious  when  it  occurs  in  the  course  of  measles. 
In  certain  patients  the  eruption  appears  in  an  irregular  and  partial  manner, 
occurring  perhaps  at  a  late  period,  and  indistinctly,  upon  the  trunk  alone  or 
upon  the  trunk  and  partially  upon  the  legs.  In  many  cases  of  deferred  or 
partial  eruption  there  is  internal  congestion  or  inflammation  of  some  part, 
which  causes  withdrawal  of  blood  from  the  surface,  and  thus  prevents  the 
normal  development  of  the  rash. 

When  the  eruption  disappears  the  third  stage  commences,  that  of  de- 
squamation. It  is  characterized  by  a  scanty  furfuraceous  exfoliation  of  the 
epidermis.  The  desquamation  is  seldom  as  great  as  in  scarlet  fever,  and  it 
occurs  most  where  the  eruption  has  been  thickest  and  the  epidermis  most 
inflamed.  Exfoliation  occurs  between  the  fourth  and  seventh  days  after 
the  commencement  of  the  eruption,  the  eighth  and  the  eleventh  of  the 
disease.  Frequently  it  does  not  take  place,  or  is  so  slight  as  not  to  be 
observed. 

With  the  disappearance  of  the  rash  the  symptoms  rapidly  abate.  The 
pulse  becomes  more  natural,  the  temperature  is  reduced,  the  digestive  organs 


MEASLES.  245 

return  to  their  normal  state,  and  convalescence  is  established.  The  cough 
continues  several  days  after  the  other  symptoms  abate,  but  it  is  less  and  less 
frequent,  and  is  not  painful. 

Complications.— The  complications  of  this  disease  are  important.  Much 
of  the  success  of  the  physician  in  the  management  of  measles  depends  upon 
a  correct  diagnosis  and  understanding  of  them.  The  most  frequent  of  these 
complications  are  bronchitis  and  broncho-pneumonia.  Slight  bronchitis  is 
uniformly  present  in  measles,  but  if  it  increase  so  as  to  cause  embarrassment 
of  respiration  and  become  a  source  of  danger,  it  is  properly  a  complication. 
This  complication,  as  well  as  pneumonia,  may  occur  at  any  period  of  measles, 
but  it  commences  most  frequently  in  the  first  stage.  Occurring  in  the  first 
stage,  it  may  prevent  the  regular  appearance  of  the  rash  ;  if  in  the  second 
stage,  it  often  causes  retrocession  of  it. 

When  bronchitis  becomes  really  serious  it  usually  has  invaded  the  minute 
bronchial  tubes.  This  disease,  designated  capillary  bronchitis  or  suffocative 
catarrh,  I  have  elsewhere  described.  The  clinical  history  of  fatal  bronchitis 
as  a  complication  of  measles  is  as  follows  :  The  respiration,  at  first  not  notably 
altered,  becomes  by  degrees  accelerated  and  the  patient  more  and  more  fret- 
ful. The  pulse,  instead  of  becoming  less  accelerated,  as  after  the  first  days 
of  simple  measles,  is  daily  more  rapid  and  the  respiration  more  frequent  and 
labored.  The  dyspnoea  gradually  increases,  the  inframammary  region  is 
depressed  during  each  inspiration,  and  the  subcrepitant  rale  is  heard  on  both 
sides  of  the  chest.  There  is  probably  collapse  or  inflammation  of  some  of  the 
lobules.  Finally,  the  prolabia  and  fingers  become  livid,  and  death  occurs  from 
apnoea.  Capillary  bronchitis,  occurring  as  a  complication  and  continuing  as 
a  sequel  of  measles,  usually  becomes  a  broncho-pneumonia.  A  large  propor- 
tion of  those  afi"ected  under  the  age  of  three  years  die.  The  anatomical  cha- 
racters of  fatal  bronchitis  occurring  in  connection  with  measles  we  have  had 
frequent  opportunities  to  inspect  in  the  Foundling  Asylum  and  Infant  Asylum. 
In  some  cases  there  have  been  evidences  of  continuous  inflammation  from  the 
epiglottis  downward,  ending  in  lobular  or  broncho-pneumonia.  Broncho- 
pneumonia as  a  complication  does  not  diff"er  materially  from  the  idiopathic 
inflammation,  except  that  it  is  more  protracted  and  fatal. 

The  next  most  frequent  serious  complication  of  measles  is  entero-colitis. 
This  may  commence  at  any  period  during  the  course  of  the  disease.  If  the 
colon  be  more  especially  the  seat  of  inflammation,  the  evacuations  contain 
mucus  and  blood,  unless  in  young  children,  in  whom  the  stools,  even  in 
severe  colitis,  commonly  have  a  green  color.  The  anatomical  character  of 
this  complication  varies  in  different  cases,  like  the  idiopathic  form  of  inflam- 
mation. Sometimes  there  is  simple  arborescence  of  the  intestinal  mucous 
membrane,  with  tumefaction  of  its  follicles ;  in  other  cases,  in  addition  to 
increased  vascularity,  the  mucous  coat  is  softened  and  thickened ;  and  in 
others  still,  especially  if  the  inflammatory  action  has  been  protracted,  ulcer- 
ation occurs,  for  the  most  part  in  the  site  of  the  solitary  glands.  Excep- 
tionally, in  fatal  cases  of  measles  attended  with  diarrhoea,  no  vascularity  is 
observed  after  death,  although  the  intestines  may  be  thickened  and  softened. 
In  such  cases  the  diarrhoea  was  probably  inflammatory,  the  injection  of  the 
vessels  having  disappeared  after  death. 

Severe  and  obstinate  diarrhoeal  aff'ections  occurring  with  measles  usually 
commence  as  the  primary  disease  is  about  declining.  They  then  become 
sequelae,  ending  fatally  in  many  instances,  especially  in  the  summer  months, 
several  days  or  perhaps  weeks  after  the  disappearance  of  the  eruption. 
Diarrhoeal  attacks  occurring  in  or  previously  to  the  eruptive  stage  are,  as 
a  rule,  mild  and  easily  relieved. 

In  some  grave  cases  measles  have  a  tendency  from  the  first  to  afi"ect  the 


246  CONSTITUTIONAL  DISEASES. 

internal  organs  more  than  the  surface.  Bronchitis,  pneumonia,  and  entero- 
colitis may  coexist  with  indistinctness  of  the  eruption  on  the  skin.  Such 
complications  render  a  fatal  result  highly  probable. 

Eclampsia  is  also  an  occasional  very  dangerous  complication.  It  some- 
times occurs  very  suddenly  and  unexpectedly.  A  child  of  five  years,  in  my 
practice,  apparently  progressing  favorably  with  measles,  was  allowed  to  sit  at 
dinner  with  the  family  ;  suddenly  and  without  premonition  eclampsia  occurred, 
the  rash  receded,  and  notwithstanding  vigorous  treatment  death  resulted  in 
a  few  hours.  Rapidly-developed  cerebral  congestion  seemed  to  be  present. 
To  prevent  such  a  complication  the  patient  should  remain  quiet  in  bed  dur- 
ing the  eruptive  stage. 

Another  very  fatal  complication  and  sequel  is  pseudo-membranous  laryn- 
gitis, commencing  when  rubeola  is  beginning  to  decline  ;  but  it  is  less  frequent 
than  pneumonia  or  entero-colitis.  In  catarrhal  or  false  croup — which,  as  has 
been  previously  stated,  is  not  infrequent  at  the  commencement  of  measles — 
the  cough  has  a  loud,  ringing  character.  In  membranous  laryngitis,  on  the 
other  hand,  it  is  hoarse  or  harsh  and  less  distinct,  on  account  of  the  presence 
of  the  pseudo-membrane  in  the  larynx.  This  form  of  laryngitis,  always  a 
grave  disease,  is  more  serious  when  it  occurs  as  a  complication  of  measles  than 
when  it  is  idiopathic,  not  only  because  the  blood  is  vitiated  and  the  system 
reduced  by  the  primary  aifection,  but  because  the  inflammation  of  the  mucous 
surface  is  in  general  more  extensive,  as  is  also  the  pseudo-membrane.  This 
membrane  in  the  croup  of  measles  often  extends  so  far  down  the  air-passages 
that  neither  intubation  nor  tracheotomy  can  produce  any  decided  ameliora- 
tion of  symptoms.  This  complication,  though  always  grave,  is  not,  however, 
necessarily  fatal.  I  have  known  cases  recover  by  inhalation  of  solvent  sprays 
when  for  days  there  had  been  dyspnoea  and  other  evidences  of  a  pretty  firm 
pseudo-membrane.  True  croup  causes  continuation  of  the  fever,  which  had 
perhaps  begun  to  abate. 

Diphtheria,  when  epidemic,  also  frequently  complicates  measles.  Much 
of  the  mortality  from  measles  in  this  city  since  the  year  1858  was  due  to 
this  cause.  In  cases  observed  by  myself,  diphtheria  usually  began  while  the 
fauces  were  still  inflamed,  and  sometimes  before  the  eruption  had  begun  to 
fade.  The  pseudo-membranous  laryngitis  or  true  croup  mentioned  above  is, 
in  most  instances,  in  localities  where  diphtheria  prevails,  a  local  manifestation 
of  this  disease. 

These  are  the  most  common  complications  of  measles.  There  are  others 
of  less  frequent  occurrence,  among  which  may  be  mentioned  stomatitis,  pha- 
ryngitis, and  otitis  sufficiently  severe  to  be  considered  complications.  Rarely, 
also,  purpura,  attended  by  hemorrhages  from  the  diff"erent  mucous  surfaces, 
occurs  in  connection  with  measles.  This  complication  is,  however,  more  fre- 
quent in  certain  other  constitutional  diseases,  as  scarlet  fever,  and  especially 
variola. 

It  is  seen  that  the  inflammations  which  occur  in  the  course  of  measles 
are  chiefly  of  the  mucous  surfaces.  In  scarlet  fever,  on  the  other  hand,  the 
inflammations  are  more  frequently  of  serous  surfaces. 

There  are  other  afi"ections  originating  in  measles  which  are  rather  sequelas 
than  complications.  Gangrene  of  the  mouth  is  one  which,  as  stated  in  another 
part  of  this  book,  occurs  more  frequently  after  measles  than  any  other  disease. 
After  a  severe  epidemic  of  measles  in  the  New  York  Foundling  Asylum  in 
1874  three  cases  of  gangrenous  vulvitis  occurred  in  those  who  had  been 
aff"ected.  Ophthalmia  commencing  in  measles  often  persists  for  weeks  or 
months.  It  may  give  rise  to  granulation  of  the  lids,  and  cases  have  been 
reported  of  violent  inflammation  of  a  purulent  character  producing  ulcera- 
tion of  the  cornea  and  destroying  vision.     The  ophthalmia  is  sometimes  very 


MEASLES.  247 

intractable.  Inflammation  of  tlie  Schneiderian  membrane,  commonly  present 
during  measles,  often  continues  as  a  sequel,  extending  back  as  far  as  tbe 
Eustachian  tube,  where  it  may  cause  swelling,  with  impairment  of  hearing, 
and  forward  to  the  lip,  where  it  may  produce  chronic  eczema.  Prof.  Moos 
has  described  the  lesions  which  occur  in  the  labyrinth  in  measles  when  the 
ear  is  affected.  Cells  and  coagulated  lymph  fill  the  semicircular  canals  and  the 
cochlea,  and  collect  in  the  lymphatics.  The  blood-vessels  in  the  Haversian 
canals  and  in  the  spiral  ligament  are  nearly  destroyed.  The  nerves  become 
gelatinous  and  atrophied  ;  the  muscular  fibres  undergo  waxy  degeneration. 
Notwithstanding  such  lesions,  permanent  deafness  is  rare  and  reparation 
seems  possible  (Congress  at  Wiesbaderi,  Sept.  22,  1887). 

Anatomical  Characters. — I  have  made  or  witnessed,  mainly  in' insti- 
tutions, a  considerable  number  of  post-mortem  examinations  of  those  who 
have  died  in  or  after  an  attack  of  measles.  In  all  there  were  lesions  due  to 
complications.  Indeed,  death  directly  from  measles  is  so  rare  that  few  have 
had  an  opportunity  of  studying  the  anatomical  characters  apart  from  the 
complications.  In  those  who  have  died  without  any  obvious  coexisting  dis- 
ease— and  these  cases  chiefly  occur  in  the  malignant  form — there  has  been 
congestion  of  the  internal  organs,  especially  marked  in  the  lungs,  and  some- 
times the  tissues  appeared  softened.  The  blood  also  in  the  malignant  form 
has  a  darker  hue  than  natural,  and  ecchymotic  patches  have  been  observed 
upon  the  mucous  surfaces  and  elsewhere,  corresponding  in  character  with  the 
petechige  under  the  skin  which  sometimes  occur  in  this  form  of  measles.  In 
cases  resulting  fatally  from  bronchitis  or  pneumonia  the  bronchial  glands  are 
commonly  tumefied  in  the  same  manner  as  the  mesenteric  glands  are  enlarged 
in  enteritis  and  the  glands  of  the  mesocolon  in  dysentery. 

Nature. — Rubeola,  like  the  other  exanthematic  fevers,  is  due  to  a  mate- 
ries  morbi,  probably  micrococci,  as  has  been  stated  above.  It  is  highly  con- 
tagious through  the  air.  It  has  been  inoculated  by  the  serum  from  vesicles 
which  sometimes  occur  in  connection  with  the  rubeolous  eruption,  and  also 
by  the  blood  from  a  patient.  Inoculation  does  not  appear  to  moderate  the 
disease,  and  as  measles,  when  contracted  in  the  ordinary  way,  is  not  in  itself 
dangerous,  but  dangerous  only  from  complications,  inoculation  is  not  per- 
formed except  as  a  matter  of  scientific  interest.  The  usual  mode  of  propa- 
gation is  through  the  air.  Measles  is  communicated  by  the  breath  and  prob- 
ably by  exhalations  fi'om  the  surface.  Under  whatever  circumstances  it 
occurs,  the  specific  principle  has  been  communicated  from  some  infected 
person.  We  frequently  meet  cases,  as  in  a  sparsely-settled  district  that  has 
come  to  my  knowledge,  in  which  exposure  cannot  be  traced.  Yet  the  im- 
munity of  certain  islands  for  centuries  till  infected  through  commerce  renders 
the  doctrine  of  an  origin  de  novo  improbable. 

Twelve  to  fourteen  days  elapse  from  the  time  of  infection  to  the  com- 
mencement of  the  eruption.  In  cases  observed  in  the  children's  department 
of  Charity  Hospital  the  incubative  period  was  ascertained  to  be  about  twelve 
days.  In  those  who  have  been  inoculated  the  incubative  period  is  said  to 
have  been  about  one  week.  Rubeola  prevails  epidemically,  like  the  whole 
class  of  infectious  diseases,  and  in  diff'erent  epidemics  the  type  may  vary  as 
well  as  the  character  of  the  complications. 

Diagnosis. — The  diagnosis  of  measles  previously  to  the  eruption  is  often 
difiicult.  The  catarrhal  symptoms  then  predominate,  and  these  are  such  as 
may  occur  independently  of  any  constitutional  or  blood  disease.  The  first 
stage,  therefore,  is  not  infrequently  mistaken  for  coryza  or  mild  bronchitis. 
The  points  of  diff"erential  diagnosis  are  the  sufi"used  appearance  of  the  eyes, 
the  greater  degree  of  fever  on  the  first  day  than  would  be  likely  to  arise  from 
so  moderate  an  amount  of  local  disease,  and  morning  remission  and  evening 


248  CONSTITUTIONAL  DISEASES. 

exacerbation  of  the  fever.     Measles  in  the  first  stage  has  been  mistaken  for 
remittent  fever.     The  catarrhal  symptoms  should  prevent  such  an  error. 

Sometimes  roseola  closely  resembles  measles  in  appearance,  but  the  rash 
of  roseola  appears  within  a  few  hours  after  the  commencement  of  febrile 
symptoms,  and  almost  simultaneously  over  the  whole  body,  and  without 
those  local  symptoms  referable  to  the  mucous  surfaces  which  characterize 
measles. 

Variola  on  the  first  day  of  the  eruption  has  sometimes  been  diagnosticated 
measles.  I  recollect  once  being  called  to  an  infant  with  fatal  confluent  small- 
pox who  was  said  to  have  measles.  A  physician  a  few  days  previously,  observ- 
ing the  red  points  in  the  commencement  of  the  eruption,  had  made  this  absurd 
diagnosis,  and,  predicting  a  favorable  result,  had  not  thought  it  necessary  to 
repeat  his  visit.  In  case  of  doubt  it  is  the  part  of  prudence  to  defer  making 
a  positive  diagnosis.  A  few  hours  sufiice  to  show  the  distinctive  characters 
of  rubeolous  and  variolous  eruptions.  But  the  anxiety  of  friends  often  neces- 
sitates the  expression  of  opinion.  The  absence  or  lightness  of  catarrhal  symp- 
toms, the  earlier  appearance  of  the  eruption,  and  its  papular  feel  under  the 
finger  in  smallpox,  enable  us  to  discriminate  between  the  two  diseases  in  the 
commencement  of  the  eruptive  stage.  Moreover,  the  symptoms  in  the  initial 
periods  are  different,  as  will  be  seen  in  our  description  of  smallpox. 

Prognosis.  —  This  is  favorable,  provided  that  no  serious  complication 
arises.  With  internal  inflammatory  complication,  on  the  other  hand,  the 
disease  becomes  much  more  grave.  A  large  proportion  thus  affected  die. 
The  prognosis  is  less  favorable  in  feeble  children  with  scanty  eruption  or  an 
eruption  appearing  at  a  late  period  and  irregularly.  Dyspnoea,  persistent  and 
great  acceleration  of  pulse,  and  coma  indicate  an  unfavorable  ending.  Con- 
vulsions occur  much  more  rarely  in  the  course  of  measles  than  in  scarlet 
fever,  and  when  they  occur  after  the  initial  period  they  usually  end  in  coma 
and  death.  The  mortality  from  measles  varies  greatly  according  to  the 
severity  of  the  type,  but  more  according  to  the  season,  the  locality,  the  sur- 
roundings, and  the  care  which  the  patients  receive,  which  determine  the  lia- 
bility to  complications.  Thus  in  the  cities  the  mortality  is  large  from  measles 
in  the  hot  iiionths  among  infants,  who  at  this  time  are  very  liable  to  gastro- 
intestinal catarrh.  It  also  seems  to  be  larger  in  the  asylums  than  in  family 
practice.  In  epidemics  in  Boston  and  Pont  de  I'Arche  the  mortality  was  5 
per  cent,  of  the  cases,  in  Neufchatel,  Switzerland,  2  per  cent.,  and  among  the 
Sioux  Indians,  at  Crow  Creek  Agency,  Dakota,  6.66  per  cent.  (^Therapeutic 
Gaz.,  July  16,  1888). 

Treatment. — Uncomplicated  rubeola  requires  little  medicinal  treatment 
except  to  palliate  symptoms.  The  child  should  be  kept  in  an  airy  apartment 
at  a  uniform  temperature  of  about  70°.  A  temperature  so  elevated  as  to  be 
uncomfortable  to  the  nurse  is  injurious  to  the  patient.  But  while  the  popular 
idea  is  erroneous  that  he  should  be  kept  in  a  heated  atmosphere,  it  is  correct 
that  currents  of  air  and  sudden  reduction  of  temperature  are  dangerous.  A 
violent  and  fatal  attack  of  croup  occurred  in  my  practice  in  a  girl  of  fifteen 
in  consequence  of  exposure  at  an  open  window  at  the  close  of  the  eruptive 
stage.  The  diet  should  be  mild,  and  for  the  most  part  liquid.  The  patient, 
indeed,  refuses  solid  food,  but  on  account  of  the  thirst  takes  liquids  more 
readily.  Farinaceous  substances,  with  milk,  afford  sufficient  nutriment  in 
ordinary  cases.  If  the  previous  health  have  been  poor  and  the  vital  powers 
reduced,  or  if  there  be  a  complication,  more  sustaining  diet  is  required. 
Stimulation  by  wine  or  brandy  is  needed  in  these  cases.  During  the  two  or 
three  weeks  succeeding  an  attack  of  measles  care  should  be  taken  to  avoid 
exposure  to  cold  or  changes  of  temperature,  since  during  this  period  there  is 
great  liability  to  inflammations  of  the  mucous  surfaces. 


MEASLES.  249 

The  coixgli  ordinarily  requires  treatment,  inasmucli  as  the  suffering  of  the 
chiki  and  loss  of  sleep  are  largely  due  to  this  symptom.  Demulcent  drinks, 
as  flaxseed  tea,  infusion  of  slippery-elm  bark,  or  solution  of  gum  Arabic,  are 
useful,  to  which,  to  render  them  more  palatable,  lemon-juice  may  be  added. 
A  small  Dover's  powder  or  the  mistura  glycyrrhizse  composita  of  the  Pharma- 
copoeia, given  occasionally,  relieves  the  severity  and  diminishes  the  frequency 
of  the  cough. 

As  the  chief  danger  in  measles  is  from  inflammation  of  the  respiratory 
organs,  local  treatment  directed  to  the  chest  is  important.  The  chest  should 
be  covered  with  cotton  wadding  or  in  cold  weather  even  oil-silk,  unless  in 
the  mildest  cases.  This  increases  the  amount  of  eruption  upon  the  surface 
imderneath,  and,  I  believe,  tends  greatly  to  prevent  complication  by  capillary 
bronchitis  and  pneumonia.  If  the  eruption  be  tardy  in  its  appearance  or 
indistinct,  it  is  well  to  produce  moderate  counter-irritation  by  some  gentle 
irritant  underneath,  as  camphorated  oil,  to  which  in  older  children  a  little 
turpentine  may  be  added. 

Afiections  which  complicate  measles  should  receive,  for  the  most  part, 
such  treatment  as  is  appropriate  for  them  when  idiopathic.  Secondary  dis- 
eases, however,  require  sustaining  measures  more  than  primary.  In  bronchial 
and  pulmonary  inflammations — which  if  they  occur  early  in  measles,  prevent 
the  regular  appearance  of  the  eruption,  or  if  in  the  eruptive  stage  cause  its 
disappearance — prompt  counter-irritation  over  the  chest  by  sinapisms  or  other- 
wise is  required.  Trousseau  states  that  he  has  derived  benefit  in  these  cases 
from  what  he  designates  urtication.  This  is  produced  by  stroking  the  chest 
two  or  three  times  daily  with  the  nettle  (  Urtica  dioica  or  Urtica  urens).  This 
causes  a  prompt  and  abundant  eruption,  and  with  a  less  amount  of  suffering 
than  one  would  suppose.  The  fever  abates,  and  the  respiration  becomes  more 
natural  in  proportion  to  the  amount  of  nettlerash.  On  the  second  day  the 
effect  is  less  than  on  the  fix'st,  and  after  three  or  four  days,  says  Trousseau, 
no  further  irritation  results  from  the  nettle.  When  counter-irritation  is  pro- 
duced, by  whatever  method,  the  chest  should  be  covered  with  a  warm  and 
soft  poultice,  as  the  ground  flaxseed  ;  derivatives  to  the  extremities  are  useful 
in  such  cases.  In  capillary  bronchitis  and  pneumonia  stimulating  expectorants 
are  required,  as  carbonate  of  ammonium.  I  frequently  write  the  following 
prescription.  It  is  useful  both  as  an  expectorant  and  cardiac  stimulant. 
Given  in  milk  or  after  food  is  taken,  it  does  not  produce  gastritis,  as  it  often 
does  in  a  more  concentrated  form  : 

R.  Ammon.  carbonat.,  gr.  xvj-^ss  ; 

Aquae  purje,  ^ij. 

Give  one  teaspoonful  in  three  or  four  of  milk  every  hour  or  two. 

Chloride  of  ammonium  is  also  a  good  remedy  in  these  cases,  employed  in 
double  the  dose  of  the  carbonate. 

Quinia  to  reduce  the  fever  and  digitalis  or  strophanti] us  or  camphor  as  a 
heart  tonic  are  also  very  useful  in  these  inflammations,  given  alone  or  alter- 
nately with  the  above. 

The  cases  of  gangrenous  vulvitis  alluded  to  above  were  treated  with  a  flax- 
seed poultice,  and  iodoform  dusted  over  the  surface  each  day  or  second  day, 
with  a  satisfactory  result.  As  regards  the  treatment  of  other  complications 
the  appropriate  measures  are  detailed  elsewhere. 


250  CONSTITUTIONAL  DISEASES. 

CHAPTER    II. 
SCAKLET  FEVER. 

It  is  supposed  by  some  who  have  studied  the  history  of  scarlet  fever  that 
it  is  of  ancient  origin,  but  the  descriptions  of  diseases  left  us  by  the  old  writers, 
and  by  those  in  the  Christian  era  until  after  the  Middle  Ages,  are  so  obscure 
or  dift'er  so  widely  in  the  statements  made  from  the  symptoms  of  scarlet  fever 
as  it  occurs  in  modern  times  that  the  impartial  critic  fails  to  find  any  clear 
evidence  of  its  occurrence  prior  to  the  last  four  or  five  centuries. 

The  first  clear  and  undoubted  portrayal  of  this  disease  is  found  in  the 
medical  literature  of  the  sixteenth  century.  Sydenham  and  his  contemporaries 
in  the  seventeenth  century  witnessed  epidemics  of  it  and  studied  its  nature 
more  thoroughly,  and  consequently  acquired  a  more  accurate  knowledge  of  it 
than  that  possessed  by  their  predecessors.  It  was  in  this  century  that  measles 
and  scarlet  fever  were  differentiated.  During  the  last  two  hundred  years 
scarlatina  has  been  the  subject  of  monographs  too  numerous  to  mention.  It 
has  long  been  regarded  as  one  of  the  most  important  maladies  of  childhood, 
on  account  of  its  frequency  and  the  great  mortality  that  attends  it,  so  that 
numerous  cases  and  many  epidemics  are  every  year  related  in  the  medical 
journals.  By  this  vast  accumulation  of  observations  and  the  patient  and 
thorough  use  of  the  microscope  our  knowledge  of  scarlet  fever  has  become 
full  and  accurate. 

As  with  most  of  the  infectious  maladies,  scarlet  fever  was  introduced  into 
the  Western  Hemisphere  by  European  navigators.  It  was  brought  to  North 
America  about  the  year  1735.  Tardily  it  spread  to  South  America,  where  it 
appeared  in  1829,  and  more  recently  it  has  been  established  in  Australia. 
It  entered  Iceland  in  1827  and  Greenland  in  1847. 

Etiology. — As  yet,  observers  do  not  agree  in  regard  to  the  parasite 
which  is  supposed  to  sustain  a  causal  relation  to  scarlet  fever.  Klebs  states 
that  it  is  highly  probable  that  both  measles  and  scarlet  fever  are  produced  by 
micrococci,  and  he  has  sketched  the  design  and  described  the  development  of 
a  microbe  which  he  designates  the  Monas  scarlatinosum. 

The  London  Medical  Times  and  Gazette  for  Jan.  28,  1882,  contains  an  account 
of  the  supposed  discovery  of  the  scarlatinous  microbe  by  Eklund  of  Stockholm,  an 
authority  in  the  microscopic  examination  of  parasites.  He  says  that  scarlet  fever 
is  rarely  absent  from  the  Swedish  capital  and  from  the  barracks  and  dwellings  on 
the  Isle  of  Skeppsholm.  In  the  urine  of  scarlatinous  patients  he  has  constantly 
found  a  prodigious  number  of  discoid  corpuscles,  oval  or  round,  their  diameter 
being  less  than  ywo^o  millimetre,  and  from  g^^  to  ^o  t^^*  ^^  ^  ^^^  blood-cell.  They 
are  colorless  or  yellowish-white,  surrounded  by  a  distinct  cell-wall,  each  containing 
a  well-defined  nucleus  of  a  deeper  hue.  Sometimes  one,  sometimes  more,  of  them 
are  seen  in  the  field  of  the  microscope.  They  exhibit  rotary  or  oscillatory  move- 
ments, especially  observed  when  a  drop  of  water  is  added  to  the  fluid. 

In  1886,  Dr.  Edington  of  Edinburgh  isolated  a  diplococcus  and  a  bacillus  from 
the  blood  and  epidermis  of  scarlatinous  patients.  He  states  that  inoculation  of  the 
bacillus  in  rabbits  caused  erythema,  followed  by  desquamation.  But  these  obser- 
vations, as  detailed  in  the  Lancet,  show  possible  sources  of  error,  and  have  therefore 
attracted  but  little  attention. 

Dr.  E.  0.  Shakespeare  describes  the  bacillus  scarlatinae  of  Edington  as  "  rods 
measuring  0.4  m.  in  thickness  and  1.2  m.  to  1.4  m.  in  length,  most  usually  forming 
excessively  long-pointed  and  curved  leptothrix  filaments,  motile;"  and  he  remai'ks, 
"  It  is  pretty  well  proven  that  this  bacillus  scarlatinae  is  the  specific  cause  of  scarlet 
fever."  ^ 

1  Annual  of  Med.  Sci.,  vol.  v.,  1888. 


SCARLET  FEVER.  251 

Whatever  may  be  the  micro-organism  which  causes  scarlet  fever,  its  mode 
of  action  and  effects  have  been  ascertained  by  clinical  observations.  Without 
doubt,  it  commonly  enters  the  system  by  the  breath,  but  it  probably  may 
enter  in  the  ingesta,  and  it  infects  the  blood.  That  it  resides  in  the  blood  has 
been  ascertained  by  inoculation  with  this  liquid,  by  which  scarlet  fever  has 
been  reproduced  in  its  typical  form.  From  the  blood  it  enters  the  tissues 
and  secretions.  Hence  handkerchiefs  or  linen  containing  the  saliva  or  mucus 
of  a  patient,  the  epidermic  scales  shed  abundantly  in  the  desquamative  period, 
and  probably  also  the  urinary  and  fecal  evacuations,  contain  the  poison,  so  as 
to  be  highly  infectious.  Even  the  discharge  of  a  scarlatinous  otorrhoea  is 
thought  by  some  to  be  contagious  for  a  considerable  time. 

Scarlatina  is  communicable  not  only  by  direct  exposure  to  a  patient,  but 
also  by  exposure  to  objects  which  happen  to  be  in  his  room  during  his  illness, 
and  to  which  the  poison  becomes  attached,  such  as  clothing,  books,  and  toys  ; 
small  packages,  as  we  have  stated  above,  sometimes  convey  and  disseminate 
the  contagious  principle. 

Observations  have  been  made  which  show  that  scarlatina  has  been  communi- 
cated by  infected  milk.  The  followino;  instance  was  published  in  a  British  journal : 
Scarlet  fever  occurred  in  the  family  of  a  milkman,  and  the  milk,  before  it  was  dis- 
tributed, remained  for  a  time  in  a  kitchen  which  had  been  occupied  by  the  patients. 
This  milk  was  taken  by  twelve  families,  and  in  six  of  these  scarlatina  occurred 
almost  simultaneously  at  a  time  when  few  cases  were  occurring  in  the  locality. 
There  had  been  no  direct  exposure  to  the  carrier  of  the  milk  nor  to  members  of  the 
affected  family  (Taylor).  In  another  instance  a  woman  and  her  son  had  scarlet  fever 
while  they  were  serving  milk  to  several  families,  and  the  disease  appeared  in  all 
these  families  except  one,  which  consisted  of  old  people  (Bell).  It  is  known  that 
milk  absorbs  volatile  substances  so  as  to  be  flavored  by  them,  and  is  shown  in  the 
experiment  of  placing  it  in  an  open  vessel  in  a  box  with  a  pineapple ;  and  it  may 
in  a  similar  manner  become  infected  by  the  specific  principle  of  scarlet  fever,  or  it 
may  be  infected  by  detached  particles  of  epidermis ;  which  is  not  improbable  when 
one  convalescing  from  scarlet  fever  is  allowed  to  milk  the  cows  or  prepare  the  milk 
for  distribution.  In  1885  an  epidemic  of  scarlet  fever  in  London  Avas  traced  to  the 
milk-supply  coming  from  a  certain  dairy  in  Hendon.  The  health  officer  of  Hendon 
discovered  a  contagious  disease  in  the  cows  of  this  dairy  communicable  to  healthy 
cows  by  inoculation  from  the  teats,  and  also  communicable  to  man.  The  symptoms 
in  the  cow  were  fever,  cough,  sore  throat,  discharge  from  nostrils  and  eyes.  Com- 
municated to  man,  the  disease  produced  malaise,  and  in  four  or  five  days  a  vesicle. 
Crookshank  believes  that  the  Hendon  disease  was  the  Jennerian  cowpox,  and  the 
symptoms  certainly  bore  a  closer  resemblance  to  cowpox  than  to  scarlet  fever. 
Probably,  therefore,  the  scarlet  fever  in  London  originated  from  some  other  source 
(^London  Lancet). 

The  scarlatinous  virus  surpasses  that  of  any  other  eruptive  fever  except  small- 
pox in  its  tenacious  attachment  to  objects  and  its  portability  to  distant  localities. 
Hence  in  the  literature  of  the  disease  are  the  records  of  many  cases  in  Avhich  the 
poison  was  conveyed  long  distances,  retaining  its  virulence  to  the  full  extent  and 
causing  an  outbreak  of  the  malady  in  the  localities  to  which  it  Avas  carried.  In 
NeAV  York,  so  frequently  has  scarlet  fever  as  well  as  measles  and  diphtheria  been 
contracted  from  the  persons  or  clothing  of  well  children  who  come  from  infected 
houses,  that  the  Health  Board  now  exclude  from  the  public  schools  all  chikh-en 
who  come  from  such  houses,  even  though  they  live  on  separate  floors  from  those 
occupied  by  the  sick.  In  one  instance  that  came  under  my  notice  a  washerwoman 
whose  child  had  scarlet  fever  communicated  the  disease  to  an  infant  in  the  house- 
hold where  she  was  employed,  by  placing  her  shawl  over  the  cradle  in  which  it 
was  lying.  A  physician  of  my  acquaintance  Avent  from  a  scarlet-fever  patient  to  a 
family  several  streets  distant,  and  took  one  of  the  children  upon  his  lap.  After  the 
usual  incubative  period  this  child  sickened  Avith  a  fatal  form  of  the  malady,  and 
the  remaining  children  of  the  household  Avere  in  time  aff'ected.  In  New  York  scar- 
let fever  has  seemed  to  me  to  be  not  infrequently  communicated  through  school- 
books,  which,  profusely  illustrated  by  pictures  and  rendered  attractive  to  the  young, 
are  often  allowed  to  lie  upon  the  bed  of  a  scarlatinous  patient,  and  be  handled  by 


252  CONSTITUTIONAL  DISEASES. 

him  during  convalescence  or  even  during  the  course  of  the  fever  if  it  be  mild.  The 
young  librarian  of  the  circulating  library  of  a  Sunday-school,  whose  pupils  came 
largely  from  the  tenement-houses,  was  occupied  a  considerable  part  of  a  day  in 
covering  and  arranging  the  books.  After  about  the  usual  incubative  period  of  scar- 
let fever  he  sickened  vrith  the  disease.  His  two  sisters  were  immediately  removed 
to  a  rural  township  three  hundred  miles  away,  and  to  an  isolated  house  where  scar- 
latina had  never  occurred.  About  one  month  after  his  recovery,  and  after  his  room 
had  been  disinfected  by  burning  sulphur  and  his  bedclothes  and  linen  had  been 
thoroughly  washed,  and  all  articles  suspected  to  hold  the  poison  had  been  either 
disinfected  or  destroyed,  the  brother  visited  his  sisters  in  the  country.  Three  weeks 
subsequently  to  his  arrival  one  of  these  sisters  sickened  with  scarlet  fever,  and  a 
week  later  the  other  also.  It  seems  that  the  exposure  must  have  occurred  several 
days  after  his  arrival  in  the  country  from  some  books  or  other  infected  article  in 
his  possession.  About  two  months  elapsed  after  the  last  case :  the  family  had 
returned  to  the  city,  the  infected  room  in  the  country-house  had  been  thoroughly 
fumigated  by  burning  sulphur  from  morning  till  evening,  when  a  little  girl  from 
an  inland  city  remained  a  few  days  in  this  house,  and  probably  often  entered  the 
room  where  the  young  ladies  had  been  sick.  In  a  few  days  she  also  sickened  with 
a  fatal  form  of  scarlatina.  Such  histories  and  experiences  are  not  infrequent.  They 
are  common  during  epidemics  of  scarlet  fever.  They  indicate  an  extraordinary 
attachment  of  the  scarlatinous  poison  to  objects,  and  show  that  it  is  not  gaseous 
nor  readily  volatilized. 

A  striking  example  of  this  fixity  of  the  poison  occurred  in  the  practice 
of  the  late  Kearney  Rogers,  formerly  a  prominent  and  much-esteemed  sur- 
geon of  Xew  York  City.  Six  children  in  a  family  had  scarlet  fever.  Three 
and  a  half  months  subsequently  another  child,  living  at  a  distance,  was 
allowed  to  return  home  and  occupy  the  apartment  in  which  the  sickness 
had  occurred.  One  week  subsequently  to  the  date  of  the  return  this  child 
sickened  with  the  same  malady.  Elliotson  states  that  a  patient  with  scarlet 
fever  was  admitted  into  one  of  the  wards  of  St.  Thomas's  Hospital,  and  for 
two  years  subsequently  young  persons  who  were  admitted  into  the  ward 
were  apt  to  take  the  disease.  Richardson  of  London  relates  the  following 
experiences  of  a  family  whom  he  attended  in  the  rural  district :  "At  a  short 
distance  from  one  of  our  villages  there  was  situated  on  a  slight  eminence  a 
small  clump  of  laborers'  cottages,  with  the  thatch  peering  down  on  the  beds 
of  the  sleepers.  A  man  and  his  wife  lived  in  one  of  these  cottages  with  four 
lovely  children.  The  poison  of  scarlet  fever  entered  the  poor  man's  door,  and 
struck  down  one  of  the  flock."  The  remaining  children  were  now  removed 
some  miles  away,  and  after  several  weeks  one  of  them  was  allowed  to  return. 
Within  twenty-four  hours  he  also  took  the  disease,  and  quickly  died.  The 
walls  of  the  cottage  were  now  thoroughly  cleaned  and  whitewashed,  the  floors 
scoured,  and  all  the  wearing  apparel  either  destroyed  or  washed.  Fou.r  months 
elapsed  after  the  last  sickness  when  one  of  the  remaining  children  returned. 
"  He  reached  his  father's  cottage  early  in  the  morning ;  he  seemed  dull  the 
next  day,  and  at  midnight  I  was  sent  for,  to  find  him  also  the  subject  of 
scarlet  fever.  The  disease  again  assumed  the  malignant  type,  and  this  child 
died."  Richardson  believes  that  the  contagion  was  attached  to  the  thatch, 
which  could  not  be  thoroughly  disinfected.  The  fact  of  this  remarkable  long- 
continued  attachment  of  the  poison  to  objects,  indicating  by  this  fixity  that 
it  is  a  solid,  is  consonant  with  the  theory  that  it  is  an  organism. 

Incubative  Period. — The  duration  of  the  incubative  period  varies  in 
different  cases.  It  is  sometimes  less  than  twenty-four  hours,  as  in  the  above 
case  reported  by  Richardson  ;  in  the  following  well-known  case,  observed  by 
Trousseau,  it  was  one  day  :  A  girl  arrived  in  Paris  from  Pau,  where  there  was 
no  scarlet  fever,  and  occupied  the  same  apartment  with  her  sister,  who  was 
sick  with  this  disease.  Twenty-four  hours  after  her  arrival  she  was  also 
attacked  with  the  same  malady. 


SCARLET  FEVER.  253 

Russeberger  attended  a  child  wlio  was  exposed  at  noon  to  scarlet  fever, 
and  took  the  disease  on  the  following  night.  B.  W.  Richardson  (^Clinical 
Essays,  1861,  vol.  i.  p.  94)  gives  his  own  experience.  He  had  applied  his  ear 
to  the  chest  of  a  patient  suffering  from  scarlet  fever,  and  was  conscious  of  a 
peculiar  odor  emitted  from  the  patient.  He  was  immediately  nauseated  and 
chilly,  and  from  that  moment  he  dated  the  beginning  of  an  attack  of  scarlet 
fever.  In  the  Transactions  of  the  Clinical  Society  of  London,  vol.  ix.,  1878, 
the  late  Charles  Murchison  gives  the  statistics  of  75  cases  showing  the  incu- 
bative period,  as  follows : 

In    4  cases  it  was  not  more  than 24  hours. 


2  " 

3  " 

4  " 
1  " 
4  " 
1  " 
1  " 

31  cases  it 


30  " 

36  " 

40  " 

41  " 

58  " 

54  " 
2J  days. 


was  within  (time  not  accurately  ascertained)  ...    4 
"     2  cases  the  incubation  did  not  exceed 4J     " 

((     2     "  "  "     "         "  6       " 

In  3  cases  Murchison  believes  that  the  incubation  was  precisely  fixed  at 
thirty-six  hours,  three  days,  and  four  and  a  half  days. 

Watson  says  that  a  man  reached  Devonshire  at  mid-day  to  see  his  daugh- 
ter, who  had  scarlet  fever.  Two  days  later  he  was  also  attacked.  Rehn  saw 
a  child  who  was  attacked  two  days  after  its  grandmother  returned  from  a 
case  of  scarlet  fever;  and  Zengerle,  a  girl  of  ten  years,  residing  at  Wangen, 
where  there  was  no  scarlet  fever,  who  took  the  disease  two  days  after  her 
mother  had  returned  from  visiting  a  family  affected  with  it.  Loochner  states 
that  a  boy  aged  four  and  a  half  years  was  attacked  one  and  a  half  days  after 
admission  into  the  infected  wards  of  an  hospital.  Armistead,  in  his  annual 
report  on  the  health  of  the  Newmarket  rural  district,  states  that  three  chil- 
dren, coming  from  a  different  part  of  the  district,  visited  Wesley,  and  stayed 
next  door  to  a  child  who  had  had  scarlet  fever  six  weeks  previously,  and  who 
was  allowed  to  play  with  these  children  on  the  evening  of  August  13th  and 
morning  of  the  14th.  The  family  then  returned  home,  and  on  the  18th,  four 
days  after  the  exposure,  all  three  children  sickened  with  scarlet  fever  (^British 
Medical  Journal,  September  30,  1882). 

Ordinarily,  therefore,  the  incubative  period,  though  varying  in  different 
cases,  is  within  six  days.  Many  cases,  however,  occur  in  which  it  seems  to 
be  longer.  Thus,  in  my  practice  scarlet  fever  appeared  in  a  family  on  April 
26,  1882.  The  patient  was  immediately  removed  to  the  third  floor  and  the 
other  children  to  the  basement.  All  communication  between  the  infected 
room  and  the  basement  was  forbidden,  but  on  May  8th,  twelve  days  after  the 
separation,  one  of  these  children  sickened  with  the  disease.  Many  observers, 
among  whom  may  be  mentioned  Niemeyer  and  Copland,  believe  that  the  incu- 
bative pei'iod  may  be  longer  than  one  week,  but  on  account  of  the  subtlety 
of  the  poison  and  the  many  modes  of  transmission,  it  is  possible  that  in  the 
instances  of  an  apparently  long  incubative  period  there  were  other  and  unsus- 
pected exposures.  When  scarlet  fever  has  been  communicated  by  inoculation, 
as  in  the  experiments  of  Rostan  and  others,  the  incubative  period  has  been 
about  seven  days,  but  Gerhardt  states  that  a  man  was  attacked  four  days 
after  an  abscess  was  opened  by  a  knife  used  upon  a  scarlatinous  patient. 
This  variation  in  the  incubative  period,  which  also  occurs  in  some  other  infec- 
tious diseases,  as  diphtheria,  is  probably  due  mostly  to  individual  differences. 


254  CONSTITUTIONAL  DISEASES. 

some  being  more  susceptible  than  others ;  but  it  may  be  due  partly  to  those 
obscure  meteorological  conditions  which  we  designate  the  epidemic  influence. 
Probably,  as  a  rule,  when  the  disease  is  cjuickly  developed  after  exposure  the 
attack  is  more  severe  than  when  several  days  elapse. 

Contagiousness.  —  The  area  of  the  contagiousness  of  scarlet  fever  is 
small :  it  apparently  embraces  only  a  few  feet.  Therefore,  close  proximity 
is  the  necessary  condition  of  its  propagation.  Hence  many  who  are  exposed, 
particularly  of  those  who  are  remotely  exposed,  do  not  contract  the  disease. 
There  is  also  an  idiosyncrasy  in  some  children,  so  that  they  resist  infection 
even  when  repeatedly  and  closely  exposed.  In  the  New  York  Medical  Record 
for  March  23,  1878,  C.  E.  Billington  states  that  of  90  children  in  26  families 
who  were  exposed  to  scarlet  fever,  43  contracted  the  disease  and  47  escaped ; 
whereas,  as  is  well  known,  comparatively  few  unprotected  childi'en  escape 
pertussis,  variola,  varicella,  or  measles  if  exposed  to  either  of  these  diseases. 
By  strict  isolation,  therefore,  the  spread  of  scarlet  fever  is  more  easily  pre- 
vented than  that  of  most  other  acute  infectious  maladies.  In  the  New  York 
Foundling  Asylum  for  a  number  of  years  children  with  scarlet  fever  wei'e 
isolated  in  a  small  room  attached  to  one  of  the  wards.  The  door  between 
the  two  rooms  was  closed,  and  not  opened  during  the  continuance  of  the 
sickness.  Entrance  into  the  small  room  was  through  another  door,  and  a 
nurse  was  assigned  to  the  scarlet-fever  cases,  with  strict  directions  that  she 
should  not  mingle  with  the  other  children.  These  simple  precautions  were 
found  sufficient  in  the  various  epidemics  of  scarlet  fever  which  occurred  in 
the  city  to  prevent  the  spread  of  the  malady  through  this  institution  ;  whereas, 
similar  measures  were  much  less  effectual  in  arresting  the  spread  of  measles 
and  pertussis.  Consequently,  an  outbreak  of  scarlet  fever  in  this  institution 
was  usually  limited  to  a  few  cases,  while  the  extension  of  measles  and  pertus- 
sis was  arrested  with  difficulty  till  a  more  efficient  quarantine  was  established. 

Variations  in  Type. — The  type  of  scarlet  fever  varies  greatly  in  different 
epidemics,  and  frequently  also  in  cases  which  occur  in  the  same  epidemic,  even 
in  the  same  family.  One  child  may  have  scarlatina  so  mildly  that  little  treat- 
ment is  required  and  convalescence  soon  begins,  while  another  has  the  malig- 
nant form,  and  soon  succumbs,  notwithstanding  the  prompt  employment  of 
the  most  efficient  and  appropriate  measures.  Ordinarily,  however,  if  the  first 
case  in  a  family  be  very  severe,  subsequent  cases  will  present  a  similar  type  ; 
but  there  are  notable  exceptions.  This  variation  in  type  in  different  years  and 
difi'erent  epidemics  is  probably  not  equalled  in  any  other  infectious  malady. 
Consecutive  epidemics  may  present  this  variation,  or  the  same  type  may  con- 
tinue for  a  series  of  years,  and  then,  from  some  unknown  cause,  change  to 
one  milder  or  more  severe.  In  England,  during  Sydenham's  life,  scarlet  fever 
was  so  mild  that  he  regarded  it  as  a  trivial  affection,  requiring  little  attention, 
like  rotheln  of  the  present  time ;  but  after  the  death  of  Sydenham,  Morton 
and  his  contemporaries  in  London  found,  to  their  sorrow,  that  the  type  of 
scarlet  fever  was  very  different  from  that  described  by  Sydenham's  pen.  The 
late  Dr.  Graves  of  Dublin  and  his  contemporaries  treated  a  mild  type  of  scar- 
let fever  with  a  very  small  percentage  of  deaths — much  less  than  that  during 
the  preceding  generation — and  they  attributed  their  success  to  their  greater 
knowledge  and  more  appropriate  use  of  remedies  than  their  ancestors  pos- 
sessed and  employed.  By  and  by  the  type  changed,  the  mortality  of  former 
years  was  restored,  and  they  discovered  that  their  previous  success  in  saving 
life  had  been  due  not  to  their  skill,  but  to  the  mild  form  of  the  malady.  A 
distinguished  physician  of  Xew  York  treated  more  than  fifty  cases  of  scarlet 
fever  in  one  of  the  institutions  without  a  single  death.  A  few  months  after- 
ward the  type  of  the  malady  changed,  and  his  own  son  perished  from  it. 

The  diseases  known  as  surgical  scarlatina  and  obstetrical  scarlatina  are  certainly 


SCARLET  FEVER.  255 

at  times  a  true  scarlet  fever,  but  it  is  probable  that  the  pathological  states  to  which 
these  terms  have  been  applied  have  in  most  instances  been  cases  of  septicsemia  or 
blood-poisoning  with  accompanying  dermatitis  so  common  in  surgical  and  obstetrical 
practice.  The  following -were  cases  of  the  kind  alluded  to.  They  occurred  in  Guy's 
Hospital,  and  were  published  by  H.  G.  Howse  in  Guy's  Hospital  Reports  for  1879  : 
On  5larch  15,  1878,  Jacobson  performed  osteotomy  upon  a  child  suffering  from  ex- 
treme rachitis.  The  operation  was  followed  by  a  moderate  febrile  movement  (100° 
to  101°),  and  after  three  days  by  the  appearance  of  an  efflorescence,  with  sore  throat 
and  the  strawberry  tongue.  The  osteotomy  had  been  performed  under  carbolic-acid 
spray  and  with  all  the  details  of  antiseptic  surgery.  The  rash  soon  faded,  the  tem- 
perature fell,  and  the  child,  temporarily  separated  from  the  other  patients  from  the 
suspicion  that  the  disease  was  scarlet  fever,  was  brought  back  to  the  ward.  The 
subsequent  history  confirmed  the  diagnosis  of  scarlet  fever,  for  the  skin  desqua- 
mated, and  on  April  1st  abundant  albumen  was  found  in  the  urine.  The  case  ter- 
minated favorably.  Three  months  previously  the  same  operation  had  been  per- 
formed on  the  other  leg,  with  no  unfavorable  symptoms.  On  April  5th,  three  weeks 
after  the  osteotomy,  a  lipoma  was  removed  from  another  patient  aged  twenty-one 
years.  The  following  day  the  temperature  rose  to  101°,  and  remained  at  that  till 
April  8th,  when  it  suddenly  increased  to  103°,  and  a  rose-rash  occurred  over  the 
body,  with  sore  throat.  On  April  9th,  Howse  excised  the  elbow-joint  of  a  girl  of 
sixteen  years  having  pulpy  disease.  On  the  10th  her  temperature  began  to  increase, 
and  on  the  11th  reached  105.8°.  Toward  evening  a  roseoloid  eruption  appeared 
ovei  her  body,  and  she  was  isolated.  On  April  12th,  Dr.  H.  excised  a  fibroid  bursa 
patellas  from  a  woman  of  twenty-nine  years.  On  the  following  day  her  temperature 
was  99°,  but  on  the  14th  it  rose  to  100°,  and  on  the  evening  of  the  15th  she  had 
rigors  and  headache.  On  the  morning  of  the  16th  the  temperature  was  102.5°,  and 
a  roseoloid  eruption  occurred  over  the  face  and  chest.  The  surgeons  now  perceived 
that  an  epidemic  of  the  so-called  surgical  scarlatina  was  occurring,  so  as  to  justify 
the  postponement  of  other  operations. 

In  the  same  volume  of  Guy's  Hospital  Reports,  James  F.  Goodhart  gives  the 
histories  of  nearly  thirty  cases  of  this  disease  occurring  during  a  series  of  years  in 
the  same  hospital.  The  patients  were  chiefly  children,  having  the  most  diverse 
surgical  ailments,  among  Avhich  may  be  mentioned  hip  disease  and  abscess,  genu 
valgum  without  operation,  necrosis  of  femur,  hydrocele  with  explorative  operation, 
a  scald,  a  sinus  over  the  great  trochanter,  spinal  disease  with  abscess,  tenotomy  for 
club-foot,  and  vesical  calculus  with  operation.  The  most  common  disease  was  caries 
or  necrosis  with  abscess.  In  cases  operated  on  the  intervals  between  the  operations 
and  the  occurrence  of  the  efflorescence  varied  from  two  days  to  more  than  two  weeks. 
Goodhart,  after  a  careful  examination  of  these  cases,  came  to  the  conclusion  that 
they  were  for  the  most  part  examples  of  true  scarlet  fever,  especially  as  a  consider- 
able proportion  of  them  occurred  in  groups,  and  there  was  a  known  exposure  of 
some  of  the  patients  to  children  admitted  into  the  hospital  with  the  sequelas  of 
scarlet  fever. 

In  the  British  Med.  Jour,  for  Jan.,  1879,  George  May,  Jr.,  reported  a  case  of 
efflorescence  in  surgical  practice  which  appears  to  have  been  scarlatinous.  A  child 
was  operated  on  for  the  radical  cure  of  hernia  on  Dec.  4th.  Toward  the  close  of 
the  same  day  he  became  restless,  vomited,  and  his  pulse  on  the  following  day  rose 
to  136.  Forty-eight  hours  after  the  operation  a  rash  appeared  on  the  chest  and 
arms,  the  abdomen  became  tense  and  painful,  and  on  the  following  day  he  died. 
The  poison,  however,  in  this  case  may  have  been  septic. 

Hillier  remarks  [Diseases  of  Children):  "  In  the  hospital  for  sick  children,  of 
the  children  who  contract  scarlatina  a  very  large  proportion  have  been  the  subjects 
of  a  surgical  operation  within  a  week  before  the  rash  appears."  Gee  says  (Rey- 
nolds's System  of  Medicine)  :  '■  It  has  been  doubted  by  some  whether  the  scarlatini- 
form  rash  which  sometimes  follows  operations  is  really  scarlatinal.  The  eruption 
appears  from  the  second  to  the  sixth  day  after  the  operation,  and,  in  the  cases  which 
have  caused  the  doubt,  is  very  fugitive  and  the  first  and  only  symptom.  Yet  that 
the  disease  really  is  scarlet  fever  would  seem  to  be  proved  by  the  following  observa- 
tions :  first,  that  the  disease  occurs  in  epidemics  ;  secondly,  that  in  a  given  epidemic 
a  severe  case  occasionally  relieves  the  monotonous  recurrence  of  the  very  mild  form  ; 
thirdly,  that  a  precisely  similar  scarlatinilla  attacks  in  the  same  epidemic  patients 
who  have  not  been  subjected  to  operation  and  who  have  no  open  sores  ;  and  lastly, 
by  way  of  a  veritable  experimentum  crucis,  that,  however  freely  the  patients  are 


256  COXSTITUTIONAL  DISEASES. 

exposed  to  ordinary  scarlet-fever  contagion  afterward,  they  do  not  contract  that 
disease.''  Paget  and  other  distinguished  London  surgeons  ■vvho  have  observed  this 
complication  of  surgical  cases  believe  that  the  patients  have  been  previously  exposed 
to  the  scarlatinous  poison,  and  that  the  surgical  diseases  or  operations  furnish  favor- 
able conditions  for  the  occurrence  of  scarlet  fever,  so  that  the  exposure,  ■which  prob- 
ablj'  would  have  been  without  result  in  ordinary  health,  causes  an  outbreak  of  the 
malady. 

Those  who  have  reported  cases  of  this  form  of  efflorescence  have  for  the  most 
part  neglected  to  state  whether  the  patients  had  had  scarlet  fever  previously,  know- 
ledge of  which  would  have  aided  in  the  diagnosis  ;  but  from  an  examination  of  the 
histories  of  cases,  especially  those  published  in  the  London  journals  in  the  last  four 
or  five  years,  there  can,  I  think,  be  little  doubt  that  surgical  maladies  of  a  certain 
kind,  especially  traumatism,  do  produce  a  state  of  system  which  predisposes  to 
scarlet  fever,  so  that  this  class  of  patients  are  especially  liable  to  contract  it.  There- 
fore, in  my  opinion,  a  considerable  proportion  of  reported  cases  of  surgical  scarla- 
tina are  genuine,  but  in  a  considerable  number,  perhaps  an  equal  number,  of  such 
cases  the  histories  and  symptoms  indicated  a  septic  rather  than  scarlatinous  efflores- 
cence, and  in  not  a  few  instances,  when  consultations  have  been  held,  opinions  dif- 
fered, some  diagnosticating  scarlet  fever,  others  septicaemia.  In  some  of  the  cases 
I  find  it  stated  that  the  fauces  presented  the  normal  appearance.  Now,  faucial  red- 
ness is  so  generally  present  in  scarlet  fever,  antedating  that  of  the  skin  and  coex- 
isting with  it,  that  its  absence  is  strong  evidence  that  the  disease  is  not  scarlatinous. 
Moreover,  when,  as  was  true  of  certain  of  the  reported  cases,  the  rash  appeared 
irregularly  upon  the  surface,  and  faded  away  in  two  or  three  days  with  the  abate- 
ment of  the  fever,  and  the  conditions  of  septic  absorption  were  present,  the  efflores- 
cence was  probably  septicaemic. 

The  following  were  apparently  cases  of  septictemic  efflorescence  :  A  child  aged 
five  years  {Brit.  Med.  Jour.,  Feb.  15,  1879)  had  inflammation  of  the  lymphatic 
glands  in  the  groin,  which  suppurated.  At  the  time  when  the  abscess  was  fully 
formed  a  rash  appeared  over  the  entire  body.  It  consisted  of  numerous  i-ed  points, 
but  was  paler  than  that  of  ordinary  scarlet  fever  ;  temperature  never  above  99°  ;  no 
sore  throat  nor  desquamation  of  cuticle.  No  child  exposed  to  her  took  scarlet  fever, 
and  her  sickness  could  not  be  traced  to  infection.  In  the  British  Med.  Jour.,  Jan.  4, 
1879,  L.  Braxton  Hicks  states  that  his  son,  attending  school  at  Reading,  was  seized 
with  a  severe  attack  of  pyrexia,  accompanied  on  the  second  day  by  delirium  and  the 
occurrence  of  a  rash-like  scarlet  fever  over  the  entire  surface.  He  had  no  decided 
redness  of  the  fauces,  though  it  was  perhaps  slightly  flushed.  The  right  buttock 
was  swollen  from  inflammation,  and  a  large,  deep-seated  abscess  formed  near  the 
tuberosity  of  the  ischium.  When  the  delirium  abated  the  boy  said  that  he  was 
standing  the  day  before  the  fever  began  with  his  legs  far  apart,  Avhen  a  schoolfellow 
stretched  them  farther  by  suddenly  pulling  on  one  of  them.  The  rash,  which  was 
nearly  universal,  lasted  three  days,  and  was  not  followed  by  desquamation.  No 
case  of  scarlet  fever  occurred  in  the  school  before  or  afterward.  In  the  same  volume 
of  the  British  Medical  Journal,  Surgeon  Frolliott,  of  the  East  India  Service,  relates 
the  case  of  a  private,  aged  twenty-three  years,  and  three  years  in  India,  who,  when 
on  duty  in  the  Punjab,  was  injured  by  the  explosion  of  an  Afghan  powder-magazine. 
The  accident  occurred  Dec.  21,  1878.  On  Dec.  25th  a  bright  scarlet  rash  appeared 
upon  the  abdomen  and  spread  over  the  entire  body.  The  following  day  the  erup- 
tion was  very  vivid,  like  a  boiled  lobster,  and  it  lasted  five  days.  The  temperature, 
which  in  the  beginning  had  been  101°,  abated  to  the  normal  after  the  rash  appeared. 
No  soreness  of  throat  nor  redness  of  the  buccal  surface  occurred,  but  the  epidermis 
desquamated,  even  from  the  palms  of  the  hands  and  soles  of  the  feet.  Now,  the 
febrile  movement  of  scarlet  fever  does  not  cease  while  the  efflorescence  is  distinct. 
It  does  not  even  diminish  when  the  eruption  appears,  while  in  the  above  case  it  fell 
to  the  normal- — a  common  occurrence  in  septicaemia,  even  when  the  blood-poisoning 
is  profound.  Moreover,  scarlet  fever  is  so  rare  in  India  that  Frolliott,  after  twelve 
years'  service,  had  only  heard  of  one  case  among  Europeans  and  natives.  The 
surgeons  who  consulted  over  the  case  of  this  private  disagreed  in  opinion,  some 
regarding  the  disease  as  septicgemic,  others  as  scarlatinous.  But  a  better  knowledge 
of  the  clinical  history  of  scarlet  fever  on  the  part  of  these  army  surgeons  would, 
I  think,  have  removed  all  doubt  as  to  the  diagnosis. 

It  is  the  opinion  of  some  reputable  surgeons  that  the  exposure  of  traumatic 
patients   to   the    scarlatinous   poison   sometimes   aggravates   the   inflammation   of 


SCARLET  FEVER.  257 

wounds,  causing  them  to  assume  an  unhealthy  appearance,  even  though  no  scarla- 
tina be  produced.  The  late  Dr.  Solly  made  the  remark,  ''  Whenever  a  case  of 
surgery  in  private  practice  takes  on  a  highh-  phlegmonous  appearance,  I  am  always 
sure  to  find  break  out,  in  the  inmates  of  the  house,  either  erysipelas  or  scarlet 
fever"  {British  Med.  Jour.,  Feb.  15,  1879).  We  will  see  that  the  scarlatinous 
poison  sometimes  causes  pharyngitis  or  nephritis  without  producing  the  general 
disease.  In  a  similar  manner  it  seems  that  it  may  aggravate  open  wounds,  intensi- 
fying the  inflammation  in  them,  while  there  is  no  efflorescence  or  other  symptom  to 
show  that  scarlatina  itself  is  present.  The  poison  appears  to  act  entirely  locally  in 
such  cases. 

Paget,  in  his  Clinical  Lectures,  says :  "I  think  it  not  improbable  that  in  some 
cases  results  occurring  with  obscure  symptoms  within  two  or  three  days  after  opera- 
tions have  been  due  to  the  scarlet-fever  poison,  hindered  in  some  way  from  its  usual 
progress. ■■  Playfair,  in  his  remarks  on  the  puerperal  state,  adds:  "Mr.  Spencer 
Wells  informs  me  that  he  has  seen  cases  of  surgical  pyaemia  which  he  had  reason  to 
believe  originated  in  the  scarlatinal  poison ;  and  his  well-known  success  as  an  ova- 
riotomist  is  no  doubt,  in  a  great  measure,  to  be  attributed  to  his  extreme  care  in 
seeing  that  no  one  likely  to  come  in  contact  with  his  patients  has  been  exposed  to 
any  such  source  of  infection.'"  Opinions  like  these,  held  by  such  prominent  mem- 
bers of  the  profession  and  sustained  by  many  observations,  should  certainly  induce 
physicians  to  prevent,  as  far  as  possible,  exposure  of  their  surgical  patients,  espe- 
cially if  they  have  sores  or  wounds,  whether  by  traumatism  or  scalpel,  to  the  scar- 
latinal poison. 

Women  during  convalescence  after  childbirth  are  very  liable  to  contract  scarlet 
fever.  In  the  Xew  York  Infant  Asylum,  which  has  maternity  wards,  a  woman  was 
admitted  from  a  house  in  which  scarlet  fever  Avas  prevailing,  and  assigned  to  a  cot 
next  that  occupied  by  one  of  the  waiting- women,  who  was  confined  soon  afterward. 
Her  labor  was  favorable,  but  three  days  afterward  she  took  scarlet  fever,  and  another 
lying-in  patient  contracted  it  from  her.  The  sore  throat  and  desquamation  were 
characteristic.  It  has  come  to  my  knowledge  that  a  physician  of  Xew  York,  in 
whose  family  scarlet  fever  was  occurring,  attended  three  women  in  succession  in 
their  confinement,  and  all  contracted  scarlet  fever,  which  presented  the  character- 
istic symptoms,  and  two  of  them  died.  Experienced  and  cautious  physicians  of 
New  York,  aware  of  the  danger,  do  not  go  directly  from  a  scarlatinous  patient  to  an 
obstetrical  case,  but  avoid  the  risk  by  intermediate  visits  to  other  patients  or  by 
remaining  for  a  time  in  the  open  air.  As  an  additional  precaution.  I  never  attend 
a  case  of  midwifery  without  first  soaking  my  fingers  in  a  solution  of  corrosive  subli- 
mate. 

Playfair,  remarking  on  this  subject,  says :  "  There  is  good  reason  to  believe  that 
the  contagium  of  zymotic  diseases  may  produce  a  form  of  disease  indistinguishable 
from  ordinary  puerperal  septicemia,  and  presenting  none  of  the  characteristic  fea- 
tures of  the  specific  complaint  from  which  the  contagium  was  derived.  This  is 
admitted  to  be  a  fact  by  the  majority  of  our  most  eminent  British  obstetricians, 
although  it  does  not  seem  to  be  allowed  by  continental  authorities,  and  it  is  strongly 
controverted  by  some  writers  in  this  country.  It  is  certainly  difiicult  to  reconcile 
this  with  the  theory  of  septicaemia,  and  we  are  not  in  a  position  to  give  a  satisfac- 
tory explanation  of  it.  I  believe,  however,  that  the  evidence  in  favor  of  the  possi- 
bility of  puerperal  septicasmia  originating  in  this  way  is  too  strong  to  be  assailable. 
The  scarlatinal  poison  is  that  regarding  which  the  greatest  number  of  observations 
has  been  made.  Numerous  cases  of  this  kind  are  to  be  found  scattered  through  our 
obstetric  literature,  but  the  largest  number  are  to  be  met  with  in  a  paper  by  Braxton 
Hicks.  Out  of  68  cases  of  puerperal  disease  seen  in  consultation,  no  less  than  37 
were  distinctly  traceable  to  the  scarlatinal  poison.  Of  these,  20  had  the  character- 
istic rash  of  the  disease,  but  the  remaining  17,  although  the  history  clearly  proved 
exposure  to  the  contagium  of  scarlet  fever,  showed  none  of  its  usual  symptoms,  and 
were  not  to  be  distinguished  from  ordinary  typical  cases  of  the  so-called  puerperal 
fever.  On  the  theory  that  it  is  impossible  for  the  specific  contagious  diseases  to  be 
modified  by  the  puerperal  state,  we  have  to  admit  that  one  physician  met  with  17 
cases  of  puerperal  septiceemia  in  which,  by  a  mere  coincidence,  the  contagion  of 
scarlet  fever  had  been  traced,  and  that  the  disease  nevertheless  originated  from  some 
other  source — an  hypothesis  so  improbable  that  its  mere  mention  carries  its  o^m 
refutation." 

Parturition,  like  traumatism,  fuimishes  in  an  eminent  degree  the  conditions  in 
17 


258  CONSTITUTIONAL  DISEASES. 

•which  septic  poisoning  occurs,  and  the  efflorescence  which  often  accompanies  septi- 
caemia bears,  as  we  have  seen,  a  very  close  resemblance  to  that  of  scarlet  fever. 
Hence  in  many  instances  the  same  difficulty  is  present  in  making  a  diflerential  diag- 
nosis between  septic  and  scarlatinous  blood-jDoisoning  in  obstetrical  cases  which 
occurs  in  surgical  practice.  But,  according  to  my  observations,  an  efflorescence 
occurring  during  the  week  following  parturition  is  in  most  instances  septic.  It  is 
only  in  exceptional  cases  that  it  is  scarlatinous.  But  if,  as  Playfair  believes,  the 
scarlatinal  poison  sometimes  produces  in  parturient  women  a  puerperal  fever  in 
which  the  chai'acteristic  scai'latinal  symptoms  are  lacking,  and  which,  in  the  present 
state  of  our  knowledge,  is  not  distinguishable  from  ordinary  septic  fever,  certainly 
the  scarlatinous  virus  sustains  a  more  frequent  causal  relation  to  childbed  fever  than 
has  been  heretofore  supposed. 

Age. — Infants  under  the  age  of  six  months  do  not  ordinarily  contract 
scarlet  fever,  although  fully  exposed,  and  those  under  four  months  nearly 
possess  immunity.  Still,  this  disease  has  been  observed  in  new-born  infants, 
contracted,  apparently,  through  the  placental  circulation.  Tourtual  states 
that  a  woman  waited  upon  her  own  husband  and  child,  both  of  whom  had 
scarlet  fever,  during  the  eighth  and  ninth  months  of  her  pregnancy  till  near 
her  confinement.  Though  she  had  no  symptoms  of  scarlet  fever,  her  infant 
had  unusual  redness  of  the  skin  and  buccal  surface  and  difficulty  of  swallow- 
ing up  to  the  fifth  day.  On  the  ninth  day  desquamation  began,  and  at  a 
later  stage  the  nails  of  the  fingers  and  toes  separated.  A  case  having  a  his- 
tory in  some  respects  similar  is  related  by  Megnert,  but  the  symptoms  were 
anomalous  for  scarlet  fever,  and  the  disease  may  have  been  ordinary  septic 
fever.  On  the  other  hand,  in  one  instance  in  my  practice  a  mother  had  scarlet 
fever,  beginning  about  the  third  day  after  her  confinement,  and  although  she 
suckled  her  infant  and  it  was  constantly  in  bed  with  her,  it  had  no  symptoms 
of  scarlet  fever,  but  became  affected  immediately  afterward  by  a  severe  form 
of  eczema,  probably  from  the  altered  quality  of  the  milk  :  and  in  two  instances 
observed  by  Murchison  new-born  infants  remained  healthy,  although  their 
mothers  sufi"ered  from  scarlet  fever. 

After  the  age  of  six  months  the  liability  to  scarlet  fever  increases  till  the 
close  of  infancy,  children  between  the  ages  of  six  months  and  one  year  being 
less  liable  to  contract  the  malady  than  during  the  second  year,  and  those  in 
the  second  year  being  less  liable  to  it  than  those  in  the  third  year.  Murchison 
collected  the  statistics  of  deaths  from  scarlet  fever  in  England  and  Wales 
during  a  series  of  years  ending  with  1861.  The  number  of  deaths  aggregated 
148,829,  and  the  percentage  of  deaths  at  different  ages  was  as  follows : 

Deaths  under  1  year 6.7    per  cent. 

"       between  1  and    2  years 14.09       " 


2  and  3 
"  3  and  4 
"        4  and    5 

5  and  10 

"      10  and  15 

"      15  and  25 

"      25  and  35 

over  the  age  of  35 


16.00 

15.13 

11.9 

25.9 

5.8 

2.6 

0.8 

0.8 


Among  the  deaths  were  10  cases  above  the  age  of  85  years,  so  that  scarlet 
fever,  though  especially  a  disease  of  childhood,  may  occur  in  any  decade  of 
life;  but  old  age,  like  early  infancy,  almost  possesses  immunity  from  it. 

I  have  preserved  the  records  of  the  ages  of  145  consecutive  cases  occurring 
in  private  practice.  If  we  add  to  these  58  cases  observed  by  Prof.  Octerlony 
(^Amer.  Journ.  of  Med.  Sci.,  July,  1882),  we  have  the  statistics  of  the  ages 
of  203  cases,  which  are  embraced  in  the  following  table : 


SCARLET  FEVEB.  259 

Under  1  year 3 

From    1  to    2  years 25 

43 


"      2  to    3 

"       3  to    5 

"       5  to  10 

"     10  to  15 

"     15  to  20 

"     20  to  30 

"     30  to  40 

57 

53 

13 

3 

4 

2 

Total 203 

Clinical  Facts  regarding  Scarlet  Fever. 

As  a  rule,  scarlet  fever  occurs  but  once,  one  attack  conferring  immunity 
from  the  disease  for  life ;  but  there  are  exceptions. 

In  1860,  I  attended  a  child  with  fatal  scarlet  fever  who  three  years  previously, 
it  was  stated,  had  passed  through  a  first  attack  with  all  the  characteristic  symptoms. 

The  following  case  occurred  in  a  family  attended  by  the  late  Dr.  Herzog :  R ,  a 

boy  of  six  years,  had  scarlet  fever  in  a  mild  form  in  January  and  February,  1875, 
followed  by  moderate  desquamation.  In  July  of  the  same  year  he  was  kicked  by  a 
horse  in  the  street,  receiving  a  deep  scalp-wound  which  required  stitching.  Three 
days  afterward  he  had,  to  appearance,  a  second  attack  of  scarlet  fever,  attended  by 
high  febrile  movement  and  followed  also  by  desquamation.  It  was  believed  by 
Dr.  H.  to  be  a  genuine  case,  and  was  so  treated.  I  am  not  able  to  state  as  regards 
the  presence  of  soreness  of  the  throat,  and  doubt  arises  whether  the  second  attack 
may  not  have  been  septicaemic.  In  April,  1876,  a  third  attack  occurred,  which  I 
saw  from  the  beginning.  It  was  accompanied  by  all  the  characteristic  symptoms — 
injection  of  the  fauces,  an  efflorescence  contitiuing  the  usual  time,  followed  by  des- 
quamation and  albuminuria,  the  latter  remaining  several  weeks.  Richardson  states 
that  three  distinct  attacks  occurred  in  his  own  person,  and  a  student  attending  the 
lecture  at  which  this  was  mentioned  informed  the  doctor  that  he  also  had  scarlet 
fever  three  times. 

Sometimes  a  second  attack  occurs  so  soon  after  the  first  that  it  has  been  described 
as  a  relapse.  The  following  was  a  case  in  point  in  the  practice  of  Godnefi"  [Meditz. 
Vestnik,  No.  iv.,  N.  Y.  Med.  Rec,  April  oO,  1881):  A  youth  of  seventeen  years 
contracted  scarlet  fever  while  taking  care  of  a  child.  It  began  with  a  chill,  and  he 
had  the  usual  efflorescence,  sore  throat,  and  tumefaction  of  the  cervical  glands.  An 
exudation  appeared  upon  his  tonsils  and  uvula,  and  his  temperature  reached  104°. 
The  urine  contained  a  trace  of  albumen  ;  the  rash  in  due  time  faded  ;  and  the  epi- 
dermis exfoliated.  On  the  fifteenth  day,  when  he  was  about  ready  to  leave  the  hos- 
pital, he  again  had  a  chill,  followed  by  fever.  The  temperature  reached  105.2°,  the 
rash  reappeared  over  the  entire  surface  except  the  face,  diphtheritic  exudations 
occurred  upon  the  fauces,  and  the  urine,  the  quantity  of  which  was  diminished, 
again  became  albuminous.  The  second  efflorescence  faded  on  the  twenty-fourth  day, 
and  on  the  twenty-seventh  exfoliation  began.  Hillier  says  :  "  I  have  seen  a  young 
woman  in  the  fever  hospital  suifering  from  a  second  attack  of  scarlatina,  the  first 
attack  having  occurred  five  weeks  previously.  She  had  quite  recovered  from  her 
first  illness,  and  was  acting  as  nurse.  In  both  seizures  the  rash,  the  sore  throat,  and 
other  symptoms  were  characteristic.  The  relapse  or  recurrence  was  less  severe  than 
the  primary  disease."  Cases  of  a  fourth  attack,  or  even  of  a  greater  number,  have 
been  reported.  The  first  seizure  is  sometimes  milder,  but  in  other  instances  is  more 
severe,  than  those  which  follow. 

Exposure  to  the  scarlatinous  poison  not  infrequently  produces  pharyngitis  with- 
out the  occurrence  of  scarlatina,  and  the  inflammation  is  usually  severe,  accompa- 
nied by  pain  in  swallowing  and  marked  febrile  movement.  This  phlegmasia  is 
distinguished  from  scarlet  fever  by  its  shorter  duration  and  the  absence  of  the  efflor- 
escence. It  occurs  in  adults  as  well  as  in  children,  and  in  those  who  have  had,  as 
well  as  in  those  who  have  not  had,  scarlatina.  So  far  as  I  have  heard,  it  is  very 
seldom  accompanied  or  followed  by  any  of  the  complications  or  sequelae  so  common 
in  and  after  scarlet  fever.  It  cannot  be  distinguished  from  ordinary  pharyngitis 
except  in  the  manner  in  which  it  occurs,  and  one  attack  does  not  preclude  another. 
The  late  George  B.  Wood  made  the  remark  that  he  never  attended  a  case  of  scarlet 


260  CONSTITUTIONAL  DISEASES. 

fever  without  suffering  from  sore  throat.  The  following  were  examples  of  this  form 
of  pharyngitis:  On  Jan.  17,  1882,  I  was  called  to  a  boy  of  three  years  with  severe 
scarlet  fever,  ushered  in  by  convulsions.  On  the  following  day  his  sister,  aged  seven 
and  three-fourths  years,  whom  I  had  attended  a  year  previously  during  a  severe 
attacii  of  scarlatina,  and  who  had  been  almost  constantly  with  the  brother,  became 
very  ill,  with  a  temperature  of  103.5°.  Examination  revealed  severe  inflammation 
of  the  fauces,  without  pseudo-membrane  or  any  other  exudation  except  muco-pus. 
On  Jan.  19  an  older  brother,  nine  years,  whom  I  had  attended  in  scarlet  fever  three 
years  previously,  was  afi"ected  in  the  same  way,  his  temperature  being  104°  and  his 
respiration  guttural  and  noisy,  especially  during  sleep,  in  consequence  of  the  great 
amount  of  faucial  swelling.  At  times  he  was  delirious.  The  inflammation  in  both 
cases  began  to  abate  about  the  third  day,  and  had  disappeared  by  the  close  of  the 
week.  That  the  contagium  of  scarlet  fever  may  be  received  into  the  system  and 
cause  pharyngitis  while  the  patient  has  immunity  from  scarlet  fever  through  a  pre- 
vious attack,  and  that  this  inflammation  may  occur  any  number  of  times,  as  in  the 
case  of  Dr.  Wood,  are  remarkable  facts. 

Now  and  then  cases  occur  which  appear  to  show  that  the  scarlatinous  poison 
may  affect  the  kidneys,  producing  nephritis,  while  there  is  no  other  manifestation 
of  its  influence.  Thus  in  my  practice  a  lady  of  about  forty-five  years  constantly 
attended  her  son,  sleeping  by  his  side,  during  an  attack  of  scarlet  fever.  Her  health 
had  previously  been  good.  When  the  boy  was  convalescent,  as  her  appetite  failed 
and  she  was  indisposed,  a  careful  examination  revealed  the  fact  that  she  had  albu- 
minuria, although  she  had  had  no  sore  throat  or  other  symptoms  of  scarlet  fever. 
After  several  weeks  of  treatment  her  disease  was  removed,  and  she  has  remained 
well  since.  In  the  British  Med.  Jour,  for  Nov.  29,  1879,  it  is  stated  that  in  a  family 
four  girls  were  found  to  be  suffering  from  desquamative  nephritis.  One  of  them 
had  recently  had  scarlet  fever,  but  the  other  three  had  presented  no  symptoms 
whatever  of  this  disease.  Such  cases,  although  probably  rare,  appear  to  show  that, 
as  the  scarlatinous  poison  may  produce  inflammation  of  the  fauces  without  the 
occurrence  of  scarlet  fever,  so  it  may  cause  nephritis  without  producing  the  general 
disease,  or  apparently  disturbing  the  functions  or  changing  the  state  of  other  parts, 
except  the  kidneys. 

Symptoms. —  Ordinary  Form. — Scarlet  fever  usually  begins  abruptly  so 
that  the  exact  time  of  its  commencement  can  be  fixed.  If  any  premonitory 
symptoms  occur,  they  are  slight,  so  as  scarcely  to  attract  attention,  as  languor 
or  the  appearance  of  fatigue.  A  dusky  aspect  of  the  surface  may  occasion- 
ally be  observed  during  the  few  hours  preceding  the  attack.  In  some  children 
the  first  symptom  is  chilliness,  and  occasionally  a  distinct  chill  occurs.  In 
the  adult  a  chill  is  ordinarily  the  first  symptom.  With  or  without  the  initial 
chilliness  fever  occurs,  of  variable  intensity  according  to  the  severity  of  the 
type,  and  accompanied  by  such  symptoms  as  usually  arise  in  a  febrile  state 
of  system,  as  cephalalgia,  anorexia,  and  thirst.  The  pulse  rises  to  110,  120, 
or  more  per  minute,  the  temperature  to  102°,  103°,  or  104°  ;  the  skin  is  hot, 
face  flushed,  and  the  eyes  bright.  Even  in  cases  that  are  not  malignant  or 
grave,  and  that  give  indications  of  a  favorable  result,  there  is  often  more  or 
less  stupor,  with  transient  delirium  and  sudden  starting  or  twitching  of  the 
extremities,  showing  that  the  cerebro-spinal  axis  is  involved. 

Vomiting  is  a  common  symptom  in  the  beginning  of  scarlet  fever,  occur- 
ring before  the  appearance  of  the  efiiorescence.  It  therefore  has  diagnostic 
value  when  the  nature  of  the  case  is  still  doubtful.  In  some  patients  it  is  an 
initial  symptom,  but  in  others  some  hours  have  elapsed  when  it  occurs.  I 
recorded  its  presence  or  absence  in  214  patients,  with  the  following  result : 
present  in  162  patients,  absent  in  52.  In  severe  forms  of  the  disease  it  is 
rarely  absent,  and  if  it  do  not  occur  it  is  probable  that  the  case  will  be  mild, 
requiring  little  treatment  and  having  a  favorable  termination.  In  epidemics 
of  unusual  mildness  the  number  of  cases  without  vomiting  may  be  in  excess 
of  those  in  which  this  symptom  occurs.  It  appears  to  be  due  to  functional 
disturbance   of   the   cerebro-spinal   system,  and  may  therefore  be  properly 


SCARLET  FEVER.  261 

regarded  as  a  nervous  symptom.  In  severe  cases  the  vomiting  is  usually 
repeated,  not  only  on  the  first  but  on  subsequent  days,  and  we  shall  see  that 
in  cases  of  great  gravity,  in  which  a  fatal  termination  is  not  improbable,  per- 
sistent vomiting,  by  which  the  food  and  stimulants  so  urgently  required  are 
rejected,  interferes  seriously  with  successful  treatment.  In  a  few  cases 
embraced  in  my  statistics  nausea  without  vomiting  was  recorded.  The  bowels 
in  ordinary  scarlatina  act  regularly  or  are  slightly  constipated.  Diarrhoea, 
which  so  commonly  accompanies  the  persistent  vomiting  in  malignant  cases, 
if  it  occur  in  this  form  of  the  malady  is  slight  and  transient  and  due  to  acci- 
dental causes.  The  food,  if  it  be  given  in  the  liquid  form  and  cool,  is  usually 
taken  readily  on  account  of  the  thirst,  except  when  deglutition  is  rendered 
painful  by  the  pharyngitis. 

The  symptoms  pertaining  to  the  nervous  system  vary  according  to  the 
severity  of  the  disease  and  the  temperament  of  the  patient.  Many  children 
during  the  progress  of  the  common  form  of  scarlet  fever  present  a  dull  or 
apathetic  appearance.  They  lie  much  of  the  time  with  their  eyes  clofeed ; 
others  are  more  restless,  and  not  a  few,  if  the  fever  be  considerable,  have 
occasional  twitchings  of  the  limbs  and  more  or  less  headache.  Eclampsia 
sometimes  occurs  on  the  first  day,  especially  in  those  predisposed  to  it,  even 
when  the  subsequent  course  of  the  disease  is  mild  and  favorable.  This  com- 
plication, very  grave  and  usually  fatal  when  it  occurs  at  a  later  stage,  is  in 
most  instances,  when  it  takes  place  on  the  first  day,  readily  controlled  by 
proper  remedies  and  with  little  detriment  to  the  patient.  But  if  it  be  attended 
by  high  elevation  of  temperature  and  marked  drowsiness,  approaching  the 
comatose  state,  it  is  very  serious  upon  the  first  as  well  as  upon  the  subse- 
quent days.  Nervous  symptoms  occurring  in  the  beginning  of  scarlet  fever, 
when  it  has  the  ordinary  favorable  type,  begin  to  abate  in  three  or  four  days, 
but  if  they  supervene  at  a  later  date,  and  especially  in  the  declining  stage, 
they  possess  more  gravity,  since  they  then  not  infrequently  result  from  and 
indicate  renal  complication. 

Early  in  the  disease,  nearly  as  soon  as  the  commencement  of  the  fever, 
the  faucial  and  buccal  surfaces  become  inflamed,  as  shown  by  redness,  swell- 
ing, and  tenderness.  The  physician  summoned  in  the  beginning  of  an  attack 
will  already,  at  his  first  visit,  observe  hyperaemia  of  the  fauces,  with  points 
of  deeper  injection  than  over  the  general  faucial  surface,  and  soon  the  buccal 
surface  also  participates.  The  inflammation  at  first  produces  preternatural 
dryness,  and  this  is  followed  by  a  viscid  secretion.  The  papillae  of  the  tongue 
enlarge  and  become  prominent,  giving  rise  to  the  appearance  known  as  straw- 
berry tongue,  which  is  so  common  in  scarlet  fever.  This  state  of  the  buccal 
and  faucial  membrane  continues  throughout  the  disease.  A  thin  fur  appears 
upon  the  tongue  on  the  first  day,  and  it  increases  on  the  second  and  third 
days,  after  which  it  is  usually  detached,  exposing  the  surface  of  the  organ, 
which  has  a  deep-red  hue,  but  in  not  a  few  patients  the  fur  remains  or  is 
reproduced  as  soon  as  shed.  Except  in  the  mildest  cases  the  Schneiderian 
membrane  also  participates  in  the  inflammation  as  the  disease  advances,  so 
that  a  thin,  irritating  discharge  containing  leucocytes  or  pus-cells  flows  from 
the  nostrils.  The  skin  is  hot  and  dry  and  cutaneous  transpiration  is  nearly 
checked.  The  respiratory  system  is  rarely  involved  in  any  notable  manner 
unless  there  be  a  complication.  Many  have  no  cough  whatever,  while  others 
have  a  slight  cough,  due  to  the  fact  that  the  catarrhal  inflammation  has 
extended  from  the  fauces  to  the  surface  of  the  glottis.  Slight  acceleration 
of  respiration,  corresponding  with  the  degree  of  fever,  may  also  be  observed. 
The  kidneys  commonly  act  regularly  and  normally  during  the  first  days,  any 
serious  impairment  of  their  functions  being  rare  before  the  close  of  the  first 
week. 


262  CONSTITUTIONAL  DISEASES. 

When  the  symptoms  described  above  have  continued  from  six  to  eighteen 
hours  the  efflorescence  appears.  It  is  first  observed  about  the  ears,  neck,  and 
shoulders  in  reddish  patches  fading  into  the  normal  hue.  These  patches  extend 
and  unite,  and  in  the  course  of  a  few  hours  the  trunk  and  upper  extremities, 
and  finally  the  legs,  are  covered.  The  scarlatinous  rash  usually,  when  fully 
developed,  resembles  that  produced  by  external  heat  or  the  application  of  a 
sinapism.  It  has  been  likened  to  the  appearance  of  a  boiled  lobster,  but  there 
are  numerous  minute  points  of  a  deeper  or  duskier  hue  than  the  surface 
generally.  In  many  patients  the  rash  appears,  especially  over  the  abdomen 
and  lower  extremities,  as  minute,  thickly-set  points,  with  the  skin  of  normal 
appearance  between  them.  Henoch  of  Berlin  says  of  scarlet  fever :  "  In 
general,  the  moderate  grades  of  eruption  prevail,  the  skin,  when  seen  from 
a  distance,  presenting  a  difliise,  more  or  less  scarlet  redness,  while  on  closer 
inspection  it  is  found  that  this  redness  is  composed  of  innumerable  red  points 
closely  situated  together,  and  separated  from  one  another  by  very  small  paler 
portions  of  skin.  The  dark-red  points  appear  to  correspond  to  the  hair- 
follicles."  On  passing  the  finger  over  the  efflorescence  no  distinct  promi- 
nences are  observed,  but  a  sensation  of  roughness  is  sometimes  imparted 
from  engorgement  of  the  cutaneous  papillas.  The  rash  disappears  on  pres- 
sure, but  it  immediately  reappears  when  the  pressure  is  removed.  Its  slow 
return  is  evidence  of  sluggish  circulation,  and  it  indicates  a  grave  and  dan- 
gerous form  of  the  malady.  The  color  is  then  usually  a  dusky  instead  of  a 
bright  red.  The  efflorescence  is  most  marked  in  dependent  parts,  as  along 
the  back,  over  the  chest  and  abdomen,  and  in  the  flexures  of  the  joints. 
Parts  pressed  upon  by  the  bedclothes,  which  confine  and  intensify  the  heat, 
present  a  deeper  coloration  than  other  portions  of  the  surface.  Often,  espe- 
cially in  mild  cases,  the  rash  is  absent  from  portions  of  the  surface  where  it 
commonly  appears,  while  it  presents  its  typical  character  elsewhere.  Tardy 
and  incomplete  establishment  of  the  rash  when  the  symptoms  indicate  an 
attack  of  ordinary  or  more  than  ordinary  severity  is  commonly  due  to  some 
perturbating  cause,  especially  diarrhoea.  In  the  London  Lancet  for  Aug.  16, 
1879,  cases  are  related  of  supposed  scarlet  fever  without  the  rash — cases  in 
which  pharyngitis  and  stomatitis  with  the  strawberry  tongue  occurred,  with- 
out efflorescence  upon  the  skin  ;  but  it  is  to  be  remembered,  as  stated  above, 
that  the  inflammations  which  commonly  attend  or  follow  scarlet  fever,  par- 
ticularly the  pharyngitis  and  nephritis,  not  infrequently  occur  in  those  who 
have  already  bad  scarlatina,  and  occur  more  than  once  from  fresh  exposure 
to  scarlatina  patients.  These  inflammations,  occurring  under  such  circum- 
stances, appear  to  be  purely  local  maladies,  produced  by  the  scarlatinous 
virus ;  and  it  seems  to  me  a  question  whether,  in  the  so-called  scarlatina 
without  efflorescence,  the  inflammations  which  are  present,  and  which  undoubt- 
edly have  a  scarlatinous  origin,  are  not  local  in  their  nature,  instead  of  being 
local  manifestations  of  the  constitutional  disease.  The  burning  and  itching 
sensation  produced  by  the  rash  increases  the  restlessness  of  the  patient,  and 
is  sometimes  the  most  annoying  of  the  symptoms. 

The  temperature  in  the  common  favorable  forms  of  scarlet  fever  usually 
varies  from  101°  in  the  mildest  cases  to  103°  or  104°  in  those  more  severe. 
If  it  attain  105°  or  over,  the  case  is  properly  designated  grave  or  severe. 
The  febrile  movement  ordinarily  fluctuates  but  little  from  day  to  day  till  the 
fourth  or  fifth  day,  when,  if  the  case  be  favorable  and  no  complication  occur, 
it  begins  to  decline.  The  temperature  is  as  high  in  the  beginning  of  the  attack 
as  subsequently. 

The  symptoms  pertaining  to  the  digestive  system  during  the  initial  period 
of  scarlet  fever  have  been  sufficiently  described.  The  subsequent  symptoms 
referable  to  this  system  do  not  difi'er  materially  from  those  present  in  the 


SCARLET  FEVEB.  263 

beginning,  except  the  absence  of  vomiting.  The  lips  are  dry  and  often 
cracked.  The  inflammation  of  the  mouth  and  throat  continues,  with  anorexia 
and  thirst.  With  the  decline  of  the  disease  the  appetite  gradually  returns, 
but  it  is  not  till  the  close  of  the  second  week  that  it  is  fully  restored.  Great 
and  continued  disturbance  of  the  digestive  apparatus,  seriously  interfering 
with  the  nutrition,  pertains  to  the  malignant  forms  of  scarlet  fever. 

The  urine  is  high-colored,  and  in  robust  children  during  the  first  days  of 
scarlet  fever  it  frequently  deposits  urates  on  cooling.  Gee,  who  has  carefully 
investigated  the  state  of  the  urine  in  scarlet  fever,  says  that  the  quantity 
of  water  is  diminished  and  the  urea  is  not  necessarily  increased  during  the 
pyrexia;  that  the  chloride  of  sodium  is  diminished  till  the  fourth,  fifth,  or 
sixth  day  :  and  that  the  phosphoric  acid  is  diminished  during  the  climax  of 
the  pyrexia,  though  not  in  the  first  three  or  four  days.  In  one  case  he  made  a 
daily  estimation  of  the  amount  of  uric  acid,  and  found  it  greatly  diminished 
on  the  second  and  third  days,  normal  on  the  fourth,  and  much  increased  on 
the  fifth.  He  believes  that  similar  variations  are  common  in  the  quantity 
of  the  products  excreted  in  the  urine.  Bile  may  also  appear  in  the  urine, 
coincident  with  a  yellow  tinge  of  the  conjunctiva.' 

The  duration  of  scarlet  fever  varies  in  different  cases.  If  the  attack  be 
very  mild,  with  little  efflorescence,  the  febrile  movement  may  decline  by  the 
fourth  or  fifth  day  ;  but  if  the  disease  be  severe,  little  or  no  amelioration 
of  symptoms  may  occur  before  the  twelfth  or  fourteenth  day,  even  when  no 
complication  has  occurred  to  increase  the  temperature  or  cause  aggravation 
of  symptoms.  Octerlony,  who  estimated  the  duration  of  scarlet  fever  from 
the  commencement  of  febrile  symptoms  to  "  the  disappearance  of  fever,  with 
marked  improvement  in  leading  symptoms,"  .  .  .  .  "  found  that  the  average 
duration  of  the  disease  in  forty  cases  was  six  and  one-sixth  days.  The 
minimum  duration  in  a  very  slightly  marked  case  was  three  days :  the  maxi- 
mum duration  was  fourteen  days."  In  general,  prolongation  of  fever  beyond 
the  usual  time  is  due  to  some  complication — more  frequently  to  unusually 
severe  pharyngitis,  with  accompanying  cellulitis,  than  to  any  other  cause. 

The  malady  whose  commencement  was  so  abrupt  declines  gradually.  In 
ordinary  cases,  by  the  close  of  the  first  week  or  in  the  beginning  of  the 
second  the  rash  becomes  less  and  less  distinct,  and  finally  disappears,  as  do 
also  the  redness  and  swelling  of  the  buccal  and  faucial  surfaces.  The  engorge- 
ment of  the  tonsils  and  of  the  papillae  of  the  tongue  subsides,  the  appetite 
returns,  the  countenance  brightens  and  becomes  natural,  and  the  child,  who 
during  the  height  of  the  fever  scarcely  noticed  objects  or  noticed  them  with 
indifference  or  even  repugnance,  can  be  amused  as  before  his  sickness. 

Desquamation  succeeds.  This  begins  at  about  the  sixth  day,  and  is  not 
completed  till  the  tenth  or  twelfth  day,  often  not  till  the  close  of  the  third 
or  in  the  fourth  week.  The  amount  of  desquamation  corresponds  with  the 
intensity  and  duration  of  the  efflorescence,  or  rather  of  the  dermatitis  which 
produces  the  efflorescence.  If  the  efflorescence  have  been  slight  and  partial, 
it  will  be  slight,  perhaps  scarcely  appreciable,  but  if  the  rash  have  been 
general,  full,  and  protracted,  exfoliation  occurs  upon  every  part.  It  begins 
about  the  face  and  neck,  and  within  a  day  or  two  appears  upon  other  parts. 
Where  the  skin  is  thin  the  epidermis  as  it  is  detached  presents  a  furfuraceous 
appearance  ;  where  it  is  thick,  as  upon  the  palms  of  the  hands  or  soles  of  the 
feet,  it  separates  in  layers  of  considerable  thickness. 

Such  is  a  brief  description  of  scarlet  fever  when  it  pursues  its  normal 
course  without  any  disturbing  element,  but  there  is  no  other  disease  in  which 
complications  and  sequelae  so  frequently  occur.     The  liability  to  them  renders 

^  Article  on  Scarlatina  in  Eeynolds's  System  of  Medicine. 


264  CONSTITUTIONAL  DISEASES. 

the  prognosis  in  every  ease  doubtful.  They  largely  increase  the  percentage 
of  deaths.      They  occur  both  in  mild  and  severe  forms  of  scarlatina. 

The  difference  in  type  in  different  cases  and  epidemics  has  already  been 
alluded  to.  Scarlet  fever  is  sometimes  so  mild  and  its  symptoms  so  slight  that 
the  diagnosis  is  necessarily  uncertain.  In  the  spring  of  1866.  I  was  called 
to  an  infant  thirteen  months  old  who  had  slight  pharyngitis  and  an  indistinct 
rash  over  a  part  of  the  surface.  In  two  days  the  eruption  had  disappeared, 
and  the  health  within  a  day  or  two  was  apparently  fully  restored.  Diagnosis 
would  have  been  doubtful  except  for  sequelae  which  clearly  indicated  the 
scarlatinous  nature  of  the  attack.  In  another  instance  two  children  passed 
through  the  entire  course  of  scarlet  fever,  playing  every  day  in  the  street. 
Although  the  intelligent  grandmother  saw  the  rash  upom  them,  its  nature  was 
not  suspected,  as  it  was  midsummer  and  cases  of  prickly  heat  common,  till 
nearly  two  weeks  afterward,  when  one  of  the  children  had  nephritis  and 
anasarca,  ending  fatally.  In  cases  so  mild  as  these  the  heat  of  the  surface 
is  but  slightly  increased,  the  pulse  but  little  accelerated,  and  the  rash  usually 
does  not  occupy  so  much  of  the  surface  as  in  ordinary  cases ;  the  appetite  is 
not  lost,  though  diminished,  and  the  thirst  is  moderate. 

Between  scarlet  fever  so  mild  that  it  terminates  in  four  or  five  days,  and 
that  of  the  grave  or  malignant  type  presently  to  be  described,  all  grades  of 
severity  exist.  Scarlet  fever  occurs  in  all  forms  from  mild  to  severe,  but 
certain  symptoms  characterize  grave  or  malignant  cases — symptoms  which 
are  absent  or  much  less  prominent  in  ordinary  scarlet  fever.  Therefore  the 
grouping  of  cases  according  to  the  type  is  proper,  and  it  facilitates  the  study- 
ing of  the  disease. 

Grave  Form  (malignant  scarlet  fever). — This  form  of  the  disease  is  in 
some  epidemics  common,  while  in  others  it  is  rare.  The  symptoms  which 
characterize  it  are  severe  from  the  beginning,  those  of  the  nervous  system 
predominating  at  first,  such  as  intense  cephalalgia,  restlessness  or  stupor, 
sudden  twitching  of  the  muscles,  and  perhaps  delirium  or  even  convulsions. 
Many  pass  rapidly  into  coma  and  die  within  two  or  three  days,  succumbing 
to  the  intensity  of  the  scarlatinous  poison  while  the  malady  is  still  in  its 
commencement.  The  rash  is  dusky.  It  disappears  by  pressure,  and  returns 
slowly  when  the  pressure  is  removed,  showing  extreme  sluggishness  of  the 
capillary  circulation.  Some  patients  are  very  drowsy,  lying  in  a  semi-comatose 
state  except  when  aroused,  and  if  aroused  are  very  restless.  Others  are  con- 
stantly restless.  If  placed  in  one  position  on  the  bed,  they  throw  themselves 
in  another  in  a  half-conscious  or  unconscious  state.  They  do  not  speak,  or 
they  mutter  like  those  afiected  by  the  graver  forms  of  typhus,  calling  the 
names  of  playmates  or  talking  incoherently  about  things  which  interested 
them  when  well.  The  thermometer  placed  in  the  axilla  is  found  to  rise  above 
103°,  which  is  a  safe  average,  to  105°  or  even  107°,  and  the  heat  of  the  sur- 
face is  pungent  except  when  the  case  approaches  a  fatal  termination,  when 
the  extremities,  ears,  and  nose  may  be  cool  while  the  trunk  and  head  are 
extremely  hot.  The  pulse  from  the  first  is  rapid,  ranging  from  130  as  the 
minimum  in  a  malignant  case  to  a  frequency  which  can  scarcely  be  counted. 
A  very  frequent  pulse  is  nearly  always  feeble  and  compressible.  Irritability 
of  the  stomach  is  one  of  the  most  common  symptoms  in  grave  cases,  so  that 
many  patients  immediately  reject  the  nutriment  and  stimulants  which  are  so 
urgently  required  to  sustain  the  vital  powers.  The  vomiting,  therefore,  if 
frequent  and  severe,  greatly  increases  the  danger,  and  in  not  a  few  instances 
this  symptom  is  associated  with  diarrhoea,  which  also  tends  to  increase  the 
prostration. 

Severe  and  dangerous  nervous  symptoms,  due  to  the  intensity  or  activity 


SCARLET  FEVER.  265 

of  the  scarlatinous  poison,  occur  chiefly  within  the  first  three  or  four  days. 
Grinding  the  teeth,  sudden  muscular  twitching,  delirium,  convulsions,  and 
profound  stupor  occur  for  the  most  part  within  this  time.  Afterward  the 
danger  is  mainly  from  exhaustion,  unless  in  the  second  week  or  subsec^uently^ 
when  nervous  symptoms  may  arise  from  urtemia. 

Those  who  survive  the  onset  of  malignant  scarlet  fever  often  have  in  the 
course  of  a  few  days  severe  pharyngitis,  with  extension  of  the  inflammation 
to  the  lymphatic  glands  and  connective  tissue  around  the  angle  of  the  jaw. 
These  inflammations  cause  more  or  less  external  swelling.  The  faucial  tur- 
gescence  around  the  entrance  of  the  larynx,  with  the  accompanying  secretions 
of  viscid  mucus  or  muco-pus,  often  causes  noisy  respiration,  and  many  at  this 
stage  of  the  attack  breathe  with  the  mouth  constantly  open  to  facilitate  the 
ingress  of  air. 

Ordinarily,  no  discharge  occurs  at  first  from  the  nasal  surface,  but  as  the 
disease  continues,  if  the  type  remain  severe,  deflexion  of  thin  muco-pus  takes 
place  from  the  Schneiderian  surface,  which  excoriates  the  cheek.  The  hps 
also  are  frequently  sore  and  swollen. 

In  malignant  cases  the  disease  is  more  protracted  than  when  the  type  is 
mild.  Thus  in  a  recent  case  in  my  practice  the  rash  was  still  distinct  at  the 
close  of  the  second  week,  though  the  temperature  had  fallen  from  105°  to 
102°,  and  some  desquamation  had  appeared.  Long  continuance  of  the  febrile 
movement  is,  however,  oftener  attributable  to  some  inflammatory  complica- 
tion than  to  the  primary  disease. 

In  all  epidemics  of  a  severe  type,  cases  now  and  then  occur  in  which  the 
poison  is  so  intense,  or  it  acts  with  such  frightful  energy,  that  death  occurs 
even  within  the  first  day.  The  patient  is  overpowered  at  the  outset  of  the 
disease  by  the  virulence  of  the  specific  principle,  perishing  in  coma,  preceded 
perhaps  by  convulsions.  The  autopsy  in  such  cases  reveals  hypersemia  of 
the  brain  and  cranial  sinuses,  blood  of  a  dark-red  color,  capillary  hemorrhages 
in  various  parts,  a  flabby  heart,  and  perhaps  some  engorgement  of  the  spleen 
and  kidneys. 

Usually,  malignant  scarlet  fever  exhibits  its  severe  type  from  the  first,  but 
cases  sometimes  occur  which  seem  mild  and  favorable  for  a  few  days,  when 
severe  symptoms  suddenly  supervene.  This  change  from  a  mild  to  a  danger- 
ous disease  is,  however,  most  frequently,  I  think,  due  to  some  complication. 

Irregular  Forms. — Deviation  from  the  normal  type  in  scarlet  fever  is  usually  due 
to  some  perturbating  cause,  which  is  often  a  pre-existing  or  coexisting  disease  or  a 
disordered  state  of  system  through  causes  distinct  from  scarlatina.  Thus,  a  little 
girl  in  my  practice  had  the  symptoms  of  scarlet  fever,  such  as  febrile  movement 
and  inflammation  of  the  buccal  and  faucial  surfaces,  nearly  a  week  before  the  scar- 
latinous eruption  appeared.  During  this  time  the  patient  had  an  intestinal  catarrh,^ 
with  diarrhoea,  which  declined  when  the  rash  occurred.  This  intestinal  disease  was 
the  apparent  cause  of  the  irregularity  in  the  malady.  If  scarlatina  occur  during  a 
severe  attack  of  entero-colitis  attended  by  purging,  the  defluxion  from  the  intestinal 
surface  may  be  such  that  no  efflorescence  appears.  Severe  scarlet  fever  itself  some- 
times appears  to  cause  gastro-intestinal  catarrh,  so  as  to  produce  an  afflux  of  blood 
toward  the  intestinal  tract  and  away  from  the  skin.  Practitioners  occasionally  meet 
cases  like  the  following,  which  I  recall  to  mind :  In  a  family  where  scarlatina  was 
prevailing  a  little  child  early  after  the  commencement  of  the  symptoms  which 
seemed  to  be  plainly  referable  to  this  exanthem  was  seized  with  vomiting  and 
purging,  which  continued  till  death  occurred  on  the  third  day.  No  efflorescence 
appeared  on  the  skin,  but  the  symptoms  indicated  the  presence  of  severe  intestinal 
catarrh,  complicating  and  masking  scarlatina.  We  are  aided  in  the  diagnosis  of  such 
cases  by  observing  the  faucial  redness,  and  we  may  discover  a  faint  efflorescence 
upon  paits  of  the  surface,  as  about  the  groin  or  in  the  flexures  of  the  joints.  In 
another  instance  an  infant  in  the  warm  months,  having  protracted  entero-colitis, 
the  usual  summer  epidemic  of  the  cities,  had  the  characteristic  symptoms  of  scarlet 


266  CONSTITUTIONAL  DISEASES. 

fever,  which  was  present  in  the  family,  but  the  diarrhoea  continued  and  no  rash 
appeared. 

In  one  who  is  much  reduced  by  an  antecedent  disease,  especially  if,  like  the 
intestinal  catarrh  mentioned  above,  it  produces  a  decided  afflux  of  blood  away  from 
the  surface  and  toward  the  interior  of  the  body,  the  eruption  is  commonly  tardy  in 
its  appearance,  indistinct,  or  wholly  absent.  On  the  other  hand,  some  maladies 
■occurring  in  connection  with  this  exanthem  do  not  change  its  symptoms,  but  them- 
selves undergo  modification.  Pertussis  may  be  cited  as  an  example,  the  cough  of 
which  is  sometimes  modified  by  an  intercurrent  attack  of  scarlet  fever,  the  symp- 
toms of  the  latter  disease  undergoing  little  change. 

Scarlet  fever  may  also  be  irregular  without  any  apparent  perturbating  cause. 
In  1867,  I  attended  a  young  lady  whose  previous  health  had  been  good,  and  whose 
brother  was  sick  at  the  time  with  scarlet  fever.  She  had  marked  elevation  of  tem- 
perature, with  severe  pharyngitis,  and,  though  her  surface  was  repeatedly  examined, 
no  efflorescence  was  seen.  Two  weeks  subsequently  she  was  affected  with  severe 
nephritis,  anasarca,  effusion  into  at  least  one  of  the  pleural  cavities,  oedema  of  the 
lungs,  and,  according  to  my  diagnosis,  hydro-pericardium,  the  case  ending  fatally. 
Rilliet  and  Barthez  state  that  a  second  attack  of  scarlet  fever  is  more  likely  to  be 
irregular  than  the  first.  Probably  this  opinion  is  correct,  especially  if  only  a  short 
time  have  elapsed  between  the  two  seizures.  Still,  as  we  have  already  stated,  both 
seizures  may  be  typical,  and  the  second  more  severe  than  the  first. 

It  would  be  impossible  to  make  a  clear  and  positive  diagnosis  of  certain  cases 
of  irregular  scarlet  fever,  in  which  cerebral,  pulmonary,  or  gastro-intestinal  symp- 
toms predominate,  were  it  not  for  the  fact  that  they  occur  in  connection  with  other 
cases  of  scarlet  fever  or  are  followed  by  sequelae  which  evidently  have  a  scarlatinous 
origin. 

Occasionally,  the  eruption,  if  it  be  intense  or  if  a  certain  condition  of  system 
be  present  in  the  patient,  is  accompanied  by  more  or  less  extravasation  of  blood- 
corpuscles  from  the  capillaries,  usually  in  points,  so  that  the  redness  does  not  entirely 
disappear  on  pressure.  In  rare  instances  certain  of  the  exanthematic  fevers  present 
an  extreme  hemorrhagic  character,  so  as  to  be  beyond  the  reach  of  remedies  and 
of  necessity  speedily  fatal.  Hemorrhagic  cases  of  this  severe  form  are  probably 
more  common  in  variola  than  in  the  other  fevers,  but  I  have  met  a  notable  case  in 
what  was  diagnosticated  scarlatina,  in  June,  1881,  a  man  in  his  thirty-second  year, 
whose  previous  health  had  not  been  good,  though  he  had  no  defined  ailment  and 
had  been  able  to  follow  his  occupation  of  harness-maker,  suddenly  became  very  ill, 
with  great  elevation  of  temperature  and  faucial  inflammation,  attended  by  marked 
prostration.  After  some  hours  an  intense  eruption  of  a  scarlatinous  appearanee 
covered  nearly  the  entire  surface,  and  on  the  following  day  hemorrhages  began  to 
occur.  The  urine  contained  a  large  proportion  of  blood ;  each  conjunctiva  was 
raised  by  hemorrhages  underneath  (ecchymosis),  so  that  its  natural  color  was  lost, 
the  eyelids  were  closed  with  difficulty,  and  blood  flowed  from  the  nostrils,  gums, 
and  under  the  skin,  forming  hemorrhagic  points  and  blotches.  One  of  the  consult- 
ing physicians,  perceiving  the  resemblance  to  hemorrhagic  variola  as  described  by 
Hebra,  suspected  that  we  had  a  case  of  this  formidable  malady  to  deal  with,  but 
the  time  for  the  appearance  of  the  variolous  eruption  passed  by  without  its  occur- 
rence. Death  took  place  on  the  fifth  day.  The  temperature  during  the  sickness 
remained  high,  though  the  record  of  it  has  been  mislaid.  Fortunately,  such  severe 
hemorrhagic  cases,  which  are  necessarily  fatal,  are  rare. 

Complications  and  Sequelae. — Scarlet  fever,  if  its  type  be  severe,  is  in 
itself  dangerous  to  life.  Many,  as  we  have  seen,  perish  from  its  direct  effects 
when  it  produces  profound  blood-poisoning.  But  while  the  ordinary  epi- 
demics of  this  malady  are  necessarily  attended  by  a  large  mortality  from  the 
virulence  and  depressing  effect  of  the  specific  principle,  unfortunately,  of  all 
the  diseases  of  modern  times,  scarlatina  ranks  first  as  regards  the  number  and 
gravity  of  its  complications  and  sequelae,  so  that  nearly  or  c{uite  as  many 
perish  from  these  as  from  the  direct  effects  of  the  poison. 

Nervous  accidents  occur  chiefly  at  two  periods — to  wit,  in  the  first  days,  when 
they  are  due  to  the  severity  and  malignity  of  the  malady  and  to  the  impressible 
nervous  temperament  of  the  child ;  and  in  the  declining  stage  or  after  the  termi- 


SCARLET  FEVER.  267 

nation  of  the  fever,  when  they  occur  from  uraemia.  If  the  type  be  malignant, 
delirium,  jactitation,  profound  stupor,  and  convulsions  frequently  occur  on  the  first 
and  second  days ;  and  these  are  symptoms  which  properly  excite  the  most  alarm 
and  demand  all  the  resources  of  our  art,  since  they  indicate  a  form  of  the  disease 
which  frequently  ends  in  speedy  death.  The  eyes  have  a  dull  or  wild  expression, 
the  conjunctiva  is  suffused,  the  heat  of  surface  pungent,  the  pulse  rapid  and  com- 
pressible or  feeble,  rising  above  150,  even  to  200,  per  minute,  and  the  temperature 
is  always  elevated  to  a  degree  that  involves  danger,  the  thermometer  not  infre- 
quently indicating  105°  or  106°.  But  this  severe  form  of  scarlet  fever,  attended  by 
so  great  elevation  of  temperature,  is  much  less  dangerous  than  in  former  times, 
even  though  it  be  complicated  by  delirium  and  convulsions,  since  we  no  longer 
hesitate  to  reduce  bodily  heat,  when  excessive,  by  the  free  use  of  cold  baths,  and 
have  discovered  potent  agents  in  the  bromides  and  chloral  for  controlling  convul- 
sions. Nevertheless,  not  a  few  perish  in  the  commencement  of  scarlet  fever  with 
predominating  cerebral  symptoms,  as  delirium  or  eclampsia,  followed  by  coma, 
under  the  best  possible  treatment.  Sometimes  the  symptoms  have  closely  simu- 
lated those  of  acute  meningitis,  and  if  the  rash  have  been  delayed  and  the  sore 
throat  is  as  yet  slight,  the  physician  may  suspect  that  he  is  dealing  with  this 
disease ;  but  autopsies  in  such  cases  show  no  inflammatory  lesions,  but  only  con- 
gestion of  the  cerebral  and  meningeal  vessels. 

As  is  stated  in  a  preceding  page,  in  every  case  of  normal  scarlet  fever  inflam- 
mation of  the  faucial  surface  is  present,  as  indicated  by  redness,  tenderness,  and 
increased  secretion  of  mucus  or  muco-pus.  It  precedes  the  efilorescence  on  the 
skin,  and  is  announced  by  pain  in  swallowing  and  on  pressure  with  the  fingers 
behind  and  below  the  angles  of  the  jaw.  In  that  form  of  scarlet  fever  which  has 
been  designated  anginose  the  pharyngitis  is  severe,  and  is  a  prominent  element  in 
the  malady,  the  uvula,  the  pillars  of  the  fauces,  and  the  faucial  sui-face  in  general 
being  infilti'ated  and  swollen.  Nevertheless,  this  inflammation,  with  the  accom- 
panying tumefaction,  is  properly  a  part  of  the  disease,  rather  than  a  complication, 
if  it  abate  with  the  subsidence  of  the  scarlet  fever  or  begin  to  abate  soon  after, 
and  if  it  produce  but  slight  destructive  change  in  the  tissue  of  the  neck.  The 
secretions  from  the  fauces  may  be  foul  and  ofi"ensive ;  even  superficial  ulcerations 
or  gangrene  may  occur  upon  the  faucial  surface,  causing  it  to  present  a  dark-brown 
or  jagged  appearance,  and  the  tissues  of  the  neck  may  be  infiltrated  to  a  certain 
extent,  and  we  designate  the  disease  a  form  of  scarlet  fever  under  the  title  anginose. 
But  when  this  condition  is  greatly  aggravated,  so  that  extensive  infiltration  and 
swelling  of  the  tissues  of  the  neck  occur,  with  an  amount  of  ulceration  or  gan- 
grene which  in  itself  involves  danger,  continuing  after  the  primary  disease  abates, 
prolonging  the  fever  and  reducing  the  strength,  it  is  proper  to  regard  the  state 
of  the  throat  as  a  complication.  In  addition  to  the  pharyngitis,  which  is  severe, 
as  described  above,  the  sides  of  the  neck  around  the  angles  of  the  jaw  become 
swollen,  hard,  and  tender.  The  inflammation  has  been  propagated  to  the  deeper 
structures  of  the  neck.  Poisonous  substances,  the  result  of  decomposition  or  vitiated 
secretions,  traverse  the  lymphatic  vessels  from  the  faucial  surface,  and  being  inter- 
cepted in  the  lymphatic  glands,  cause  adenitis,  and  the  inflammation  extends  from 
the  glands  to  the  adjacent  connective  tissue,  which  becomes  hard,  tender,  swollen, 
and  infiltrated  with  inflammatory  products.  This  tumefaction  sometimes  begins 
by  the  second  or  third  day,  but  it  is  usually  about  the  close  of  the  first  week  or 
in  the  beginning  of  the  second  week  that  it  becomes  so  considerable  as  to  consti- 
tute a  source  of  danger  and  anxiety.  It  is  in  most  cases  bilateral,  though  one  side 
may  begin  to  swell  before  the  other  and  remain  larger  throughout. 

In  severe  cases  of  this  complication  the  tumefaction  extends  from  ear  to  ear,  filling 
up  the  space  below  and  around  the  angles  of  the  jaw  and  under  the  chin.  Not  only  is 
deglutition  diflicult,  but  it  is  difficult  to  open  the  mouth  sufiiciently  to  inspect  the 
fauces,  and  attempts  to  do  so  cause  much  pain.  The  lymphatic  glands,  which  lie  in  the 
inflamed  area  and  participate  in  the  inflammation,  are  greatly  enlarged  by  hyper- 
plasia, the  round  granular  lymph-cells  multiplying  so  abundantly  that  the  glands 
increase  to  many  times  their  normal  size.  Most  of  the  tumefaction  is,  however,  due 
to  extension  of  the  inflammation  to  the  connective  tissue  of  the  neck.  The  cellu- 
litis, which  resembles  that  occurring  in  other  conditions,  is  attended  by  distention 
of  the  capillaries,  the  abundant  formation  of  young  round  cells,  and  transudation 
of  serum  (Billroth).  A  moderate  amount  of  tumefaction  may  disappear  by  resolu- 
tion, but  if  it  be  considerable  it  seldom  abates  in  this  way,  but  by  the  tedious  and 


268  CONSTITUTIONAL  DISEASES. 

exhausting  process  of  suppuration  or  gangrene.  If  the  swelling  at  its  most  prom- 
inent point  presents  a  reddish  hue,  all  hope  of  producing  resolution  must  be  aban- 
doned ;  it  cannot  be  effected  by  any  medicine  or  appliance  within  the  resources  of 
our  art.  The  abscess  which  forms  is  likely  to  be  diffuse,  so  as  to  involve  danger  of 
pvEemia,  unless  it  be  soon  opened  and  properly  washed  out.  With  the  discharge 
of  the  pus  the  swelling  gradually  softens  and  declines.  In  other  cases  gangrene 
results.  The  vessels  in  the  inflamed  part  are  compressed  by  the  inflammatory  prod- 
ucts, so  that  they  no  longer  convey  the  blood  which  is  required  for  the  purpose  of 
nutrition.  It  is  a  law  of  the  system  that  whenever  the  circulation  ceases  the 
tissues  which  receive  their  nutritive  supply  through  the  obstructed  vessels  lose  their 
vitality.  Hence  gangrene  occurs  in  all  that  portion  of  the  swelling  in  which  the 
circulation  is  arrested.  The  skin  over  it  peels  off,  the  dead  tissue  underneath  is 
brown  or  dark,  and  soon,  if  life  be  prolonged,  the  slough  begins  to  separate.  The 
prognosis  as  regards  this  complication  depends  largely  on  the  size  of  the  slough. 
If  it  be  large,  death  will  probably  result,  since  the  strength  of  the  system  is  already 
reduced  by  the  primary  disease,  and  the  reparative  process  will  necessarily  be  slow, 
while  abundant  suppuration  tends  to  increase  the  exhaustion.  In  some  of  the 
worst  cases  of  cervical  gangrene  which  I  have  seen  the  slough  has  laid  bare  the 
muscles  and  vessels  of  the  neck,  producing  in  one  case  a  cavity  or  excavation  suffi- 
ciently large  to  admit  a  hen's  egg.  Often  the  slough  extends  under  the  skin,  so  that 
the  deepest  recesses  of  the  cavity  are  not  visible,  and  occasionally,  in  cases  which 
have  ended  fatally  in  my  practice,  severe  hemorrhage  occui*red  from  the  concealed 
vessels.  If  the  ulcerative  or  gangrenous  process  extends  so  deeply  into  the  tissues 
of  the  neck  that  hemorrhages  occur,  death  is  the  common  result:  but  if  the  destruc- 
tive action  be  of  moderate  extent  and  other  conditions  favorable,  we  may  expect 
recovery  through  cicatrization,  with  perhaps  some  deformity  by  contraction  of  the 
cicatrix. 

When  the  inflammation  of  the  connective  tissue  of  the  neck  is  extensive,  in- 
volving both  the  lateral  and  anterior  regions  of  the  neck,  the  patient  is  in  a  perilous 
state.  The  cellulitis,  when  extensive  and  accompanied  by  much  swelling,  may  pro- 
duce oedema  of  the  glottis,  may  obstruct  respiration  by  compressing  the  air-passages 
or  the  laryngeal  nerves,  may  cause  compression  of  the  jugular  veins,  and  thus  give 
rise  to  dangei-ous  cerebral  symptoms,  or  may  lay  bare  and  injure  important  muscles 
and  nerves,  as  we  have  seen.  If  the  ulceration  or  gangrene  be  extensive,  and  death 
do  not  occur  by  hemorrhage  from  arterial  or  venous  twigs,  septic  poisoning  may 
occur,  increasing  still  more  the  fatal  nature  of  the  malady. 

Some  cases  of  this  complication  are  melancholy  in  the  extreme,  as  one  related 
by  Cremen,  in  which  ulceration  of  the  pharynx  occurred,  allowing  the  escape  of 
food  and  preventing  deglutition.  In  severe  scarlatinous  pharyngitis  the  inflamma- 
tion sometimes  extends  along  the  Eustachian  tube,  causing  its  occlusion.  This  acci- 
dent will  be  considered  when  we  treat  of  otitis  media,  another  grave  complication. 
It  often  also  extends  into  the  nares,  causing  catarrh  of  the  Schneiderian  mucous 
membrane,  with  discharge  of  muco-pus  from  the  surface.  Not  infrequently  ulcera- 
tion or  gangi-ene  occurs  in  the  faucial  surface,  producing  more  or  less  destruction 
of  tissue  and  forming  excavations,  while  the  cutaneous  surface  retains  its  integrity 
and  is  not  even  reddened.  The  following  case  shows  how  grave  the  complication 
which  we  are  now  considering  sometimes  is  when  the  external  surface  of  the  neck 
is  not  involved,  and  how  the  inflammation  by  extension  outward  from  the  fauces 
may  involve  the  middle  ear : 

Case  1. — Annie  K ,  aged  two  and  a  half  years,  an  inmate  of  the  New  York 

Foundling  Asylum,  was  well,  except  an  eczema  of  the  scalp,  until  the  night  of  April 
3,  1882,  when  she  was  attacked  with  vomiting  and  diarrhoea.  She  was  feverish  and 
drowsy,  and  at  2  p.  m,  on  the  4th  the  scarlatinous  efflorescence  appeared  upon  her 
neck,  body,  and  lower  extremities ;  tongue  coated ;  pharynx  red ;  temperature 
(axillary)  103°;  pulse  160.  The  symptoms  and  aspect  indicated  a  grave  form  of 
the  malady,  and  the  usual  sustaining  treatment  was  ordered.  On  April  5th  the 
temperature  was  102°,  pulse  144,  tongue  less  coated,  eruption  fading,  less  stupor, 
no  albumen  in  urine.  April  6th,  morning  temperature  102°,  pulse  160;  passed  a 
restless  night ;  stools  thin  and  too  frequent ;  has  grayish  patches  in  the  throat ;  p.  m. 
temperature  103.2°,  pulse  150.  April  7th,  the  diarrhoea  continues,  and  she  has  a 
copious  muco-purulent  discharge  from  the  nostrils  ;  p.  m.  temperature  103.6°,  pulse 
160.  April  10th,  the  temperature  has  continued  at  about  103°  ;  the  patient  is  very 
sick,  with  a  constant  foul-smelling  discharge  from  the  nostrils  ;  breath  very  offen- 


SCARLET  FEVEB.  269 

sive  ;  temperature  103.5°,  pulse  about  180.  April  12tli,  general  appearance  a  little 
better,  but  the  posterior  surface  of  the  fauces  is  completely  covered  by  a  thick  pseudo- 
membrane  ;  had  four  loose  stools  last  night ;  temperature  and  pulse  the  same  as  at 
last  record  ;  a  dark,  offensive,  and  jagged  coating  over  the  fauces,  and  a  dark,  foul 
discharge  from  the  nostrils  as  before  :  examination  of  the  chest  negative.  April 
14th,  is  much  prostrated ;  temperature  104.5°,  pulse  rapid  and  weak ;  respiration 
noisy :  diminished  resonance  over  lower  two-thirds  of  left  side  of  chest ;  ulcers 
upon  the  mouth  and  tongue  :  fauces  red  and  ulcerated.  April  17th,  pulse  150,  tem- 
perature 100.5°;  general  appearance  somewhat  better,  but  the  diarrhoea  continues, 
and  patches  of  a  diphtheritic  character  have  appeared  upon  the  lips  ;  moist  rales 
in  left  side  of  chest.  The  symptoms  continued  nearly  the  same  until  April  23d, 
when  she  died.  A  dull  percussion  sound  and  distinct  bronchial  respiration  were 
observed  in  the  left  scapular  region  during  the  last  days  of  her  life. 

Autopsy  nine  hours  after  death  by  the  curator :  Body  well  nourished  ;  the  tis- 
sues have  a  jaundiced  hue  ;  lips  sore ;  on  turning  the  head  to  one  side  pus  runs 
from  the  left  ear  and  dirty  muco-pus  from  the  mouth.  Brain  normal ;  on  opening 
the  petrous  portion  of  the  left  temporal  bone  the  middle  ear  is  found  full  of  pus, 
which  communicated  freely  with  the  external  ear  through  a  perforated  membrana 
tympani :  the  Eustachian  tube  cannot  be  traced  in  the  sloughy  tissue,  and  a  passage 
filled  with  pus  extends  from  the  ear  to  the  fauces  ;  opposite  the  greater  cornua  of 
the  hyoid  bone  are  two  deep  ulcers,  each  having  about  the  diameter  of  a  ten-cent 
piece,  with  sloughy  and  offensive  base  and  sides ;  the  left  ulcer  communicates  by 
a  ragged  and  wide  sinus  with  a  dark  and  sloughy  cavity  of  about  four  drachms 
capacity;  this  cavity  is  located  in  the  neck  under  the  angle  of  the  jaw,  apparently 
occupying  the  site  of  a  disintegrated  gland,  and  it  opens  upon  the  surface  of  the 
fauces.  The  surface  of  the  larynx  has  a  dusky,  dirty  appearance,  sprinkled  with 
little  cheesy-looking  spots,  and  covered  by  a  dirty,  foul-appearing  liquid,  as  if  some 
of  the  ichorous  pus  had  escaped  into  it  from  the  neck ;  about  one  and  a  half  inches 
below  the  vocal  cords  there  is  an  unmistakable  pseudo-membrane  ;  below  this,  near 
the  bifurcation,  the  trachea  has  a  bright-red  color,  as  if  a  pseudo-membrane  had 
been  peeled  from  it,  leaving  the  surface  raw.  The  detachment  of  a  pseudo-mem- 
brane from  this  part,  if  it  did  occur,  must  have  been  ante-mortem,  for  the  organ 
had  been  carefully  handled  in  making  the  autopsy.  Between  the  apex  of  the  left 
lung  and  the  median  line  the  tissues  of  the  neck,  dissected  upward,  are  found 
indurated,  yellow,  and  giving  an  offensive  odor,  showing  that  the  cervical  cellulitis 
had  extended  downward  farther  than  usual.  The  bronchial  glands  have  undergone 
hyperplasia,  being  enlarged  and  hard.  The  right  lung  is  normal ;  about  one-half 
of  the  left  lower  lobe  is  consolidated,  and  when  cut  is  found  to  be  gangrenous  and 
offensive.  The  liver  is  apparently  somewhat  enlarged ;  spleen  normal  in  size ; 
gastric  mucous  membrane  has  a  congested  appearance  and  is  covered  with  mucus  ; 
mesenteric  glands  enlarged,  pale,  and  firm  ;  Peyer"s  patches  swollen  and  pale ;  at 
lower  end  of  ileum  some  pigmentation  of  these  glands ;  in  large  intestine  the 
solitary  glands  are  enlarged,  and  a  few  of  them  pigmented  ;  kidneys  pale,  cortex 
thickened,  and  markings  indistinct.  Microscopical  examination  :  In  the  pia  mater 
perhaps  a  little  increase  of  cells  ;  meninges  of  brain  otherwise  normal.  The  trachea 
shows  well-marked  diphtheritic  inflammation  ;  it  contains  a  film  of  pseudo-membrane ; 
evidences  of  inflammation  occur  also  upon  the  laryngeal  surface,  though  less  marked 
than  in  the  trachea.  The  solidified  portion  of  the  lung  exhibits  the  ordinary  lesions 
of  broncho-pneumonia,  with  some  interstitial  change.  In  the  kidneys  we  find  paren- 
chymatous nephritis,  with  some  cell-growth  in  the  Malpighian  bodies. 

The  above  case  has  been  related  at  length,  not  only  because  it  shows  how 
severe  and  destructive  the  inflammation  of  the  throat,  extending  into  the 
tissues  of  the  neck,  sometimes  is,  but  because  four  other  complications  or 
sequelae  were  also  present — to  wit,  otitis  media,  diphtheria,  nephritis,  and 
pneumonia.  We  see  how  formidable  a  disease  scarlet  fever  sometimes  is 
when  attended  by  the  inflammations  to  which  it  so  frequently  gives  rise,  for 
a  child  older  and  stronger  than  this,  if  thus  afi"ected.  would  inevitably  have 
perished  with  the  best  possible  treatment. 

In  localities  where  diphtheria  is  endemic,  as  in  New  York  City  and  Paris, 
scarlet  fever  is  often  complicated  by  pseudo-membranous  inflammations  of  the 
fauces  and  air-passages.     In  severe  cases  the  Schneiderian  as  well  as  the 


270  CONSTITUTIONAL  DISEASES. 

faucial  surface  is  covered  with  pseudo-membrane,  so  that  it  can  be  readily 
seen  on  inspecting  the  anterior  nares.  Occasionally,  this  exudation  appears 
upon  the  laryngeal  and  tracheal  surfaces,  as  in  the  case  which  I  have  related 
above  and  in  others  presently  to  be  related,  causing  dangerous  embarrassment 
of  respiration.  This  complication  sometimes  begins  almost  at  the  commence- 
ment of  scarlet  fever,  but  in  most  instances  it  does  not  occur  before  the  third 
or  fourth  day,  and  it  sometimes  does  not  appear  till  in  the  declining  stage  of 
the  fever.  When  it  begins  it  intensifies  the  fever  and  produces  general 
aggravation  of  symptoms. 

The  elaborate  treatise  by  Sanne  of  Paris  on  diphtheria  contains  a  chapter 
entitled  "  Secondary  Diphtheria."  In  it  the  author  says,  what  all  who  are 
familiar  with  diphtheria  will  agree  to,  that  secondary  diphtheria  does  not 
differ  in  nature  from  the  primary  form,  and  that  it  exhibits  a  tendency  "  to 
occupy  the  organs  which  are  themselves  the  seat  of  the  more  pronounced 

local  determinations  of  the  primitive  malady Diphtheria  is  seen  in 

the  course  or  sequel  of  numerous  diseases.  Some  appear  to  have  a  special 
proclivity  for  engendering  diphtheria ;  these  are  specific  maladies :  measles, 
scarlet  fever,  pertussis."  Sanne's  statistics  relating  to  the  seat  of  scarlatinous 
diphtheritic  exudation  are  as  follows  : 

Fauces  alone  attacked 15  cases. 

Fauces  with  larynx  attacked 4  " 

Fauces  with  nasal  fossa  attacked 8  " 

Fauces  with  larjTQx  and  nasal  fossa  attacked 4  " 

Fauces  with  larynx  and  bronchi  attacked  1  " 

Fauces  with  nasal  fossa  and  lips  attacked 1  " 

Fauces  with  lips  and  skin  attacked 1  " 

Fauces  unaffected 3  " 

Diphtheria  generalized 2  " 

Larynx  only  affected 2  " 

Nasal  fossa 1  " 

The  pellicular  exudate  upon  the  laryngo-tracheal  surface  is  treated  else- 
where in  this  book. 

Coryza  frequently  commences  at  or  about  the  time  of  the  pharyngitis. 
The  inflammation  of  the  Schneiderian  membrane  is  continuous  posteriorly 
with  that  of  the  fauces,  and  is  announced  by  redness  and  swelling,  inability 
to  breathe  freely  through  the  nostrils,  and  an  irritating  ichorous  discharge. 
Simple  coryza  in  itself  involves  little  danger,  though  it  is  an  unpleasant  com- 
plication, and  in  the  nursing  infant  it  may  interfere  with  drawing  the  nipple. 
Diphtheritic  coryza,  on  the  other  hand,  which  is  frequently  present  when 
diphtheria  complicates  scarlet  fever,  involves  danger,  since  it  is  apt  to  cause 
ulcerations,  hemorrhages,  and  septic  poisoning.  When  the  local  symptoms 
are  unusually  severe  and  the  discharge  abundant,  it  is  probable  that  inflam- 
mation has  in  some  cases  extended  to  the  antrum  of  Highmore. 

Inflammation  of  the  Middle  Ear  is  another  unpleasant  and  not  infrequent 
complication.  The  statistics  of  different  aurists  collated  by  Dr.  C.  H.  May, 
and  presented  in  a  paper  on  scarlatinous  otitis  read  before  the  Pgediatric  Sec- 
tion of  the  New  York  Academy  of  Medicine,  March  4, 1889,  show  that  about 
5  per  cent,  of  all  aural  affections  result  from  scarlet  fever,  and  in  10  per  cent, 
of  the  cases  of  total  deafness  the  loss  of  hearing  is  from  this  disease.  It  is 
due  to  extension  of  the  catarrh  from  the  pharynx  along  the  Eustachian  tube 
to  the  tympanum.  In  a  considerable  proportion  of  cases  of  otitis  media  this 
tube  is  occluded  by  the  infiltration  and  swelling  of  its  mucous  membrane,  so 
that  the  muco-pus  escapes  with  difficulty  or  is  retained.  Hence  severe  ear- 
ache, an  increase  of  the  febrile  movement,  and  outward  bulging  of  the  mem- 
brana  tympani  occur.     Sometimes  headache  or  other  cerebral  symptoms  arise, 


SCARLET  FEVER.  271 

probably  from  the  fact  that  the  meningeal  artery,  which  supplies  the  meninges, 
is  connected  by  anastomosing  branches  with  the  tympanum.  In  one  of  the 
cases  related  above  it  will  be  recollected  that  the  ulceration  and  abscess 
extended  from  the  fauces  to  the  middle  ear,  the  entire  Eustachian  tube 
having  disappeared  in  the  ulcerative  process. 

Frequently,  the  otitis  escapes  detection,  its  symptoms  being  masked  or 
obscured  by  the  general  disease,  until  the  membrana  tympani  is  perforated 
and  otorrhcea  begins  ;  but  by  careful  examination  the  nature  of  the  complica- 
tion can  usually  be  ascertained  before  the  ear  is  injured  to  this  extent,  for  a 
patient  too  young  to  speak  will  often  press  with  the  fingers  against  the  painful 
ear  or  lie  with  the  ear  pressed  upon  the  pillow,  evidently  having  an  increase 
of  suffering  if  placed  in  any  other  position.  One  old  enough  to  speak  and  in 
proper  mental  condition  makes  known  the  earache  as  soon  as  it  occurs.  In 
most  instances  the  scarlet  fever  has  continued  some  days  when  the  otitis 
begins.  The  otitis  may  begin  insidiously,  but  in  other  instances  it  begins 
with  a  chill  and  a  rise  of  temperature  to  104°  or  105°.  The  pain  referred  to 
the  ear  may  be  paroxysmal,  and  it  is  usually  worse  at  night.  It  may  radiate 
from  the  ear,  following  the  branches  of  the  fifth  nerve.  The  patient  expe- 
riences pain  on  pressure  upon  and  around  the  tragus,  and  when  the  inflamma- 
tion extends  to  the  mastoid  cells,  pressure  upon  the  mastoid  process  is  also 
painful.  The  otitis  may  be  unilateral,  but  in  a  large  proportion  of  cases  it 
is  bilateral. 

The  mucous  membrane  of  the  tympanum,  red  and  swollen  from  inflamma- 
tion, secretes  muco-pus  abundantly,  and  this,  pent  up  in  the  cavity,  must 
obtain  an  exit  before  relief  occurs.  It  is  well  if  the  secretion  escape,  though, 
with  difficulty,  down  the  Eustachian  tube.  The  destructive  action  of  the  pus 
upon  the  delicate  structure  of  the  ear  is  often  such  that  within  a  few  days 
irreparable  harm  is  done  and  more  or  less  deafness  results.  Relief  can  occur, 
if  the  Eustachian  tube  remain  closed,  only  by  perforation  of  the  membrane 
and  the  discharge  of  the  secretions  into  the  external  meatus.  When  this 
takes  place  the  inflammation  in  the  most  favorable  cases  gradually  abates,  the 
aperture  in  the  drum  closes,  and  the  integrity  of  the  auditory  apparatus  is 
preserved.  In  severe  cases  the  mastoid  cells  participating  in  the  inflammation 
become  filled  with  muco-pus  and  tender  to  the  touch,  and  often  the  collateral 
oedema  causes  tumefaction  and  narrowing  of  the  external  ear,  which  subside 
with  the  discharge  of  pus  from  the  tympanum. 

Unfortunately,  there  is  for  many  a  more  melancholy  history — a  more 
destructive  inflammation,  involving  permanent  impairment  or  total  loss  of 
hearing.  This  most  frequently  takes  place  in  strumous  or  feeble  children. 
All  grades  of  inflammation  and  destructive  action  occur  in  different  cases. 
The  perforation  in  the  drum-membrane  may  be  large  or  the  membrane  may 
be  completely  destroyed,  and  the  detached  ossicles  escape  one  by  one  into 
the  external  meatus,  and  in  a  few  instances,  fortunately  rare,  this  occurs  in 
both  ears,  producing  complete  and  permanent  deafness.  In  my  own  practice 
this  has  never  occurred,  but  I  have  met  one  or  two  adults  who  were  totally 
deaf  from  this  cause. 

The  mucous  membrane  which  lines  the  bony  wall  of  the  middle  ear  has 
the  function  of  the  periosteum,  and  therefore  when  inflamed  and  subjected  to 
pressure  is  liable  to  ulcerate.  As  in  other  parts  of  the  skeleton  under  similar 
conditions,  superficial  caries  or  necrosis  of  the  underlying  bone  is  liable  to  occur. 
The  carious  or  necrotic  process  may  extend  to  the  mastoid  cells.  An  ofi'ensive 
otorrhcea,  continuing  for  months  or  years,  indicates  the  persistence  of  this 
pathological  state  of  the  tympanum,  which  is  rendered  so  obstinate  by  the 
presence  of  dead  bone.  A  moment's  survey  of  the  anatomical  relations  of 
the  middle  ear  shows  the  danger  to  which  these  patients  are  liable.     A  thin 


272  CONSTITUTIONAL  DISEASES. 

bony  septum,  perforated  -with  blood-vessels,  and  sometimes  containing  con- 
genital apertures,  separates  the  tympanum  from  the  cranial  cavity  above. 
Posteriorly  lie  the  mastoid  cells,  connected  with  the  tympanum  by  one  large 
and  several  small  apertures.  Anteriorly  is  the  commencement  of  the  Eus- 
tachian tube,  and  in  close  proximity  to  the  tympanum  lies  the  carotid  canal, 
and  at  one  point  also  the  superior  petrosal  sinus.  Virchow  has  shown  how 
inflammation  extending  from  the  ear  in  otitis  media  sometimes  produces  such 
compression  of  the  veins  or  sinuses  by  the  swelling  from  the  infiltration  and 
exudation  that  the  circulation  is  arrested,  and  the  fibrin  contained  in  the 
blood  of  these  vessels  is  precipitated,  forming  thrombi,  with  the  most  disas- 
trous efi'ect  upon  the  individual.  Pus  may  also  burrow  in  the  interstices  of 
the  bone,  causing  great  pain,  or  the  pent-up  secretions,  having  no  outlet  for 
escape,  may  in  time  undergo  caseous  degeneration,  producing  the  conditions 
in  which  tuberculosis  so  often  originates. 

Death  not  infrequently  occurs  in  chronic  otitis  media  in  another  way. 
The  otorrhoea,  after  months  or  years,  suddenly  ceases,  the  child  complains  of 
constant  severe  headache  and  is  feverish,  and  the  case  ends  in  coma,  preceded 
perhaps  by  convulsions.  Meningitis  has  occurred,  produced  by  extension  of 
the  inflammation  through  the  thin  bony  septum  which  divides  the  tympanum 
from  the  cranial  cavity,  and  at  the  autopsy  hypersemia  of  the  meninges,  fibrin, 
pus,  perhaps  softening  of  the  brain  and  an  abscess,  are  found  in  the  portion 
of  the  encephalon  adjacent  to  the  tympanum.  Therefore,  otitis  media,  though 
it  often  ends  favorably,  is  in  many  patients  an  obstinate,  dangerous,  and  even 
fatal  sequel  of  scarlet  fever. 

The  complication  known  as  scarlatinous  rheumatism  is  regarded  by  some 
as  a  synovitis,  but  its  symptoms,  especially  its  shifting  from  joint  to  joint, 
seem  to  ally  it  to  the  rheumatic  affections.  In  some  epidemics  it  is  common. 
It  usually  begins  toward  the  close  of  the  first  week  or  in  the  second  week, 
and  its  common  seat  is  in  the  ankle,  phalangeal,  and  wrist  joints.  It  is 
attended  by  very  little  swelling  in  most  patients,  though  the  joints  are  tender 
and  painful  on  pressure.  It  does  not  seem  to  retard  convalescence  materially, 
but  it  produces  suff"ering  and  involves  danger  as  regards  the  heart.  It  sub- 
sides in  a  few  days  with  the  ordinary  treatment  of  acute  rheumatism,  and 
even  without  special  treatment,  the  chief  danger  being  that,  as  in  idiopathic 
rheumatism,  endocarditis  may  arise,  with  permanent  crippling  of  the  valves. 
The  following  was  a  case  of  valvular  disease  having  this  origin.  It  occurred 
in  my  practice. 

Case  4. — Freddy  M ,  aged  four  years,  sickened  with  scarlet  fever  March  6, 

1879.  The  usual  vomiting  occurred  on  the  first  day,  and  the  temperature  was  104°. 
The  case  progressed  favorably  till  March  14th,  when  he  complained  of  pain  in  both 
wrists,  both  ankles,  and  both  knees.  On  March  17th  the  general  condition  was  good, 
the  urine  contained  no  albumen  and  apparently  few  urates,  but  he  still  had  pain  in 
the  joints  of  the  upper  and  lower  extremities  and  in  the  back ;  pulse  140,  tempera- 
ture 103°  ;  breathes  with  a  slight  moan;  urates  in  the  urine,  but  no  albumen.  A 
distinct  mitral  regurgitant  murmur  is  now  heard  for  the  first  time.  Under  the  use 
of  salicylate  of  sodium  the  pain  in  the  joints  soon  ceased,  but  the  mitral  murmur 
is  permanent. 

The  following  prescription  is  for  a  child  of  five  years : 

B.  01.  gaultherias,  f^j  ; 

Sodii  salicylat.,  ,^iij  ; 

Syrupi,  f^ij  ; 

Aquae,  fo^^- — Misce. 

Sig.  :  Give  one  teaspoonful  every  four  hours  in  water. 

Of  the  serous  inflammations  complicating  scarlet  fever,  pericarditis  has 
been,  according  to  Piilliet  and  Barthez,  most  frequently  observed.     In  this 


SCARLET  FEVER.  273 

country  it  is  probably  more  common  than  is  usually  supposed,  but  it  is  less 
frequently  detected  than  pleuritis,  the  symptoms  of  which  are  more  con- 
spicuous. 

The  following  case,  which  occurred  in  my  practice,  was  an  example  of  this 
complication  : 

Case  5. — C ,  girl,  aged  five  years  and  ten  months,  sickened  with  severe 

scarlet  fever  on  April  4th.  Was  delirious ;  pulse  158  ;  had  vomiting  and  consti- 
pation. April  10th,  pulse  varies  from  124  to  153,  no  delirium  ;  a  considerable 
quantity  of  urates  in  the  urine.  April  11th,  has  to-day,  for  the  first  time,  severe 
pain  in  the  epigastrium,  with  tenderness  and  moderate  distention.  Otherwise 
symptoms  favorable,  but  severe ;  pulse  140 ;  respiration  moderately  accelerated 
and  vesicular  in  every  part  of  the  chest.  From  this  date  the  symptoms  continued 
about  the  same  till  April  14th,  when  the  dyspnoea  became  more  marked  and  the 
action  of  the  heart  rapid  and  tumultuous.  The  epigastric  pain,  distention,  and 
tenderness  continued :  the  percussion  sound  was  dull  over  the  lower  part  of  the 
chest;  the  dyspnoea  became  rapidly  worse,  although  the  pulse  had  considerable 
volume ;  and  at  5  p.  m.  death  occurred.  At  the  autopsy  about  one  ounce  of  turbid 
serum,  with  a  soft  deposit  of  fibrin,  was  found  in  the  pericardium.  Each  pleural 
cavitv  contained  from  sis  to  eight  ounces  of  transparent  serum,  and  both  lungs 
were"  readily  inflated,  except  a  little  of  the  posterior  portions  of  both  lower  lobes : 
no  fibrinous  exudation  over  the  lungs.  The  liver  extended  four  inches  below  the 
margin  of  the  ribs,  and  upon  its  convex  surface  in  the  epigastrium,  corresponding 
with" the  seat  of  the  pain,  was  a  rough  patch  of  fibrin  about  one  and  a  half  inches 
in  diameter.  The  bronchial  mucous  membrane  was  moderately  injected,  as  was 
also  that  of  the  colon,  and  the  kidneys  appeared  hypereemic. 

Among  the  serous  inflammations  which  complicate  or  follow  scarlet  fever, 
pleuritis  is  one  of  the  most  important.  It  usually  begins  in  the  desquamative 
stage,  and  is  frecjuently  suppurative,  on  account  of  the  feeble  state  of. the 
patient  when  it  commences.  It  has,  in  my  practice,  been  tedious,  as  all 
empyemas  are,  and  it  does  not  differ  in  its  clinical  history  from  the  idio- 
pathic disease.  I  have  met  cases  of  scarlatinous  empyema  in  which,  from 
opposition  of  the  family,  or  for  other  reasons,  thoracentesis  was  not  per- 
formed and  death  occurred  ;  others  in  which  this  operation  effected  a  cure  ; 
and  one,  at  least,  in  which  the  patient  recovered  by  escape  of  pus  through 
a  bronchial  tube  and  its  expectoration.  The  pleuritis  is  seldom  latent,  or  so 
masked  by  the  symptoms  of  the  general  disease  that  it  is  liable  to  be  over- 
looked. On  the  other  hand,  the  cough,  embarrassment  of  respiration,  and 
pain  referred  to  the  affected  side  render  diagnosis  easy. 

Dilatation  of  the  heart  is  common  in  grave  cases  of  scarlet  fever,  such 
cases  as  are  properly  termed  malignant.  It  is  indicated  by  a  feeble  and  quick 
pulse.  Acute  infectious  maladies,  especially  those  of  a  malignant  type  and 
accompanied  by  a  marked  rise  in  temperature,  are  very  liable  to  cause  paren- 
chymatous degenerations  in  organs,  prominent  among  which  is  granulo-fatty 
degeneration  of  the  muscular  fibres  of  the  heart.  This  weakens  very  much 
the  contractile  power  of  the  heart.  But  early  in  malignant  cases,  probably 
before  the  muscular  fibres  are  damaged,  the  contractile  power  of  the  heart  is 
feeble  from  impaired  innervation,  the  result  of  the  general  weakness.  Hence 
this  organ,  when  weakened  by  structural  change  and  insufficiently  stimulated 
through  diminished  innervation,  may  not  fully  empty  itself  during  the  systole, 
and  consequently  it  becomes  dilated.  Dilatation  of  the  heart  and  imperfect 
contraction  of  its  auricular  and  ventricular  walls  facilitate  the  formation 
of  clots  in  the  cavities  of  the  heart ;  and  this  appears  to  be  the  immediate 
cause  of  death  in  not  a  few  instances.  An  ante-mortem  clot  occurring  in  any 
of  the  cavities  of  the  heart  necessarily  seriously  obstructs  the  circulation, 
unless  it  be  of  small  size.  Hence  the  dyspnoea,  which  may  occur  suddenly, 
and  the  change  of  pulse  to  one  of  marked  feebleness  and  frequency.     Large, 

18 


274  CONSTITUTIONAL  DISEASES. 

firm  white  clots  are  most  frequently  found  in  the  right  cavities.  They  inter- 
lace with  the  chordge  tendineaj,  lie  even  within  the  auriculo-ventricular  open- 
ing, and  send  prolongations  into  the  pulmonary  artery  and  the  cavae.  Asso- 
ciated with  the  white  clots  are  dark,  soft  clots  and  fluid  blood.  The  left 
cavities  may  be  contracted  and  empty,  or  they  may  contain  dark,  soft  clots 
or  white  ante-mortem  clots.  Clots  in  the  left  ventricle  are  sometimes  pro- 
longed into  the  aorta  as  far  as  the  brachiocephalic  branches,  while  those  in 
the  left  auricle  may  extend  to  the  pulmonary  veins.  If  dilatation  of  the 
heart  be  so  great  that  clots  form  in  its  cavities,  speedy  death  is  probable. 
Sometimes  a  patient  passes  through  scarlet  fever  and  appears  in  a  fair  way 
to  recover,  when  he  succumbs  to  some  exhausting  sequel  distinct  from  the 
heart,  and  at  the  autopsy  the  heart  is  found  dilated  and  containing  whitish 
clots,  which  are  probably  ante-mortem,  and  which  hastened  death  by  obstruct- 
ing the  circulation.  Under  such  circumstances  this  state  of  the  heart  is 
attributable  in  great  measure  to  the  complication  which  has  weakened  its 
contractile  power. 

The  following  was  a  case  in  point ;  it  occurred  in  the  New  York  Found- 
ling Asylum : 

Case  6. — R.  A ,  aged  three  years,  had  scarlet  fever,  beginning  March  23, 

1882.  The  symptoms  were  favorable  at  first,  but  serious  complications  and  sequelae 
occurred,  which  were  fatal.  The  record  of  April  18th  reads:  "Appears  well  nour- 
ished, but  is  angemic  ;  has  otorrhcea  ;  no  oedema  ;  skin  desquamating  ;  dulness  on 
percussion  over  upper  third  of  right  side  of  chest,  anteriorly  and  posteriorly  ;  mucous 
rales  and  rude  breathing  over  same  area  ;  fine  rales  posteriorly  over  lower  part  of 
left  side  of  chest ;  pulse  160,  respiration  68,  temp.  101f°."  April  20th,  is  feeble 
and  takes  nutriment  with  difficulty ;  tongue  thickly  coated :  pulse  160,  respiration 
68,  temp.  101|-°.  April  26th,  condition  about  the  same  as  at  last  record,  but  he  is 
evidently  weaker ;  the  lips  are  ulcerated  and  fauces  still  swollen.  May  2d,  cannot 
speak  distinctly ;  a  brownish,  foul-smelling  secretion  lodges  on  the  spoon  used  in 
depressing  the  tongue  ;  left  side  of  face  swollen.  On  the  following  night  eight  con- 
vulsions occurred,  attended  by  orthopnoea  and  mucous  r§.les  in  the  chest  from  pul- 
monary oedema.     Diarrhoea  supervened  and  the  patient  died  about  midnight. 

Autopsy. — Body  moderately  wasted  and  very  white  :  several  dark-blue  spots  on 
scalp  and  face  from  hemorrhages  underneath.  A  careful  examination  showed  the 
presence  of  broncho-pneumonia  in  each  lung,  with  considerable  infiltration  of  the 
walls  of  the  bronchi  and  cylindrical  dilatation  of  many  of  them ;  cavities  of  the  heart 
dilated,  so  that  this  organ  appears  much  enlarged,  and  its  shape  approaches  the  glob- 
ular ;  its  apex  is  rounded  or  obtuse  ;  transverse  diameter  of  the  right  ventricle,  when 
its  walls  were  open  and  drawn  apart,  was  three  and  a  fourth  inches  ;  that  of  the  left 
ventricle  three  and  a  quarter  inches.  Similar  measurements  of  the  heart  of  another 
child  of  about  the  same  age,  believed  to  be  normal,  were  about  one  inch  less  in  each 
direction.  All  the  cavities  contain  white  firm  clots  along  with  soft  dark  clots. 
Lesions  observed  in  other  organs  were  carefully  noted,  some  of  which  were  serious  ; 
but  the  immediate  cause  of  death  appeared  to  be  imperfect  contraction  of  the  heart 
and  the  formation  of  clots  in  its  cavities. 

The  nephritis  which  gives  rise  to  symptoms,  and  therefore  interests  the 
practitioner,  commonly  begins  in  the  declining  period  of  scarlet  fever  or  dur- 
ing the  desquamative  stage,  and  is  in  many  instances  plainly  attributable  to 
exposure  to  cold  or  to  currents  of  air.  It  originates  either  during  this  period, 
or,  if  it  has  previously  existed  as  a  mild  renal  catarrh,  it  now  becomes  aggra- 
vated. Dropsy,  which  always  attracts  attention,  does  not  occur  till  the  nephritis 
has  continued  for  some  time. 

Why  nephritis,  with  the  subsequent  dropsy,  so  frequently  occurs  after 
scarlet  fever  is  not  fully  understood.  Rilliet  and  Barthez  attribute  it  to  dis- 
turbance of  the  function  of  the  skin.  The  fact  has  long  been  observed  that 
the  kidneys  become  aff'ected  nearly  if  not  quite  as  frequently  after  mild  as 
severe  cases.     Indeed,  the  chief  danger  in  mild  cases,  when  the  patients  are 


SCARLET  FEVER.  275 

but  a  short  time  in  bed  and  are  soon  allowed  to  go  about,  is  from  the  nephritis. 
Chilling  the  surface  and  checking  cutaneous  transpiration  appear  to  be  the 
immediate  cause  of  this  inflammation  in  a  considerable  proportion  of  cases. 
Therefore,  severe  attacks  of  scarlet  fever  with  abundant  rash  and  desquama- 
tion, which  require  the  patient  to  be  kept  in  bed  the  proper  time  and  in  a 
warm  room  two  or  three  weeks,  appear  to  be  less  frequently  followed  by  this 
renal  disease  than  are  milder  cases  which  are  more  carelessly  treated. 

The  following  is  a  resume  of  Klein's  examinations  in  twenty-three  cases. 

1.  Parenchymatous  Nephritis,  Proliferation  of  Nuclei,  Hyalme  Degeneration  of 
Arterioles. — -The  Glomerulo-nejjhritis  of  Klebs. — Klein  found  increase  of  nuclei 
(probably  epithelial)  in  the  glomeruli,  and  hyaline  degeneration  of  the  intima  of 
minute  arteries,  especially  marked  in  the  afferent  arterioles  of  the  Malpighian 
bodies.  The  intima  of  these  vessels  was  in  places  as  swollen  as  to  resemble  cylin- 
drical or  spindle-shaped  hyaline  masses,  and  cause  narrowing  of  the  lumina  of  the 
vessels  in  which  this  degeneration  occurred.  Klein  observed  in  some  specimens  so 
great  hyaline  degeneration  of  the  capillaries  of  the  Malpighian  bodies  that  circula- 
tion through  them  was  obstructed.  In  the  more  advanced  or  protracted  cases  this 
hyaline  substance  in  the  glomeruli  began  to  assume  a  fibrous  appearance.  Bowman's 
capsule  was  considerably  thickened.  This  hyaline  degeneration  of  the  Malpighian 
bodies  Klein  discovered  in  the  earliest  cases  which  fell  under  his  observation. 

Also  in  the  earliest  cases  the  multiplication  or  germination  of  the  nuclei  of  the 
muscular  coat  of  the  arterioles  was  observed,  with  a  corresponding  increase  in  the 
thickness  of  the  walls  of  these  vessels.  This  change  in  the  muscular  element  was 
found  in  the  arterioles  in  different  parts  of  the  kidney,  but  it  was  most  conspicuous 
in  these  vessels  at  their  point  of  entrance  into  the  Malpighian  bodies  ;  and  it  was 
distinctly  noticed  in  other  arterioles,  both  in  the  cortex  and  in  the  base  of  the 
pyramids. 

In  the  glandular  portion  of  the  kidneys  other  anatomical  alterations  were  ob- 
served, indicating  parenchymatous  nephritis.  There  were  swelling  of  the  epithelial 
lining  of  the  convoluted  tubes  ;  multiplication  of  the  nuclei  of  the  epithelial  cells, 
especially  in  ascending  tubules,  which  lay  close  to  the  afferent  arterioles  of  Malpig- 
hian corpuscles;  granular  matter,  and  even  blood,  in  the  cavity  of  Bowman's  cap- 
sule and  the  convoluted  tubes ;  cloudy  swelling  and  granular  disintegration  of  epi- 
thelium in  some  parts  of  the  convoluted  tubes ;  detachment  of  epithelium  from  the 
membrane  of  larger  ducts  of  the  pyramids  in  some  cases.  These  parenchymatous 
changes  are  already  known  to  the  profession  through  the  observations  and  writings 
of  Dickinson,  Fenwick,  Johnson,  Simon,  and  others. 

Klein,  in  commenting  on  the  hyaline  degeneration  which  he  observed,  states 
that  Neelsen  found  the  walls  of  the  capillaries  of  the  pia  mater  thickened,  highly 
refractive,  and  of  a  lardaceous  appearance  in  certain  acute  infectious  maladies,  as 
variola,  typhoid  fever,  measles,  and  in  one  case  scarlet  fever.^  Usually,  only  a  small 
portion  of  the  capillaries  were  thus  affected,  most  frequently  at  the  point  of  division 
into  branchlets.  In  a  few  instances  Neelsen  noticed  degeneration  of  arterioles 
extending  a  considerable  distance,  with  fusion  of  the  intima,  media,  and  adventitia, 
and  chemical  examination  showed  that  the  substance  produced  by  this  degeneration 
had  similar  properties  to  elastic  tissue.  Although  the  examinations  by  Neelsen 
relate  to  the  pia  mater,  two  of  his  observations  are  especially  interesting :  first, 
that  the  hyaline  change  affects  chiefly  vessels  near  their  point  of  branching ;  and, 
secondly,  that  the  hyaline  substance  is  of  the  nature  of  elastic  tissue,  for  in  the 
kidney  in  scarlatinous  nephritis  the  arterioles  undergo  the  change  in  question 
chiefly  near  their  point  of  branching  into  the  capillaries  of  the  glomerulus  :  and 
the  intima  being  the  part  which  undergoes  the  hyaline  change,  it  is  probable,  in 
the  opinion  of  Klein,  that  the  same  substance  is  produced  by  the  degeneration  in 
walls  of  the  vessels  of  the  kidney  which  Neelsen  observed  in  the  pia  mater,  and 
therefore  that  it  is  of  the  nature  of  elastic  tissue. 

This  hyaline  degeneration  of  the  arterioles  is  also  very  marked  in  the  spleen  in 
scarlet  fever ;  and  in  studying  the  minute  anatomy  of  the  intestines  and  spleen  in 
typhoid  fever  Klein  has  found  the  same  degeneration  of  the  intima  of  the  minute 
vessels.  He  believes  that  this  hyaline  change  and  the  proliferation  of  muscle-nuclei 
which  thus  occur  at  an  early  period  in  scarlet  fever  in  the  renal  vessels  when  the 

^  Archiv  der  Heilkunde,  1876. 


276  CONSTITUTIONAL  DISEASES. 

kidneys  become  affected  are  due  to  an  irritating  cause  acting  similarly  to  that  in 
typhoid  fever. 

Klein  calls  attention  to  the  interesting  examinations  of  the  scarlatinous  kidney 
made  by  Klebs,  who  attributed  the  diminished  urination  and  the  ureemic  poisoning 
in  certain  cases  in  which  the  kidneys  do  not  exhibit  any  marked  change  to  the 
naked  eye  to  what  he  designates  glomerulo-nephritis.  Klebs  says:  "In  the  post- 
mortem examination  the  kidneys  are  found  slightly  or  not  at  all  enlarged,  firm, 
....  the  parenchyma  very  hypergemic.  Only  the  glomeruli  appear,  on  close 
inspection,  pale  like  small  white  dots.  The  urinary  tubes  are  often  not  changed  at 
all.  Occasionally  the  convoluted  tubes  are  slightly  cloudy.  The  microscopic 
examination  shows  that  there  are  neither  interstitial  changes  nor  proliferation 
of  epithelium,  the  so-called  renal  catarrh  generally  supposed  to  be  present  in  these 
conditions  on  account  of  the  absence  of  other  perceptible  derangements ;  and  there 
seems,  therefore,  leaving  out  the  glomeruli,  the  congestion  of  the  kidneys  alone  to 
remain  to  account  for  the  symptoms  during  life."  But  that  mere  congestion  is 
insufficient  to  produce  the  symptoms  appears  from  the  fact  that  it  does  not  cause 
them  under  other  circumstances.  Klebs  finds,  "on  microscopic  examination  of  the 
glomerulus,  the  whole  space  of  the  capsule  filled  with  small  somewhat  angular 
nuclei,  imbedded  in  a  finely  granular  mass.  The  vessels  of  the  glomerulus  are 
almost  completely  covered  by  nuclear  masses." 

Klein,  commenting  on  these  examinations  by  Klebs,  states  that  in  all  early 
cases  which  he  examined  he  observed  great  abundance  of  nuclei  of  the  glomeruli, 
but  a  condition  like  that  described  and  figured  by  Klebs  ^  he  has  seen  in  only  a  few 
glomeruli ;  for  a  general  state  of  these  bodies  as  described  by  this  observer,  and 
such  an  excessive  proliferation  of  the  nuclei  that  the  blood-vessels  are  completely 
compressed,  was  not  seen  in  one  of  the  twenty-three  cases.  Klein  therefore  ques- 
tions whether  the  diminished  urination  and  retention  of  the  urea  in  scarlet  fever, 
when  the  kidneys  do  not  exhibit  any  conspicuous  catarrhal  or  other  change,  is  due, 
unless  in  exceptional  instances,  to  compression  of  the  vessels  of  the  glomeruli  by 
nuclear  germination,  but  believes,  rather,  that  the  obstructed  circulation,  and  con- 
sequent diminished  urinary  excretion,  are  largely  due  to  the  changed  state  of  the 
arterioles.  Klein  adds  that  perhaps  undue  contraction  of  the  arterioles,  through 
stimulation  by  the  blood-irritant,  may  also  be  a  factor  in  causing  arrest  of  circula- 
tion in  the  Malpighian  corpuscles.  As  regards  cases  that  perished  early,  he  found 
the  parenchymatous  change  slight,  so  that  a  careful  examination  was  required  in 
order  to  detect  cloudy  swelling  and  granular  degeneration. 

2.  Interstitial  Nephritis. — A  second  set  of  changes  Klein  observed  in  cases  that 
died  about  the  ninth  or  tenth  day.  In  such  cases  he  found  changes  due  to  inter- 
stitial, in  addition  to  those  produced  by  parenchymatous,  nephritis.  Round  cells, 
lymphoid  cells,  or  whatever  else  they  should  be  called,  were  seen  in  the  connective 
tissue  of  the  kidneys.  In  the  kidneys  of  those  that  died  at  the  end  of  the  first  Aveek 
after  the  commencement  of  nephritis,  infiltration  with  round  cells  was  observed  in 
the  connective  tissue  around  the  large  vascular  trunks.  At  a  later  stage  this  infil- 
tration had  extended  into  the  bases  of  the  pyramids  and  into  the  cortex.  The 
gradual  increase  in  extent  and  intensity  of  this  infiltration  was  so  decided  in  the 
cases  which  Klein  observed  that  he  has  no  hesitation  in  concluding  that  when 
interstitial  nephritis  occurs  it  begins  about  the  end  of  the  first  week,  in  the  man- 
ner already  stated — to  wit,  as  a  slight  infiltration  of  the  tissues  around  the  large 
vascular  trunks,  and  gradually  extends,  so  that  portions  of  the  cortex,  and  rarely 
portions  of  the  base  of  the  pyramids,  are  changed  into  firm,  pale,  round-cell  tissue 
in  which  the  original  tubes  of  the  cortex  become  lost. 

The  infiltration  of  the  cortex  with  round  cells,  beginning  at  the  roots  of  the 
interlobular  vessels,  spreads  rapidly  toward  the  capsule  of  the  kidney,  and  laterally 

among  the  convoluted  tubes  around  the  Malpighian  bodies In  the  course 

of  this  process  considerable  parts  of  the  peripheral  cortex,  occasionally  of  a  cunei- 
form shape,  with  the  base  nearest  the  capsule  of  the  kidney,  become  changed  into 
whitish,  firm,  bloodless,  cellular  masses,  in  which  Malpighian  corpuscles  and  uri- 
nary tubes  are  only  imperfectly  recognized,  being  more  or  less  degenerated.  In 
some  cases  attended  by  this  infiltration  of  the  cortex  Klein  observed  a  more  or  less 
dense  reticulation  of  fibres,  especially  around  the  interlobular  arteries,  containing 
in  its  meshes  lymph-cells,  chiefl.y  uninuclear. 

^  Handbuch  der  Pathol. ,  p.  646,  fig.  72. 


SCARLET  FEVER.  277 

In  a  child  of  five  years  that  died  after  a  sickness  of  thirteen  days  Klein  found 
evidence  of  intense  interstitial  inflammation,  and  also  emboli,  consisting  of  fibrin 
with  a  few  cells,  in  the  ai'teries,  both  in  those  of  large  size  and  in  the  arterioles, 
chiefly  Avhere  they  enter  the  Malpighian  corpuscles.  He  states  that  in  the  speci- 
mens which  he  examined  the  more  intense  the  degree  of  interstitial  change,  the 
greater  was  the  enlargement  of  the  kidneys,  and  the  more  distinct  also  were  the 
evidences  of  parenchymatous  nephritis  in  the  urinary  tubes,  which  either  contained 
casts  or  were  in  process  of  destruction.  By  being  crowded  with  inflammatory  prod- 
ucts, especially  cells,  the  Malpighian  corpuscles  were  obliterated,  undergoing  fibrous 
degeneration.  A  very  curious  fact  observed  was  the  deposit  of  lime  in  the  urinary 
tubes,  first  of  the  cortex,  and  then  also  of  the  pyramids,  at  an  early  stage  of  scarlet 
fever,  when  the  kidneys  otherwise  showed  only  slight  change.  Several  observers, 
as  Biermer,  Coats,  and  Wagner,  have  each  described  a  case  of  scarlet  fever  with 
interstitial  nephritis,  which  they  consider  unusual ;  but  Klein  has  apparently  demon- 
strated, as  we  have  seen,  by  a  large  number  of  microscopic  examinations,  that  this 
form  of  nephritis  is  common  after  the  ninth  or  tenth  day. 

Nephritis,  in  proportion  to  its  extent  and  gravity,  is  accompanied  by  languor, 
febrile  movement,  thirst,  loss  of  appetite  and  strength.  At  first  the  patient  expe- 
riences but  slight  pain  in  the  head  or  elsewhere,  and  the  quantity  of  urine  is  not 
notably  diminished :  but  as  the  disease  continues  urination  becomes  less  frequent 
and  the  urine  more  scanty.  Albuminuria  occurs,  while  the  urea  is  only  partially 
excreted,  and  therefore  it  accumulates  in  the  blood.  If  the  nephritis  be  so  severe 
or  protracted  that  this  principle  accumulates  to  a  certain  extent,  grave  symptoms 
occur,  as  headache,  vomiting,  apathy  or  restlessness,  and,  more  dangerous  than  all, 
eclampsia,  which  is  not  unusual  in  these  cases.  Microscopic  examination  of  the 
urine  shows  the  presence  in  this  liquid  of  blood-corpuscles,  granular  epithelial 
cells,  and  hyaline  or  granular  casts  or  both.  The  specific  gravity  of  the  urine  is 
diminished.  But  a  large  quantity  of  albumen  in  the  urine  may  render  the  specific 
gravity  as  high  or  higher  than  in  health. 

The  altered  state  of  the  blood  soon  gives  rise  to  transudation  of  serum,  first 
observed  in  most  cases  as  an  anasarca  occurring  in  the  feet  and  ankles.  The 
oedema,  if  not  checked  by  treatment  or  through  mildness  of  the  disease,  extends 
over  the  limbs,  scrotum,  and  sometimes  upon  the  trunk.  It  is  well  if  the  dropsy 
remain  limited  to  the  subcutaneous  connective  tissue,  but,  unfortunately,  it  is  apt 
to  occur,  if  the  nephritis  continue,  in  and  around  the  internal  organs,  producing, 
mentioned  in  the  order  of  frequency,  pulmonary  oedema,  effusion  into  the  pleural 
and  peritoneal  cavities,  the  pericardium,  the  encephalon,  and  lastly  into  the  con- 
nective tissue  of  the  larynx,  causing  that  A^ery  fatal  complication,  oedema  of  the 
glottis.  Although  this  is  the  common  order  in  which  dropsies  occur,  exceptions 
are  not  infrequent.  Even  the  anasarca  may  not  be  the  first  to  appear,  although  in 
the  vast  majority  of  cases  it  has  the  precedence.  Thus,  Rilliet  relates  the  case  of  a 
boy  of  five  years  who  twenty  days  after  the  occurrence  of  scarlet  fever,  and  six 
hours  after  the  appearance  of  bloody  and  albuminous  urine,  had  double  hydro- 
thorax,  rapidly  developed.  As  long  as  the  hydrothorax  continued  no  anasarca  was 
observed,  but  as  it  declined  anasarca  appeared.  Legendre  cites  a  case  in  which 
oedema  of  the  lungs  occurred  without  anasarca  or  other  dropsy.  Occasionally,  the 
anasarca  and  internal  dropsies  take  place  nearly  simultaneously.  The  nephritis 
and  consequent  serous  effusions  usually  appear  within  three  weeks  after  scarlet 
fever  ends,  but  cases  occur  in  which  the  effusions  are  first  observed  as  late  as  the 
fourth  and  fifth  weeks.  The  patient  may  be  considered  to  possess  immunity  from 
this  sequel  if  he  have  reached  the  close  of  the  fifth  week  after  the  abatement  of 
scarlet  fever  without  its  occurrence. 

The  dropsy  is  usually  acute,  but  it  may  assume  the  chronic  forDi,  since  the 
nephritis  which  causes  it,  happily  curable  in  most  instances,  may,  if  neglected, 
become  chronic.  Whether  the  dropsy  in  itself  involve  danger  depends  in  great 
part  on  its  location.  Anasarca  and  ascites  may  exist  a  long  time  with  little  sufier- 
ing  or  danger,  but  a  small  amount  of  serum  in  certain  other  localities  causes 
alarming  symptoms  and  speedy  death.  Qlldema  of  the  lungs,  hydro-pericardium, 
oedema  of  the  glottis,  and  intracranial  effusions  are  always  dangerous,  and  the  last 
two  are  sometimes  fatal  within  twentj^-four  to  forty-eight  hours.  Qildema  of  the 
lungs  has  been  fatal  within  twelve  hours'  from  the  appearance  of  the  first  symp- 
toms of  obstructed  respiration. 


278  CONSTITUTIONAL  DISEASES. 

Cerebral  symptoms  occurring  during  scarlatinous  nephritis  are  probably 
sometimes  due  to  the  irritating  effect  of  the  retained  urea  on  the  nervous 
centre.  In  other  cases  the  cause  appears  to  be  a  cerebral  cedema  or  compres- 
sion of  the  brain  by  effusion  of  serum  within  the  ventricles  and  upon  the 
surface  of  the  brain.  Headache,  dull  or  severe,  dilatation  of  the  pupils  or 
their  oscillation  in  a  uniform  light,  vomiting  with  little  apparent  nausea,  are 
common  symptoms  of  scarlatinous  nephritis  when  it  has  continued  a  few  days, 
and  the  excretion  of  urea  is  so  diminished  that  this  substance  begins  to  exert 
its  poisonous  effect  on  the  system.  Such  symptoms  are  frequently  followed 
by  somnolence  threatening  coma  or  by  eclampsia,  unless  the  patients  are 
promptly  and  properly  treated.  In  some  patients  that  die  of  scarlatinous 
nephritis,  death  occurring  in  convulsions  or  coma,  no  appreciable  lesions  are 
observed  within  the  cranium,  unless  more  or  less  congestion,  the  fatal  ending 
being  attributable  to  the  uraemia.  In  other  instances  we  find  an  effusion  of 
serum  within  the  ventricles  or  upon  the  surface  of  the  brain.  Although  the 
symptoms  in  scarlatinous  nephritis  and  uremia  may  appear  very  unfavorable, 
the  prognosis  is  usually  good  under  prompt  and  appropriate  treatment.  Thus 
severe  convulsions  and  a  degree  of  somnolence  that  bordered  on  coma  may 
abate,  and  convalescence  be  fully  established  within  a  few  days.  Eilliet  and 
Barthez  announce  ten  recoveries  in  thirteen  patients  affected  with  convulsions 
due  to  this  renal  affection. 

Anatomical  Characters. — Scarlet  fever  being,  as  we  have  seen,  a  con- 
stitutional febrile  disease  of  an  ataxic  nature,  and  accompanied  by  certain 
inflammations,  necessarily  affects  the  composition  of  the  blood ;  but  since  this 
disease  varies  so  greatly  in  type  or  severity,  the  state  and  appearance  of  this 
liquid  also  vary.  At  the  autopsies  of  the  more  malignant  cases  we  find  the 
blood  dark  and  fluid,  with  small,  soft,  and  dark  clots  in  the  heart  and  large 
vessels.  In  other  cases  the  clots  are  large,  firm,  and  solid,  as  described  in  a 
preceding  page.  In  malignant  cases  that  end  fatally  Eilliet  and  Barthez 
state  that  both  the  large  and  small  vessels  of  the  cerebral  meninges  and  the 
brain  are  found  hyper^emic,  but  in  a  variable  degree.  In  those  who  die  in 
coma,  preceded  by  delirium  or  convulsions,  during  the  eruptive  stage  the 
intracranial  congestion  is  usually  marked,  with  pei'haps  some  transudation  of 
serum,  but  without  inflammatory  lesions.  The  fibrin  in  scarlet  fever  remains 
in  about  normal  proportion,  except  as  it  is  increased  by  inflammatory  com- 
plications. Andral  found  an  increase  in  the  proportion  of  blood-corpuscles 
from  127  to  136  parts  in  1000. 

The  respiratory  apparatus,  except  the  Schneiderian  membrane,  is  usually 
normal  when  no  complications  exist.  Samuel  Fenwick '  made  post-mortem 
examination  in  sixteen  cases  of  scarlet  fever,  and  concludes  from  them  that 
inflammation  of  the  mucous  membrane  of  the  stomach  and  intestines  occurs 
like  that  of  the  skin,  followed  by  desquamation  of  the  epithelial  cells,  like 
that  of  the  epidermis.  I  have  had  the  opportunity  of  examining  the  stomach 
and  intestines  of  those  who  died  of  scarlet  fever  in  the  eruptive  stage,  and 
have  not  found  any  unusual  hyperjemia  of  the  gastro-intestinal  surface 
except  when  gastro-intestinal  inflammation,  usually  indicated  by  diarrhoea, 
had  occurred  as  a  complication. 

In  some  cases  the  abdominal  organs  exhibit  changes  which  suggest  a 
resemblance  to  typhoid  fever.  The  spleen  is  enlarged  and  somewhat  soft- 
ened, and  Peyer's  patches  and  the  solitary  glands  are  thickened  and  promi- 
nent, but  less  in  degree  than  typhoid  fever.  The  mesenteric  glands  also  are 
in  a  state  of  hyperplasia.     In  other  patients  these  parts  appear  normal. 

Klein  made  microscopic  examination  of  the  liver  in  eight  cases,  and  states 
that  he  found  granular  opaque  swelling  of  liver-cells,  and  changes  in  the 

^  London  Lancet,  July  23,  1864. 


SCARLET  FEVER.  279 

internal  and  middle  coats  of  certain  arteries  similar  to  those  observed  in  the 
kidneys  which  have  been  described  above.  He  also  found  evidences  of  inter- 
stitial inflammation,  as  an  increase  of  round  cells  and  connective  tissue  in  the 
liver.  He  remarks  also  that  he  observed  hyaline  degeneration  of  the  intima 
of  arteries  in  the  spleen.  Rilliet  and  Barthez  state  that  swelling  and  soften- 
ing of  the  spleen  are  exceptional  in  scarlet  fever,  but  are  sufficiently  common 
to  merit  attention.  In  post-mortem  examinations  which  I  have  witnessed 
nothing  noteworthy  has  appeared  to  the  naked  eye  in  the  state  of  the  liver, 
nor  ordinarily  in  that  of  the  spleen. 

The  efflorescence,  though  one  of  the  anatomical  characters,  has  perhaps 
been  sufficiently  described  in  the  foregoing  pages.  It  begins  over  the  neck, 
chest,  and  groins  as  numerous  reddish  points  not  larger  than  a  pin's  head, 
closely  crowded  together,  but  with  skin  of  normal  color  between.  It  is  esti- 
mated that  the  aggregate  efflorescence  and  aggregate  normal  skin  over  a  given 
area  are  about  equal.  If  the  cutaneous  circulation  be  active  and  the  rise 
of  temperature  considerable,  these  spots  extend  and  coalesce,  producing  an 
efflorescence  like  erythema  or  like  the  hue  of  a  boiled  lobster,  to  which  it 
has  been  likened.  The  efflorescence,  less  upon  the  face  than  upon  the  trunk, 
contrasts  in  this  respect  with  that  of  measles,  in  which  the  rash  is  full  in  the 
face,  often  causing  some  swelling  of  the  features.  It  is  also  less  upon  the 
palmar  and  plantar  surfaces  than  elsewhere.  It  scarcely  causes  any  percep- 
tible elevation  of  the  skin,  but  in  certain  localities,  as  upon  the  backs  of  the 
hands  and  upon  the  forearms,  it  communicates  the  sensation  of  slight  rough- 
ness. The  seat  of  the  efflorescence  is  mainly  in  the  superficial  layers  of  the 
skin,  but  it  is  said  that  it  sometimes  has  occurred  upon  a  cicatrix,  as  that 
from  a  burn.  In  the  robust  and  in  favorable  cases  in  which  the  circulation 
is  active  the  rash  has  a  scarlet  hue,  and  when  the  cutaneous  capillaries  are 
emptied  and  the  skin  rendered  pale  by  pressure  with  the  fingers,  the  circula- 
tion immediately  returns  when  the  pressure  is  removed.  In  malignant  cases 
the  color  is  not  scarlet,  but  dusky  red,  and  so  sluggish  is  the  capillary  circula- 
tion that  the  skin  when  pressed  upon  recovers  the  blood  very  slowly.  In 
grave  cases  also  extravasation  of  blood  in  minute  points  or  transudation  of  its 
coloring  matter  sometimes  occurs  in  portions  of  the  surface  when,  of  course, 
decolorization  is  not  fully  produced  by  pressure.  In  cases  ending  fatally, 
during  the  eruptive  stage  the  efflorescence  may  entirely  disappear  in  the 
cadaver,  or  it  remains  upon  parts  of  the  surface,  especially  depending  por- 
tions. Desquamation  is  attributable  to  the  exaggerated  proliferation  of  the 
epidermis  and  the  loosening  of  its  attachment  by  the  inflammation. 

Diagnosis. — In  the  commencement  of  scarlet  fever,  prior  to  the  eruption, 
no  symptoms  or  appearances  exist  which  enable  us  to  make  a  positive  diag- 
nosis. Positive  statement  in  reference  to  the  nature  of  the  attack  should  be 
deferred,  for  the  credit  of  the  physician.  Still,  if  a  child  with  no  appreciable 
local  disease  sufficient  to  cause  the  symptoms  a  few  days  after  exposure  to 
scarlet  fever,  or  during  an  epidemic  of  this  malady,  be  suddenly  seized  with 
fever,  the  pulse  rising  to  110,  120,  or  more,  and  the  temperature  to  102°. 
103°,  or  105°,  scarlatina  should  be  suspected.  The  diagnosis  is  rendered  more 
certain  at  this  early  stage  if  vomiting  occur,  and  especially  if  the  fauces  be 
red,  for  hyperjemia  of  the  fauces,  due  to  commencing  pharyngitis,  is  one  of 
the  earliest  and  most  constant  of  the  local  manifestations  of  scarlatina. 

When  the  eruption  has  appeared  the  nature  of  the  malady  is  in  most 
instances  apparent.  The  punctate  character  of  the  eruption  before  it 
becomes  confluent,  its  occurrence  within  twenty-four  hours  after  the  fever 
begins  over  almost  the  entire  surface,  its  absence  or  scantiness  upon  the  face, 
and  especially  around  the  mouth,  serve  to  distinguish  it  from  other  diseases. 

Scarlet  fever  and  measles  were  long  considered  identical  by  the  profes- 


280  CONSTITUTIONAL  DISEASES. 

sion,  and,  tliougli  the  ordinary  forms  of  these  maladies  can  be  readily  distin- 
guished from  each  other,  cases  occur  in  which  the  differential  diagnosis  is 
attended  by  some  difficulty.  But  there  are  differences  in  the  symptoms  and 
course  of  the  two  diseases  which  aid  in  discriminating  one  from  the  other. 
Measles  begins  with  marked  catarrhal  symptoms,  as  if  from  a  severe  cold. 
Mild  conjunctivitis,  causing  weak  and  watery  eyes,  coryza,  and  mild  laryngo- 
bronchitis,  with  accompanying  cough,  precede  the  eruption  three  or  four  days 
and  continue  during  the  eruptive  stage.  The  fever  during  the  first  or  initial 
stage  of  measles  is  remittent,  the  evening  temperature  being  two  or  three 
degrees  higher  than  that  in  the  morning.  Contrast  this  with  the  invasion 
of  scarlet  fever,  in  which  the  only  catarrh  is  that  of  the  buccal  and  faucial 
surfaces,  and  there  is  consequently  little  or  no  cough,  and  the  rise  in  tem- 
perature, ordinarily  high  in  the  beginning,  is  nearly  uniform  in  the  different 
hours  of  the  day.  The  scarlatinous  eruption  appears,  as  we  have  seen,  within 
twelve  to  twenty-four  hours  about  the  neck  and  upper  part  of  the  chest,  and 
spreads  over  the  body  in  a  shorter  time  than  that  of  measles,  which  appears 
on  the  third  day.  The  rash  of  measles  begins  to  fade  at  the  close  of  the  third 
or  in  the  fourth  day  after  its  appearance,  that  of  scarlet  fever  not  till  from  the 
sixth  to  the  eighth  day.  In  nearly  all  cases  of  measles,  even  when  the  rash 
is  confluent  upon  the  face  and  a  considerable  part  of  the  trunk  in  consequence 
of  the  high  fever  and  active  cutaneous  circulation,  we  observe  the  character- 
istic rubeolar  eruption  upon  certain  parts  of  the  surface,  as  the  extremities  ; 
which,  in  connection  with  the  history,  renders  diagnosis  certain. 

Erythema  resembles  the  scarlatinous  eruption,  but  its  duration  is  com- 
monly shorter.  It  is  limited  to  a  part  of  the  surface,  and  it  is  accompanied 
by  much  less  fever.  The  temperature  in  erythema  does  not  usually  rise  above 
100°,  unless  for  a  few  hours,  whereas  in  scarlet  fever  it  continues  several  days 
considerably  above  100°.  The  scarlatinous  efflorescence  has  also  a  brighter 
red  or  more  scarlet  hue  than  that  of  erythema,  except  that  in  the  more  malig- 
nant cases,  in  which  the  severity  of  the  symptoms  renders  the  diagnosis  clear. 
But  an  important  aid  in  diff"erentiating  the  one  from  the  other  of  these  diseases 
is  the  fact  that  in  erythema  there  is,  with  few  exceptions,  no  faucial  inflam- 
mation, and  in  the  few  instances  in  which  it  is  present  it  is  slight  and  tran- 
sient, fading  within  a  day  or  two. 

Scarlet  fever  is  readily  diagnosticated  from  diphtheria,  although  the 
affinity  is  close  between  these  two  maladies.  The  early  appearance  of  the 
pseudo-membrane  upon  the  fauces  in  diphtheria,  its  absence  in  scarlet  fever, 
and  the  absence  of  any  appearance  resembling  it  until  the  fever  has  con- 
tinued some  days,  and  the  characteristic  efflorescence  upon  the  skin  in  scarlet 
fever,  render  diagnosis  easy.  If  scarlet  fever  have  continued  some  days 
when  first  seen  by  the  physician,  the  diphtheritic  pseudo-membrane  may  be 
present  as  a  complication,  or  the  fauces  may  present  an  appearance  like 
diphtheria  from  ulceration  or  sloughing  and  the  presence  of  foul  and  offen- 
sive secretions,  which  produce  a  dark -grayish  and  fetid  mass  over  the  faucial 
surface.  Under  such  circumstances  the  character  of  the  disease  is  ascer- 
tained by  the  history  of  the  case,  and  especially  by  the  occurrence  of  the 
scarlatinous  eruption.  An  erythema  tran.sient  and  limited  to  a  part  of  the 
surface  sometimes  appears  in  the  commencement  of  diphtheria,  and  at  a  later 
period,  as  a  result  of  the  toxaemia  upon  the  extremities.  Roseoloid  points 
and  patches  often  occur  upon  the  extremities.  Both  kinds  of  rash  can  be 
readily  diagnosticated  from  that  of  scarlet  fever,  for  the  erythema,  as  has 
been  stated,  is  transient  and  partial,  and  does  not  exhibit  minute  points  of 
deeper  injection,  while  the  toxsemic  rash  differs  in  form  and  aspect  from  that 
of  scarlet  fever,  and  appears  at  a  stage  when  the  scarlatinous  efflorescence  has 
faded  or  begun  to  fade. 


SCARLET  FEVER.  281 

The  efflorescence  of  rotheln  sometimes  closely  resembles  that  of  scarlet 
fever,  though  it  is  usually  more  like  that  of  measles  ;  but  it  is  ordinarily 
accompanied  by  symptoms  which  are  much  milder  than  those  of  scarlet  fever, 
and  it  begins  to  abate  as  early  as  the  third,  and  disappears  on  the  fourth,  day. 
The  eyes  have  a  suffused  appearance,  the  temperature  may  reach  102°  or 
103°,  and  the  efflorescence  may  be  as  general  over  the  body  as  that  of  scarlet 
fever,  but  there  is  not  the  aspect  of  serious  indisposition,  and  the  speedy 
-abatement  of  the  symptoms  shows  that  the  disease  is  not  scarlet  fever. 

Prognosis. — The  prognosis  depends  on  the  form  of  scarlet  fever,  whether 
mild  or  severe,  the  strength  of  the  patient,  and  the  presence  or  absence  of 
complications  or  sequelae.  The  type  of  the  disease  is  sometimes  so  mild 
throughout  an  epidemic  or  during  a  series  of  years  that  death  seldom  occurs, 
whatever  the  mode  of  treatment ;  but  afterward  the  type  changes,  and  the 
percentage  of  deaths  increases  and  remains  high  till  another  amelioration  in 
the  type  occurs. 

Sydenham  in  the  middle  of  the  seventeenth  century  stated  that  scarlet 
fever,  as  he  saw  it  in  London,  was  so  mild  that  it  scarcely  deserved  the  name 
of  disease  :  "  Vix  nomen  morbi  merebatur."  Morton  some  years  later,  and 
Huxham  in  the  following  century,  had  abundant  reason  to  regret  the  change 
of  type,  and  now  throughout  Great  Britain  scarlet  fever  is  one  of  the  most 
fatal  and  most  dreaded  of  the  diseases  of  childhood.  In  Dublin  during  the 
present  century,  prior  to  1834,  scarlet  fever  was  uniformly  mild,  so  that  on 
one  occasion  of  eighty  patients  in  an  institution  all  recovered.  In  1834  the 
type  of  the  disease  totally  changed  and  epidemics  of  unusual  virulence 
occurred.  The  type  frequently  changes  from  mild  to  severe  or  severe  to 
mild,  not  only  in  consecutive  years,  but  in  consecutive  months.  A  few  years 
since  a  distinguished  physician  of  New  York  treated  about  fifty  cases  of  scar- 
let fever  in  one  of  the  institutions  without  a  single  death,  but  a  few  months 
later  the  type  of  the  malady  changed,  and  his  own  son  was  among  those  who 
perished  from  it.  The  prevailing  type  of  the  disease  should  therefore  be  con- 
sidered in  giving  the  prognosis  when  in  the  commencement  of  a  case  we  are 
asked  the  probability  as  regards  the  termination. 

Extensive  statistics,  including  those  collected  by  Murehison  from  various 
sources,  show  that  in  different  epidemics  the  mortality  may  vary  as  much  as 
from  3  per  cent.  (Eulenberg  of  Coblentz)  to  19.3  per  cent,  (cases  seen  by 
myself  in  New  York  City  in  1881-82,  many  of  which  were  complicated  by 
diphtheria),  or  even  to  34  per  cent,  (epidemic  in  the  Palatinate  in  1868-69). 
The  hospital  statistics  of  Rilliet  and  Barthez  gave  46  deaths  in  87  cases,  or 
about  53  per  cent. 

The  mortality  is  nearly  equal  in  the  two  sexes,  but  age  has  a  marked 
influence  on  the  percentage  of  deaths.  The  period  of  the  greatest  mortality, 
and  also  of  the  greatest  frequency,  of  scarlet  fever  is  between  the  ages  of  one 
and  six  years.  The  following  are  statistics  bearing  on  the  relation  of  the  age 
to  the  percentage  of  deaths : 

From  the  close    From  the  5th  to 
Under  1  year,    of  1st  till  close         the  12th 
of  5th  year.  year. 

Fleishman:  Cases       .        8  204  260 

Deaths    .         6  88  51 

1st  to  close  of  6th  to  121:h       From  the  12th 

6th  year.  year.  to  20th  year. 

Kraus:  Cases      .       13  113  106  40 

Deaths    .4  29  10  2 

7th  to  16th  year. 
Volt:  Cases       .         5  166  109 

Deaths   .1  24  10 


282  CONSTITUTIONAL  DISEASES. 

From  1st  to  close 
Under  1  year.         of  5th  year.       Over  5  years. 

Koset:  Ca,ses       .       43  156  88 

Deaths    .16  31  3 

Under  5  years.  5th  to  10th  year.  10th  to  15th  year.  Over  15  years. 
Kussinger:    Cases       .     101  126  47  27 

Deaths    .21  20  3  0 

These  statistics,  which  I  believe  correspond  with  the  observations  of  others, 
show  that  although  few  cases  occur  in  the  first  year,  the  percentage  of  deaths 
is  large,  and  that  a  majority  of  the  total  deaths  from  this  malady  occur  under 
the  age  of  sis  years.  After  the  sixth  year  the  greater  the  age  the  less  the 
proportionate  number  of  deaths. 

Observations  have  thus  far  failed  to  establish  any  connection  in  the  atmos- 
pheric conditions  of  temperature  or  moisture  and  the  type  of  scarlet  fever. 
Grave  as  well  as  mild  epidemics  have  occurred  in  all  climates  and  seasons. 

Scarlet  fever  is  liable  to  so  many  complications  and  sequelse  that  a  phy- 
sician should  not  predict  a  certain  favorable  termination  in  the  beginning, 
however  mild  and  regular  the  symptoms  may  be.  But  a  favorable  result 
may  be  expected  if  the  attack  be  mild,  the  efflorescence  appear  at  the  proper 
time  and  extend  over  the  entire  surface,  the  angina  be  moderate  and  accom- 
panied by  little  or  no  cellulitis  or  adenitis,  with  pulse  under  140,  temperature 
not  above  103°,  and  no  marked  nervous  symptoms. 

Whether  the  complications  or  sequelae  be  dangerous  depends  upon  their 
character.  Rheumatism  has  never  in  my  practice  been  dangerous,  nor  has  it 
materially  retarded  convalescence,  except  when  it  affected  the  heart,  causing 
pericarditis  or  endocarditis,  when  it  involves  great  danger.  Nephritis,  if  it 
be  moderate,  attended  by  little  albuminuria  and  serous  effusion  and  by  the 
occurrence  of  few  renal  casts  in  the  urine,  commonly  ends  favorably  under 
judicious  treatment,  as  we  have  already  stated  ;  but  severe  nephritis,  with 
abundant  albuminuria  and  casts  and  serous  effusions,  soon  gives  rise  to 
alarming  symptoms,  and  is  the  cause  of  death  in  a  considerable  number  of 
instances.  A  similar  remark  is  applicable  to  the  angina,  which  occurs  in  all 
grades  of  severity.  If  it  be  attended  by  much  cellulitis,  with  considerable 
ulceration  or  necrosis,  the  state  is  one  of  danger  in  consequence  of  the  diffi- 
culty in  administering  sufficient  nutriment,  as  well  as  from  the  diminished 
assimilation  and  the  loss  of  strength  due  to  the  prolonged  inflammatory 
fever,  the  septic  poisoning,  and  the  occasional  hemorrhages.  Complication 
by  pharyngeal  or  nasal  diphtheria,  now  so  common  where  diphtheria  is 
endemic,  also  greatly  increases  the  danger. 

Many  cases,  even  when  their  course  is  normal  and  without  complications, 
involve  danger,  and  some  are  necessarily  fatal,  from  the  direct  effect  of  scar- 
latinous blood-poisoning.  Such  are  grave  or  malignant  forms  of  the  disease 
which  the  experienced  eye  recognizes  at  a  glance.  Death  often  occurs  rapidly 
from  the  toxsemia.  Such  cases  are  characterized  by  high  temj)erature  (105° 
or  106°),  rapid  pulse,  dusky-red  hue  of  the  surface  from  languid  capillary 
circulation,  pungent  heat,  frequent  vomiting,  diarrhoeal  stools,  a  dry-brown 
tongue,  and  marked  nervous  symptoms,  such  as  delirium,  great  restlessness, 
or  stupor.  Not  a  few  in  this  form  of  scarlet  fever  take  eclampsia,  which  is 
likely  to  be  severe  and  repeated,  and  to  end  in  fatal  coma. 

Other  inflammatory  complications  and  sequelae,  which  have  been  described 
in  the  preceding  pages,  retard  convalescence  and  jeopardize  the  life  of  the 
patient,  such  as  empyema,  endocarditis,  pericarditis,  and  pneumonia.  Otitis 
media  is  seldom  immediately  dangerous,  although  it  may  be  painful  and 
involve  serious  consequences,  even  a  fatal    meningitis,  as  has  been  stated 


SCARLET  FEVER.  283 

above,  after  months  or  years  of  otorrhoea.  Anomalous  cases  are  believed  to 
be,  as  a  rule,  more  dangerous  than  such  as  are  attended  by  an  early  and  full 
efflorescence  and  have  the  usual  symptoms. 

Treatment. — Prophylaxis. — Since  the  discovery  by  Jenner  of  the  pro- 
phylactic power  of  vaccination  as  regards  smallpox,  the  attention  of  the 
profession  has  been  frequently  directed  to  the  prevention  of  scarlet  fever. 
Belladonna  has  been  employed  for  this  purpose  by  a  class  of  practitioners 
who  believe  in  the  theory  that  an  agent  which  produces  symptoms  similar  to 
those  of  a  disease  is  antagonistic  to  that  disease,  and  therefore  tends  to  pre- 
vent it,  or,  if  it  be  present,  to  render  it  milder ;  and  since  this  herb  causes  an 
efflorescence  upon  the  skin  and  redness  of  the  fauces,  it  was  selected  as  the 
proper  preventive  and  remedial  agent  for  scarlet  fever.  Its  use,  however,  for 
this  purpose  has  been  fruitless,  and  it  is  now  nearly  or  quite  discarded. 

It  is  now  known,  from  a  considerable  number  of  observations,  that  scarlet 
fever  occasionally  occurs  in  the  domestic  animals  during  epidemics  of  the 
disease  in  children.  It  is  stated  that  Spinola  observed  it  in  the  horse  ;  that 
Heim  saw  a  dog  that  occupied  the  same  bed  with  a  scarlatinous  patient  sicken 
with  fever,  which  was  followed  by  desquamation  ;  that  Letheby  saw  scarlatina 
in  swine,  and  Kraus  in  young  cattle.  Prominent  veterinary  surgeons,  as 
Williams  of  Great  Britain,  admit  the  occurrence  of  scarlatina  in  animals,  and 
the  hope  has  arisen  that  since  smallpox  is  modified  in  cattle  so  as  to  afford 
us  the  vaccine  virus,  perhaps  scarlet  fever  may  also  be  modified  by  passing 
through  one  of  the  Ipwer  animals,  so  that  a  milder  and  less  fatal  form  of  the 
disease  might  be  produced  in  man  by  inoculation  from  the  animal.  Inocula- 
tions have  been  made  to  ascertain  whether  the  scarlet  fever  of  animals  occurs 
in  a  modified  form,  but  so  far  without  result.  Under  the  circumstances  the 
experimenter  who  propagates  so  dangerous  a  disease  by  inoculation  renders 
himself  liable,  it  seems  to  me,  to  criminal  proceedings  in  the  courts. 

In  the  present  state  of  our  knowledge  the  most  reliable  and  certain  pro- 
phylaxis is  the  isolation  of  patient  and  nurses  and  the  thorough  and  judicious 
employment  of  disinfectants  upon  their  persons  and  in  the  apartments.  All 
furniture  and  articles  not  absolutely  required  should  be  removed  from  the 
sick-room,  and  no  one  should  be  allowed  to  enter  it  except  the  medical  attend- 
ant and  nurses.  Constant  ventilation  should  be  insisted  on  by  lowering  the 
upper  and  raising  the  lower  sash  of  the  window  two  or  three  inches  in  mild 
weather.  Even  in  stormy  weather  sufficient  ventilation  can  be  obtained  in 
this  way  without  exposing  the  patient  to  currents  of  air,  which  should  be 
avoided. 

The  New  York  Board  of  Health  enforces  the  following  regulations  to 
prevent  the  spread  of  scarlet  fever  as  well  as  other  acute  infectious  maladies  : 

^'■Care  of  Patients. — The  patient  should  be  placed  in  a  separate  room,  and 
no  person  except  the  physician,  nurse,  or  mother  allowed  to  enter  the  room 
or  to  touch  the  bedding  or  clothing  used  in  the  sick-room  until  they  have 
been  thoroughly  di.sinfeeted. 

'■'Infected  Articles. — All  clothing,  bedding,  or  other  articles  not  absolutely 
necessary  for  the  use  of  the  patient  should  be  removed  from  the  sick-room. 
Articles  used  about  the  patient  such  as  sheets,  pillow-cases,  blankets,  or 
clothes,  must  not  be  removed  from  the  sick-room  until  they  have  been  disin- 
fected by  placing  them  in  a  tub  with  the  following  disinfecting  fluid :  eight 
ounces  of  sulphate  of  zinc,  one  ounce  of  carbolic  acid,  three  gallons  of  water. 
They  should  be  soaked  in  this  fluid  for  at  least  an  hour,  and  then  placed  in 
boiling  water  for  washing. 

"  A  piece  of  muslin  one  foot  square  should  be  dipped  in  the  same  solution 
and  suspended  in  the  sick-room  constantly,  and  the  same  should  be  done  in 
the  hallway  adjoining  the  sick-room. 


284  CONSTITUTIONAL  DISEASES. 

"  All  vessels  used  for  receiving  the  discharges  of  patients  should  have 
some  of  the  same  disinfecting  fluid  constantly  therein,  and  immediately  after 
being  used  by  the  patient  should  be  emptied  and  cleansed  with  boiling  water. 
Water-closets  and  privies  should  also  be  disinfected  daily  with  the  same  fluid 
or  a  solution  of  chloride  of  iron,  one  pound  to  a  gallon  of  water,  adding  one 
or  two  ounces  of  carbolic  acid. 

'•  All  straw  beds  should  be  burned. 

•'  It  is  advised  not  to  use  handkerchiefs  about  the  patient,  but  rather  soft 
rags,  for  cleansing  the  nostrils  and  mouth,  which  should  be  immediately  there- 
after burned. 

"  The  ceilings  and  side-walls  of  a  sick-room  after  removal  of  the  patient 
should  be  thoroughly  cleaned  and  lime-washed,  and  the  woodwork  and  floor 
thoroughly  scrubbed  with  soap  and  Avater." 

By  such  measures  of  prevention  there  can  be  no  doubt  that  the  number 
of  cases  of  scarlet  fever  has  been  reduced. 

But  do  the  health  boards  accomplish  all  that  they  are  able  to  do  in  sup- 
pressing scarlet  fever  as  well  as  diphtheria  ?  The  New  York  Health  Board 
excludes  children  from  the  schools  who  live  in  the  houses  where  these  diseases 
are  occurring,  gives  directions  in  reference  to  the  care  of  the  patient  and  the 
disposition  of  infected  articles,  and  promises  to  disinfect  the  sick-room  when 
word  is  sent  to  the  board.  But  these  measures  are  inadequate  or  are  only 
partially  successful  in  preventing  these  diseases.  To  my  knowledge,  many 
families  in  New  York  never  send  word  that  they  are  ready  for  the  disinfection 
of  the  apartments,  and  many  families  in  the  tenement-houses  move  away  as 
soon  as  possible.  The  vacated  rooms  are  re-rented  to  families  who  have  no 
knowledge  of  the  previous  sickness,  and  are  surprised  when  their  children 
immediately  after  are  taken  sick.  It  would  be  better  if  the  health  board  in 
every  instance  disinfected  the  infected  apartments  after  the  termination  of 
the  sickness,  whether  the  family  are  willing  or  not.  3Ioreover,  the  reader  is 
referred  to  our  remarks  on  the  prevention  of  diphtheria  for  evidence  of  the 
inadequacy  of  the  sulphur  fumigation. 

But  the  suppression  of  scarlet  fever  cannot  be  effected  without  the  co-ope- 
ration of  the  attending  physician.  He  can  accomplish  more  than  the  health 
board  in  the  way  of  prophylaxis.  More  than  a  quarter  of  a  century  has 
elapsed  since  the  late  Dr.  William  Budd  of  England  recommended  prophy- 
lactic lueasures,  and  the  following  is  his  testimony  in  regard  to  the  result : 
"  The  success  of  this  method  in  my  own  hands  has  been  very  remarkable. 
For  a  period  of  nearly  twenty  years,  during  which  I  have  employed  it  in  a 
very  wide  field,  I  have  never  known  the  disease  to  spread  beyond  the  sick- 
room in  a  single  instance,  and  in  very  few  instances  within  it.  Time  after 
time  I  have  treated  this  fever  in  houses  crowded  from  attic  to  basement  with 
children  and  others,  who  have  nevertheless  escaped  infection.  The  two  ele- 
ments in  the  method  are  separation  on  the  one  hand  and  disinfection  on  the 
other.''  1 

In  my  opinion  it  is  quite  possible  to  realize  the  experience  of  Dr.  Budd 
if  proper  prophylactic  measures  be  employed  from  the  beginning  of  the  sick- 
ness. The  attending  physician  at  his  first  visit  and  at  each  subsequent  visit 
should  consider  it  an  imperative  duty  to  direct  the  employment  of  adequate 
preventive  measures.  Health  boards  give  directions  that  objects  not  required 
to  promote  the  comfort  of  the  patient  should  be  removed  from  the  sick-room, 
and  no  one  be  allowed  to  enter  it  except  the  physician,  nurse,  and  mother. 
The  floor  and  walls  of  the  apartment  should  be  bare,  but  I  would  go  farther 
than  the  health  board,  and  insist  that  no  reading  matter,  especially  books  and 
primers,  be  allow  in  the  room,  or  if  allowed  they  should  subsequently  be 

^  British  Medical  Journal,  January  9,  1869. 


SCARLET  FEVER.  285 

burnt,  since,  as  we  have  seen,  the  specific  poison  obtaining  lodgment  between 
the  leaves  is  not  readily  reached  by  disinfectants,  and  may  communicate  the 
disease  months  afterward.  I  recommend  for  disinfection  of  the  room  at  my 
first  visit,  and  also  for  cases  of  diphtheria,  the  following  prescription  : 

R.   Acidi  carbolici, 

01.  eucalypti,  da.  ^j  ; 

Spts.  terebinth.,  gvj. — Misce. 

Two  tablespoonfuls  are  added  to  one  quart  of  water  in  a  tin  wash-basin  or 
similar  vessel  with  broad  surface,  and  maintained  in  a  state  of  constant 
simmering  over  a  gas-  or  oil-stove  during  the  entire  sickness.  The  odor  of 
this  vapor  is  agreeable  rather  than  unpleasant,  and  it  appears  to  disinfect  to 
a  considerable  extent  the  breath  and  exhalations  from  the  body  of  the  patient. 
At  the  same  time,  I  order  inunction  of  the  entire  surface  every  third  hour 
with  the  following : 

R.  Acidi  carbolici, 

Ol.  eucalypti,  da.  3j  ; 

01.  olivse,  o"^J' 

Dr.  Jamieson  recommends  disinfection  of  the  fauces  by  the  frequent 
application  of  a  saturated  solution  of  boric  acid  in  glycerin.  This  or 
some  other  non-irritating  solution  should  be  often  applied,  not  only  to  the 
fauces,  but  also  in  the  anginose  cases  to  the  nostrils.  I  have  recommended 
the  application  of  corrosive  sublimate  solution,  two  grains  to  the  pint,  applied 
to  the  fauces  by  a  camel-hair  pencil  or  by  cotton  wadding  wound  around  a 
slender  stick,  in  the  same  manner  in  which  Dr.  Oatman  and  others  emplov  it 
in  diphtheria. 

The  cautious  physician  in  attending  a  case  of  scarlet  fever  will  always 
bear  in  mind  the  possibility  that  his  person  or  clothing  may  become  infected, 
and  be  the  vehicle  through  which  the  poison  may  be  communicated  to  others. 
In  examining  the  fauces  of  a  patient  he  should  stand  a  little  to  one  side,  so 
that  no  muco-pus,  if  the  patient  cough,  be  received  on  his  clothing ;  nor  will 
he  go  directly  from  a  scarlatinous  patient  to  a  child  with  another  sickness,  or 
to  a  midwifery  case,  without  first  washing  his  hands,  hair,  and  face  in  a 
corrosive-sublimate  solution,  and  changing  his  outer  apparel ;  or  if  he  visit 
a  child  without  such  precautionary  measures,  he  will  not  approach  any  nearer 
than  is  sufficient  to  enable  him  to  determine  its  ailment  and  condition. 

Hygienic  Treatment. — The  room  occupied  by  a  scarlatinous  patient  should 
be  commodious  and  sufficiently  ventilated.  Its  temperature  should  be  uni- 
form, at  about  70°  during  the  course  of  the  fever.  When  the  fever  begins  to 
abate  and  desquamation  commences,  a  temperature  of  72°  to  75°  is  prefer- 
able, so  that  there  is  less  danger  that  the  surface  may  be  chilled  during 
unguarded  moments,  as  at  night,  when  the  body  may  be  accidentally  uncov- 
ered, since  sudden  cooling  of  the  surface  at  this  time  may  cause  nephritis  or 
some  other  dangerous  inflammation.  Henoch  does  not  believe  in  the  theory 
that  the  nephritis  is  commonly  produced  by  catching  cold,  but  many  observa- 
tions show  that  those  who  are  carefully  protected  from  vicissitudes  of  tem- 
perature, who  remain  during  convalescence  in  a  warm  room,  and  are  pro- 
tected by  abundant  clothing,  more  frequently  escape  this  complication  than 
such  as  are  under  no  restraint  of  this  kind  and  are  carelessly  exposed  in  times 
of  changeable  weather.  Nevertheless,  it  is  true  that  a  certain  proportion 
suff"er  from  nephritis  however  judicious  the  after-treatment  may  be.  The 
best  hygienic  management  does  not  always  prevent  its  occurrence.  The 
patient  should  not,  therefore,  leave  the  house  until   four  weeks  after  the 


286  CONSTITUTIONAL  DISEASES. 

beginning  of  the  fever,  and  in  inclement  weather  not  till  a  longer  time  has 
elapsed.  So  long  as  desquamation  is  going  on  and  the  skin  has  not  regained 
its  normal  function,  the  patient  should  remain  indoor,  and  when  finally  he  is 
allowed  to  leave  the  house  he  should  be  warmly  clothed. 

Therapeutic  Treatment. — In  order  to  treat  scarlet  fever  successfully,  it  is 
necessary  to  bear  in  mind  that  it  is  a  self-limited  disease,  running  a  certain 
time  and  through  certain  stages,  and  that  it  is  not  abbreviated  by  any  known 
treatment.  Therapeutic  measures  can  only  moderate  its  symptoms  and  ren- 
der it  milder.  The  severity  of  the  disease  is  indicated  by  its  symptoms,  and 
the  symptoms  are  to  a  certain  extent  under  our  control. 

Mild  Cases. — A  patient  with  a  temperature  under  103°  and  with  only  a 
moderate  angina  does  not  require  active  treatment,  but,  however  light  the 
disease,  he  should  always  be  in  bed  and  in  a  room  of  uniform  temperature, 
as  stated  above.  Instances  have  come  to  my  notice  in  the  poor  families  of 
New  York  in  which  scarlet  fever  was  not  diagnosticated,  and  the  patients 
were  allowed  to  go  about  the  house,  and  even  in  the  open  air,  in  the  eruptive 
stage,  till  some  severe  complication  or  an  aggravation  of  the  type  created 
alarm  and  medical  advice  was  sought,  when  it  appeared  that  a  grave  and  dan- 
gerous condition  had,  through  carelessness  and  ignorance,  resulted  from  a 
mild  and  favorable  form  of  the  malady.  The  physician  when  summoned  to 
a  case  however  mild,  should  never  fail  to  take  the  temperature,  note  the 
pulse,  inspect  the  fauces,  and  inquire  in  reference  to  the  fecal  and  urinary 
evacuations,  that  he  may  detect  early  any  unfavorable  changes  which  may 
occur. 

Since  in  all  cases  of  mild  as  well  as  severe  scarlet  fever  more  or  less 
blood-deterioration  and  angina  are  present,  the  following  prescription  of  the 
tincture  of  the  chloride  of  iron  and  pineapple  will  be  found  useful : 

R.  Tine,  ferri  chloridi,  ,^ij  ; 

Syrupi  ananassse  sativse,  §v. — Misce. 

Shake  bottle.     Give  one  teaspoonful  every  two  hours  to  a  child  of  three  years 

I  have  long  since  discarded  the  potassium  chlorate  as  a  local  remedy  for 
affections  of  the  throat,  but  the  above  prescription  is  beneficial  as  a  tonic  and 
astringent.     The  following  is  also  a  useful  prescription  : 

R.  Quinise  sulj^hat.,  gr.  xvj  ; 

Syr.  pruni  virginiani, 

Syr.  yerbse  santse  comp.,  da.  3J. — Misce. 

Sig.  One  teaspoonful  every  fourth  hour  to  a  child  of  three  to  five  years. 

The  treatment  of  scarlatina  by  antiseptic  remedies  will  be  considered 
hereafter. 

The  itching  and  dryness  of  the  surface,  which  increase  the  discomfort  of 
the  patient  in  mild  as  well  as  severe  scarlatina,  are  relieved  by  the  ointment 
mentioned  in  treating  of  prophylaxis.  The  linen  should  be  changed  every 
day  and  the  bed  thoroughly  aired. 

Ordinary  Cases  and  Cases  of  Severe  Type. — A  safe  temperature  in  scarlet 
fever  may  be  considered  at  or  below  103°.  If  it  rise  above  this,  measures 
designed  to  abstract  heat  are  very  important — more  important  even  in  many 
cases  than  the  medicinal  agents  which  are  commonly  used  to  combat  this 
disease.  Since  a  high  temperature  retards  assimilation,  promotes  deleterious 
tissue-change,  and  causes  rapid  emaciation  and  loss  of  strength,  measures 
designed  to  reduce  it  are  urgently  needed.  "  The  production  of  heat  depends 
chiefly  on  oxidation  of  the  constituents  of  the  body  "  (Billroth).  Therefore, 
fever  indicates  an  increase  of  the  oxidation  and  a  molecular  disintegration 


SCARLET  FEVER.  287 

above  tLe  healthy  standard.  Hence  the  augmentation  of  urea  in  the  urine 
and  the  progressive  emaciation  and  loss  of  weight  which  characterize  the 
febrile  state.  Fever  also  diminishes  the  secretions  by  which  food  is  digested 
and  destroys  the  appetite,  so  that  repair  of  the  waste  is  insufficient.  More- 
over, a  high  temperature  continuing  for  a  time  tends  to  produce  degenerative 
changes,  albuminous  and  fatty,  in  the  tissues,  the  more  rapidly  the  higher 
the  temperature,  so  that  the  functions  of  organs  are  seriously  impaired. 
Among  the  most  dangerous  of  the  tissue-changes  is  granulo-fatty  degenera- 
tion of  the  muscular  fibres  of  the  heart.  In  dogs  and  rabbits  that  have  per- 
ished from  a  high  temperature  artificially  produced  by  experimenters  gran- 
ular clouding  of  the  elementary  tissues  has  been  found  after  death. ^  A  high 
temperature,  therefore,  in  itself  involves  danger,  and  if  it  occur  in  an  ataxic 
disease  like  scarlet  fever,  and  be  protracted,  it  greatly  diminishes  the  chances 
of  a  favorable  issue.  As  an  agent  in  reducing  heat  without  producing 
depression  the  following  prescription  has  given  in  my  practice  better 
results  than  any  other : 

R.  01.  cinnatnomi,  gtt.  v ; 

Phenacetinse,  Qij  ; 

Sodii  bromidi,  gij  ; 

Caffeini  citrat.,  gr.  xv  ; 

Sacch.  lactis,  3J. — Misce. 
Divid.  in  chart.  No.  xv. 
To  a  child  of  ten  years  give  one  powder  every  three  or  four  hours  ;  give  half  a 
powder  to  a  child  of  five  or  six  years. 

Patients  with  a  high  temperature  and  impending  convulsions  have  been 
rescued  by  this  remedy. 

The  temperature  can  be  reduced  without  shock  or  injury  to  the  child  by 
the  judicious  use  of  cold  water  externally.  The  cold-water  treatment  is  not 
necessary  if  the  temperature  be  under  103°,  though  useful  if  judiciously 
employed  by  sponging  when  the  temperature  is  at  102°  or  103°  ;  but  if  it  rise 
above  103°  it  is  required,  and  the  more  urgently  the  higher  the  temperature. 
The  external  use  of  cold  water  as  an  antipyretic  in  the  febrile  diseases  is  now 
almost  universally  recommended  by  physicians,  but  it  still  meets  with  oppo- 
sition on  the  part  of  families,  especially  in  the  treatment  of  the  exanthematic 
fevers,  and  the  directions  for  its  employment  are  therefore  not  likely  to  be 
fully  carried  out  during  the  absence  of  the  medical  attendant.  The  old  theory 
that  the  fevers  require  warmth  and  sweating  has  such  a  firm  hold  on  the 
popular  mind  that  some  years  longer  will  be  required  for  its  removal. 

The  modes  of  applying  cold  water  recommended  by  cautious  and  expe- 
rienced physicians  are  various.  Von  Ziemssen  recommended  that  the  patient 
be  immersed  in  water  at  a  temperature  of  90°,  and  cool  water  be  gradually 
added  till  the  temperature  fall  to  77°.  In  a  few  minutes  the  patient  is 
returned  to  his  bed,  his  surface  dried,  and  he  is  covered  by  the  proper  bed- 
clothes, when  his  temperature  will  probably  be  found  reduced  two  or  two  and 
a  half  degrees.  If  the  patient  complain  of  chilliness  or  his  pulse  be  feeble, 
he  should  be  immediately  removed  from  the  bath  and  stimulants  adminis- 
tered, either  whiskey  or  brandy,  for  if  the  extremities  remain  cool  and  the 
capillary  circulation  sluggish,  the  eff"ect  may  be  injurious,  since  some  internal 
inflammation  may  arise  to  complicate  the  fever.  Under  such  circumstances 
increased  alcoholic  stimulation  is  required. 

The  cold  pack  is  also  effectual  for  reducing  the  temperature.  The  patient 
is  placed  upon  a  mattress  protected  by  oil  cloth,  and  is  covered  by  a  sheet 
wrung  out  of  water  at  a  temperature  of  70°.     This  is  covered  by  one  or  two 

1  See  experiments  by  Mr.  J.  W.  Legg,  Lond.  Path.  Soc.  Trans.,  vol.  xxiv.,  and  others. 


288  CONSTITUTIONAL  DISEASES. 

blankets.  In  half  an  hour  he  is  returned  to  bed,  and  will  be  found  to  have  a 
temperature  two  or  three  degrees  less  than  that  before  the  bath.  Another 
method  is  to  apply  the  sheet  wrung  out  of  water  at  90°,  and  then  reduce  the 
temperature  by  adding  water  at  a  lower  degree  from  a  sprinkler.  In  most 
eases,  however,  I  prefer  to  reduce  the  temperature  by  the  constant  applica- 
tion to  the  head  of  an  India-rubber  bag  containing  ice.  The  bag  should  be 
about  one-third  filled,  so  that  it  should  fit  over  the  head  like  a  cap.  At  the 
same  time,  as  a  potent  means  of  abstracting  heat,  at  least  when  the  tempera- 
ture is  at  or  above  104°,  a  similar  application  should  be  made  by  an  elongated 
rubber  bag  lying  over  the  neck  and  extending  from  ear  to  ear.  Cold  applied 
over  the  great  vessels  of  the  neck  promptly  abstracts  heat  from  the  blood, 
while  it  diminishes  the  pharyngitis,  adenitis,  and  cellulitis  ;  which  is  an  import- 
ant gain.  At  the  same  time,  it  is  proper  to  sponge  frequently  the  hands  and 
arms  with  cool  water.  If  the  temperature  with  this  treatment  be  not  suffi- 
ciently reduced,  one  or  two  thicknesses  of  muslin  frequently  wrung  out  of  ice- 
water  should  be  placed  along  the  arms  and  upon  either  side  of  the  face.  By 
such  local  measures,  which  are  agreeable  to  the  patient  and  without  shock  or 
perturbing  eifect  on  the  system,  we  can  reduce  the  temperature  two  or  three 
degrees.  By  adding  alcohol  or  one  of  the  alcoholic  compounds  to  the  water 
the  popular  objection  to  the  use  of  cold  is  overcome. 

Trousseau,  in  the  treatment  of  sthenic  cases  attended  by  a  high  tempera- 
ture, was  in  the  habit  of  placing  the  patient  naked  in  a  bath-tub,  and  directing 
three  or  four  pailfuls  of  cold  water  to  be  thrown  over  him  in  a  space  of  time 
varying  from  one-quarter  of  a  minute  to  one  minute,  after  which  he  was 
returned  to  bed  and  covered  by  the  bedclothes  without  being  dried.  Reaction 
immediately  occurred,  often  with  more  or  less  perspiration.  This  treatment 
was  repeated  once  or  twice  daily,  according  to  the  gravity  of  the  symptoms. 
Trousseau,  alluding  to  this  treatment,  says:  "I  have  never  administered  it 
without  deriving  some  benefit."  But  the  application  of  cold  water  in  a  man- 
ner that  does  not  excite  or  frighten  the  patient  seems  preferable.  Henoch, 
having  a  large  experience,  gives  the  following  advice  in  reference  to  the  water 
treatment :  "If  the  fever  continue  high  and  the  apparently  malignant  symp- 
toms described  above  develop,  the  head  should  be  covered  with  an  ice-bag, 
....  and  the  child  placed  in  a  lukewarm  bath,  not  under  25°  R.  (88.25°  F.). 
I  decidedly  oppose  cooler  baths,  because  in  scarlatina,  which  presents  a  tend- 
ency to  heart-failure,  cold  may  produce  an  unexpected  rapid  collapse  more 
than  in  any  other  affection.  But  I  strongly  recommend  washing  the  entire 
body  every  three  hours  with  a  sponge  dipped  in  cool  water  and  vinegar."  ^ 
In  grave  cases  with  a  high  temperature  the  application  of  cold  should  be 
sufficient  to  produce  a  decided  reduction  of  heat,  otherwise  the  full  benefit 
from  its  use  is  not  obtained.  With  proper  stimulation  and  proper  precautions, 
prostration  does  not  occur  from  the  ice-bags  to  the  head  and  neck  and  cool 
sponging  of  other  parts  so  long  as  the  temperature  does  not  fall  below  102° 
or  103°.  The  danger  alluded  to  by  Henoch  can  only  occur  from  the  use  of  the 
pack  or  general  bath,  and  the  water  treatment  can  be  efficiently  carried  out 
and  the  temperature  sufficiently  reduced  without  resorting  to  these.  Even 
Currie  of  Edinburgh,  who  first  drew  attention  to  the  benefit  from  the  cold- 
water  treatment  of  scarlet  fever  in  an  age  when  the  sweating  treatment,  and 
even  the  exclusion  of  cool  and  fresh  air  from  the  apartment  were  deemed 
necessary,  recommended  cold  effusion  only  in  sthenic  cases  with  full  and 
strong  pulse  ;  and  he  mentions  as  a  warning  two  cases  with  quick  and  feeble 
pulse  and  cool  extremities  in  which  death  occurred  immediately  after  the  use 
of  the  water. 

In  severe  cases  with  frequent  and  rapid  pulse,  in  which  ante-mortem  heart- 
^  Diseases  of  Children. 


SCARLET  FEVER.  289 

clots  are  liable  to  occur,  the  ammonium  carbonate  is  often  useful.  It  should 
be  dissolved  in  water  and  given  in  milk  in  as  large  doses  as  three  grains  every 
hour  or  second  hour  to  a  child  of  five  years.  It  aids  in  producing  stronger 
contraction  of  the  cardiac  muscular  fibres,  and  thus  diminishes  the  danger 
of  the  formation  of  thrombi.  Ten-drop  doses  of  the  aromatic  spirits  of  ammo- 
nia may  be  employed  instead  of  the  carbonate,  given  in  sweetened  water.  It 
is  especially  useful  if  the  stomach  be  irritable.  A  wineglassful  of  milk  should 
be  employed  for  this  purpose,  so  that  the  medicine  do  not  cause  gastritis. 

In  severe  cases  attended  by  considerable  angina  and  foul  and  offensive 
secretions  upon  the  faucial  surface  an  antiseptic,  as  boric  acid  is  required.  If 
no  drink  be  allowed  for  a  few  minutes  after  the  dose,  so  as  not  to  wash  it  too 
soon  from  the  fauces,  the  antiseptic  effect  is  more  certainly  produced.  Those 
old  enough  should  be  directed  to  hold  the  medicine  for  a  moment  like  a  gargle 
in  the  throat  before  swallowing  it.  I  employ  boric  acid  by  preference,  as  in 
the  following  formula : 

R.  Acid,  boric,  .^ss  ; 

Tr.  ferri  chloridi,  fgij  ; 

Glycerini,  \^^   p. 

Syrupi,  j       •   o-'  ' 

Aquse,  f^ij. — Misce. 

Sig.  Give  one  teaspoonful  every  two  hours  to  a  child  of  five  years. 

More  minute  directions  will  presently  be  given  for  the  treatment  of  the 
pharyngitis  when  we  speak  of  the  complications. 

Alcohol,  whether  administered  in  one  of  the  stronger  wines,  as  sherry,  or 
in  whiskey  or  brandy,  is  a  most  useful  remedy  in  scarlet  fever,  and  is  indeed 
indispensable  in  all  grave  cases  which  are  attended  by  feeble  capillary  circula- 
tion and  evidences  of  prostration.  Milk  is  also  the  best  vehicle  for  this  agent. 
The  wine-whey  or  milk-punch  should  be  given  every  hour  or  second  hour. 
In  scarlet  fever,  as  well  as  diphtheria,  comparatively  large  doses  are  required, 
as  a  teaspoonful  of  whiskey  or  brandy  every  hour  or  second  hour  for  a  child 
of  five  years. 

During  convalescence  the  hygienic  treatment  already  described  is  import- 
ant. Nutritious  diet  and  a  moderate  amount  of  alcoholic  stimulants  are 
required,  while  the  patient  is  kept  indoor  and  protected  from  currents  of 
air  as  long  as  desquamation  is  occurring.  More  or  less  anaemia  is  present 
in  most  convalescent  patients,  so  that  a  mild  tonic  containing  iron  will  aid  in 
restoring  the  health.  Elixir  of  calisaya-bark  and  iron,  preparations  of  beef, 
iron,  and  wine,  or  the  liquid  ferri-peptonati  in  teaspoonful  doses  will  be  found 
useful  under  such  circumstances.  Inunction  of  the  entire  surface  with  the 
mixture  of  carbolic  acid,  oil  of  eucalyptus,  and  sweet  oil,  as  recommended 
above,  should  be  continued  as  long  as  the  epidermis  desquamates. 

Treatment  of  Complications  and  Sequelse. — Local  measures  designed  to 
diminish  or  cure  the  pharyngitis  are  important  in  all  but  the  mildest  cases. 
They  are  more  especially  required  in  the  anginose  variety  and  in  those  not 
infrequent  cases  in  which  diphtheria  complicates  scarlatina.  Formerly  it  was 
necessary,  in  making  applications  to  the  fauces,  to  employ  the  brush  or  pro- 
bang  for  those  too  young  to  use  the  gargle,  but  hand-anatomizers,  as  Richard- 
son's or  Delano's,  which  are  now  in  common  use,  afford  a  quick  and  easy 
method  for  making  such  applications.  Six  or  eight  compressions  of  the  bulb 
of  a  good  atomizer  are  sufficient  to  cover  the  fauces  with  the  spray.  Those 
hand-atomizers  in  the  shops  which  have  slender  metallic  points  are  likely  to 
prick  the  buccal  surface  and  cause  bleeding  if  the  child  resist  and  toss  the 
head.  To  prevent  this  I  recommend  the  single-bulb  atomizer  with  a  simple 
19 


290  CONSTITUTIONAL   DISEASES. 

rubber  tip.  The  following  will  be  found  useful  mixtures  for  the  atomizer 
for  ordinary  cases : 

R.  Creosoti,  Morson's  Beechwood,  gtt.  iij-iv ; 

Acid,  borici,  .^ij~iij  J 

Glycerini,  f^ij  ; 

Aqua?,  f3vj. — Misce. 

R.   Carl  Seilei-'s  Tablet  for  the  Throat,      no.  j  ; 
Creosote,  Morson's,  gtt.  ij  ; 

Aquffi  destillat.,  5iij- — Misce. 

Spray  either  mixture  over  surface  of  the  throat  every  two  hours. 

If  diphtheritic  exudation  complicate  the  scarlatinous  angina,  or  the  surface 
of  the  throat  in  consequence  of  ulceration  or  necrosis  present  an  appearance 
like  that  in  diphtheria,  when  the  exudation  begins  to  soften,  being  foul, 
jagged,  of  a  dirty-brown  appearance  from  dead  matter  and  fetid  secretions, 
those  mixtures  for  spraying  the  throat  will  be  found  useful  which  are  recom- 
mended in  our  remarks  relating  to  the  local  treatment  of  diphtheria. 

The  following  mixture  is  also  beneficial  for  local  treatment  when  the 
faucial  surface  is  foul  and  offensive  from  the  exudations  and  secretions. 
It  should  be  applied  by  a  large  camel's-hair  pencil  every  three  to  six  hours : 


R.  Acidi  carbolici, 

gtt.  X  ; 

Liq.  ferri  subsulphatis, 

f.^ij ; 

Glycerini, 

.5j ; 

Aquse, 

giij.— Misce. 

In  all  cases  of  scarlatinous  pharyngitis  sufficiently  severe  to  require  special 
treatment,  cool  applications  should  be  made  over  the  neck  from  ear  to  ear,  as 
by  two  thicknesses  of  muslin  frequently  squeezed  out  of  cold  water,  or  by 
the  elongated  India-rubber  bag  already  recommended  in  our  remarks  relating 
to  the  methods  to  reduce  temperature. 

In  the  first  days  of  scarlet  fever  the  coryza  is  slight  and  no  discharge  from 
the  nostrils  occurs,  so  that  no  local  treatment  is  required ;  but  before  the  ter- 
mination of  the  malady,  in  cases  of  ordinary  gravity,  a  nasal  discharge  usually 
supervenes,  producing  more  or  less  redness  and  excoriating  the  upper  lip. 
Moreover,  in  localities  where  diphtheria  occurs,  if  this  malady  complicates 
scarlet  fever,  it  usually  affects  the  nostrils  at  the  same  time  that  the  fauces 
are  invaded.  These  conditions  require  local  treatment  of  the  nares.  It  should 
be  remembered  that  the  Schneiderian  membrane  is  midway  in  sensitiveness, 
as  it  is  in  location,  between  the  conjunctival  and  buccal  surfaces,  and  is 
readily  irritated  by  strong  applications.  Medicinal  applications  made  to  it 
must  be  much  milder  than  those  which  the  fauces  tolerate.  They  should 
always  be  applied  warm,  and  a  teaspoonful  of  any  mixture  properly  employed 
is  sufficient  for  each  nostril  at  one  sitting.  The  applications  should  usually 
be  made  every  two  to  four  hours,  according  to  the  gravity  of  the  case  and 
the  amount  of  the  discharge.  The  best  instrument  for  this  purpose  is  a 
small  syringe  of  glass  with  curved  neck  and  bulbous  rubber  tip.  The 
chikVs  head  should  be  thrown  back  and  the  piston  depressed  rapidly,  so  as 
thoroughly  to  wash  out  the  nasal  cavity.  The  application  can  also  be  made 
through  an  atomizer  with  a  rounded  tip  or  a  tip  covered  by  rubber  tubing. 
The  following  is  a  useful  prescription  : 

R.  Acidi  borici,  3J  ; 

Sodii  biborat.,  .^ij  ; 

Aqua>  purffi,  Oj. — Misce. 


SCARLET  FEVER.  291 

It  is  evident,  from  what  has  been  stated  above,  that  the  condition  of  the 
^ear  should  be  closely  observed  in  and  after  scarlet  fever.  If  the  patient  have 
earache,  considerable  relief  may  be  obtained  in  the  commencement  by  drop- 
ping a  few  drops  of  laudanum  and  sweet  oil  into  the  ear  and  covering  it  by 
some  hot  application,  either  dry  or  moist,  which  will  retain  the  heat.  A  light 
bag  containing  common  table-salt,  heated,  or  dry  and  hot  chamomile-flowers, 
will  also  answer  the  purpose.  Water  as  hot  as  can  be  well  tolerated  dropped 
into  the  ear  or  allowed  to  trickle  from  a  fountain  syringe,  so  as  to  fill  the  ear, 
is  also  very  beneficial  in  allaying  the  pain.  A  4  per  cent,  solution  of  nitrate 
of  cocaine,  with  an  equal  quantity  of  laudanum,  dropj^ed  into  the  ear,  will 
often  give  considerable  relief.  If  the  hot  applications  over  the  ear  are  not 
well  borne.  Dr.  C.  H.  May,  aurist,  recommends  applying  a  long  and  narrow 
ice-bag  immediately  behind  the  auricle  and  extending  under  and  in  front  of 
the  ear,  so  as  to  cover  the  temporo-maxillaiy  region,  and  at  the  same  time 
instilling  into  the  ear  hot  salt  water  (^j  to  Oj).  to  which  laudanum  or  cocaine 
is  added.  He  also  states  that  antipyrine  in  large  doses  is  also  useful  in  reliev- 
ing the  pain.^  If  the  pain  be  not  quickly  relieved,  a  leech  should  be  applied 
at  the  base  of  the  tragus.  0.  D.  Pomeroy,  an  experienced  aurist  of  New 
York;  says  :  ■'  Leeching  employed  at  the  right  time  rarely  fails  to  subdue  the 
pain  and  inflammation.  The  posterior  face  of  the  tragus  is  ordinarily  the  best 
place  for  applying  the  leech,  but  it  may  be  applied  in  front  of  the  ear  or 
behind,  wherever  the  tenderness  on  pressure  is  greatest.  In  my  opinion, 
paracentesis  may  frequently  be  rendered  unnecessary  by  the  timely  iise  of 
one  or  two  leeches  applied  to  the  meatus." 

If  the  otitis  continue,  as  shown  by  pain  in  the  ear.  of  which  children  old 
enough  to  speak  bitterly  complain,  and  which  caiises  those  too  young  to  speak 
to  press  their  fingers  into  or  against  their  ears,  this  inflammation  should  not 
be  neglected,  as  it  may  involve  serious  consequences.  Multitudes  of  children 
have  had  permanent  impairment  or  even  loss  of  hearing,  with  caries  or  necro- 
sis of  the  walls  of  the  middle  ear  and  of  the  mastoid  cells,  which  might  have 
been  prevented  by  prompt  and  skilful  management  of  the  ear  in  the  early 
stage  of  the  inflammation.  If,  therefore,  the  otitis  continue  without  mitiga- 
tion of  pain  after  the  above  measures  have  been  employed,  paracentesis  of  the 
drumhead  is  probably  required.  The  following  directions  for  performing  this 
-operation,  which  will  be  useful  for  country  practitioners  who  may  not  be  able 
to  obtain  the  assistance  of  a  specialist,  are  furnished  by  Dr.  Pomeroy :  "  The 
forehead  mirror  should  be  worn,  in  order  to  leave  the  hand  free  to  operate  by 
either  artificial  or  day  light.  A  good-sized  speculum  is  introduced  into  the 
meatus.  Then  an  ordinary  broad  needle,  about  one  line  in  diameter,  with  a 
shank  of  about  two  inches,  such  as  oculists  use  for  puncturing  the  cornea, 
•should  be  held  between  the  thumb  and  fingers,  lightly  pressed,  so  as  not  to 
dull  delicate  tactile  sensibility.  The  part  being  well  under  light,  the  most 
bulging  portion  of  the  membrane  should  be  lightly  and  quickly  punctured 
with  a  very  slight  amount  of  force.  The  posterior  and  superior  portion  of  the 
membrane  is  the  most  likely  to  bulge.  The  chordae  tympani  nerve  ordinarily 
lies  too  high  up  to  be  wounded.  The  ossicles  are  avoided  by  selecting  a  pos- 
terior portion  of  the  membrane.  After  puncture  the  ear  should  be  inflated  by 
an  ear-bag  whose  nozzle  is  inserted  into  a  nostril,  both  nostrils  being  closed, 
so  as  to  force  the  fluid  from  the  tympanum.  The  puncture  may  need  to  be 
repeated  at  intervals  of  a  day  or  two,  provided  that  the  pain  and  bulging 
return." 

Albert  H.  Buck  of  New  York,  in  a  highly  instructive  paper  read  before 
the  International  Medical  Congress  in  1876,  writes  as  follows  of  paracentesis 
of  the  membrana  tympani  in  scarlatinous  otitis :  '-In  this  one  slight  opera- 
1  Pediatric  Sec.  of  N.  Y.  Acad,  of  Med.,  March  14,  1889. 


292  CONSTITUTIONAL  DISEASES. 

tion,  which  in  itself  is  neither  dangerous  nor  very  painful,  lies  the  power  to 
prevent  the  whole  train  of  disagreeable  and  dangerous  symptoms."  Buck 
relates  an  instructive  example :  The  age  of  the  patient  was  three  years,  and 
the  earache  had  been  complained  of  only  about  twenty-four  hours.     "  Toward 

morning,"  says  he,  "  I  was  sent  for,  as  the  pain  had  become  constant 

An  examination  with  the  speculum  and  reflected  light  showed  an  oedematous 
and  bulging  membrana  tympani  (posterior  half),  the  neighboring  parts  being- 
very  red,  though  as  yet  but  little  swollen.  In  the  most  prominent  portion 
of  the  membrane  I  made  an  incision  scarcely  three  millimetres  (one-tenth 
inch)  in  length,  and  involving  simply  the  different  layers  of  the  membrana 
tympani.  This  was  almost  immediately  followed  by  a  watery  discharge  (with- 
out the  aid  of  inflation),  which  ran  down  over  the  child's  cheek.  At  the  end 
of  three  or  four  minutes  the  child  had  ceased  crying,  and  in  less  than  a  quar- 
ter of  an  hour  she  was  fast  asleep.  At  first  the  discharge  was  very  abun- 
dant and  mainly  watery  in  character,  but  it  steadily  diminished  in  quantity 
and  became  thicker,  till  finally,  on  the  fourth  day,  it  ceased  altogether.  On 
the  tenth  day  the  most  careful  examination  of  the  ear  could  not  detect  any 
trace  of  either  the  inflammation  or  the  artificial  opening."  The  ear  had  prob- 
ably been  saved  from  ulceration  of  the  drum  membrane,  long-continued  sup- 
purative otitis,  and  perhaps  permanent  impairment  of  hearing. 

When  an  opening  has  been  made  in  the  membrana  tympani,  either  by 
incision  or  ulceration,  it  is  advisable  in  some  instances  to  inflate  the  tym- 
panum by  Politzer's  method,  which  has  been  alluded  to  above.  The  nozzle 
of  an  India-rubber  bag  with  a  flexible  tube  attached  is  introduced  into  the 
nostril  on  the  affected  side,  and  both  nostrils  are  compressed  against  it.  The 
patient  fills  his  mouth  with  water,  which  he  swallows  at  a  given  signal,  as 
after  the  words  one,  two,  three,  spoken  by  the  operator.  During  the  act  of 
swallowing,  which  opens  the  Eustachian  tube,  the  rubber  bag  is  forcibly  com- 
pressed, which  forces  the  air  along  the  tube  into  the  middle  ear  and  facilitates 
the  escape  of  the  pent-up  secretions  in  the  tympanic  cavity.  Dr.  May  recom- 
mends cleansing  the  nostrils  and  pharynx  with  a  warm  sokition  of  salt,  one 
drachm  to  the  pint,  before  the  use  of  Politzer's  bag. 

If  the  otitis  have  continued  unchecked  by  treatment  until  the  secretions 
within  it,  after  days  and  nights  of  suffering,  have  escaped  by  ulceration 
through  the  drumhead,  the  opportunity  for  prompt  and  certain  cure  is  passed. 
Still,  the  patient  under  these  circumstances  may  quickly  recover,  or  there 
may  be  the  other  alternative  described  above,  in  which  the  ear  is  badly  dam- 
aged and  chronic  inflammation  established  in  the  walls  of  the  tympanum, 
giving  rise  to  an  offensive  otori'hoea.  In  this  state  of  the  ear  internal  rem- 
edies are  indicated,  such  as  surgeons  employ  in  suppurative  inflammations  of 
bone  occurring  in  other  parts  of  the  system.  Cod-liver  oil  and  iodide  of  iron 
are  required,  especially  by  patients  of  strumous  diathesis,  the  object  being  to 
promote  a  more  healthy  state  of  system,  so  as  to  prevent  extension  of  the 
inflammation  and  facilitate  the  healing  process.  Carbolized  solutions,  as  the 
following,  syringed  warm  into  the  ear  in  which  otorrhcea  is  occurring,  are 
useful  in  promoting  cleanliness  and  increasing  the  comfort  of  the  patient : 


R.  Acidi  carbolici, 

^ss ; 

Glycerini, 

m ; 

Aquae, 

f5iv.- 

— Misce. 

But  recently  an  effectual  curative  agent  for  local  treatment  has  been  discov- 
ered in  boric  acid,  by  the  use  of  which  the  discharge  quickly  diminishes 
and  the  condition  of  the  ear  more  certainly  and  rapidly  improves  than  by  the 
use  of  carbolized  lotions. 


SCARLET  FEVER.  293 

R.  Acidi  borici,  ^ij  ; 

Glycerini, 

AquEe,  da.  Oss. 

Sig.  Instil  sufficient  to  lill  external  ear  several  times  daily. 

The  following  astringent  has  also  been  employed  with  good  results  for 
the  otorrhoea  resulting  from  scarlet  fever  as  well  as  from  other  causes : 

R.   Zinci  sulphatis, 

Aluminis,  om.  gr.  v  ; 

Aquae,  f§j. — Misce.  . 

A  few  drops  of  this  should  be  dropped  into  the  ear,  or,  if  the  ear  be  sensitive 
and  painful,  five  drops  should  be  added  to  a  teaspoonful  of  warm  water  and 
dropped  or  syringed  into  the  ear. 

But  in  recent  times  aurists  have  discovered  in  iodoform  a  remedy,  the 
action  of  which  is  safe  and  efficient  for  protracted  otorrhoea  with  granula- 
tions. The  ear  should  first  be  thoroughly  cleansed  by  syringing  with  warm 
water  and  dried,  and  iodoform,  to  which  a  little  balsam  of  Peru  is  added  to 
mask  the  disagreeable  odor,  should  be  pressed  down  to  the  bottom  of  the 
auditory  canal  by  any  convenient  instrument.  It  is  anodyne,  astringent,  and 
disinfectant,  and  should  be  employed  in  a  dry  state  in  considerable  quantity. 

The  sequelae  of  otitis  media,  such  as  granulations  sprouting  out  from  the 
drumhead,  some  of  which  may  be  of  large  size  and  are  known  as  polypi,  may 
require  treatment  by  the  aurist.  A  polypus  may  sometimes  be  removed  by 
the  forceps,  or,  better,  by  the  snare.  Polypi  not  large  and  favorably  located 
can  sometimes  be  cured  by  an  astringent  powder,  as  iodoform,  sulphate  of 
zinc,  alum,  or  aristol.  The  otitis  externa  produced  by  the  irritating  dis- 
charge which  flows  from  the  middle  ear  soon  disappears  when  the  flow  ceases. 

The  renal  affection — which,  as  we  have  seen,  so  often  commences  in  the 
declining  period  of  scarlet  fever  or  during  convalescence,  in  mild  as  well  as 
severe  cases — is  frequently  more  dangerous  than  the  primary  disease.  It 
largely  increases  the  percentage  of  deaths.  A  clear  appreciation  of  its  thera- 
peutic requirements  is  important,  since  by  judicious  treatment  many  recover 
who  would  inevitably  be  sacriflced  by  improper  measures.  The  family  should 
be  informed  that  the  danger  from  scarlet  fever  does  not  cease  with  the  decline 
of  the  eruption,  and  that  the  kidneys  may  become  seriously  affected  by  too 
early  exposure  of  the  patient  to  currents  of  air  or  sudden  changes  of  tem- 
perature, by  which  cutaneous  transpiration  is  checked.  He  should  therefore 
be  kept  indoor  in  a  comfortable  and  uniform  temperature  three  or  four  weeks 
after  the  termination  of  the  fever,  until  desquamation  has  entirely  ceased  and 
the  new  epidermis  is  sufficiently  thick  and  fix-m  to  protect  the  surface.  Dur- 
ing the  changeable  temperature  of  the  autumnal,  winter,  and  spring  months 
even  longer  confinement  at  home  may  be  advisable. 

The  nephritis  and  consequent  alliuminuria  antedate  by  some  days  the  occurrence 
of  dropsy,  and  a  physician  should  never  discharge  a  scarlatinous  patient  without  one 
or  more  examinations  of  his  urine.  When  hisvisits  cease  the  nurse  should  be  in- 
structed to  make  the  examinations  by  heat  and  nitric  acid  during  the  ensuing 
month,  and  if  any  evidence,  however  slight,  appear  that  the  kidneys  are  involved, 
he  should  be  notified,  in  order  that  appropriate  treatment  may  be  immediately  com- 
menced. Early  and  correct  treatment  of  the  nephritis  is  attended  by  much  better 
results  than  delayed  treatment,  and  many  more  patients  are  doubtless  now  saved 
than  in  former  times,  when  little  attention  was  given  to  the  state  of  the  kidneys 
until  dropsy  or  other  prominent  symptoms  appeared.  I  have  found  no  mother  "or 
nurse  so  ignorant  that  she  could  not  properly  employ  the  test  of  nitric  acid  and 
heat,  and  if  she  be  solicitous  for  the  welfare  of  the  child,  she  will  not  hesitate  to 
carry  out  the  dii-ections  and  immediately  notify  the  physician  if  the  tests  employed 
produce  the  least  cloudiness  or  turbidity  of  the  urine. 


294  CONSTITUTIONAL  DISEASES. 

The  patient  as  soon  as  nephritis  commences,  as  shown  by  the  state  of  the  urine, 
should  be  put  to  bed  in  a  room  of  warm  and  equable  temperature  (72°  to  75°  F.). 
His  diet  should  be  liquid,  consisting  of  milk,  farinaceous  food,  and  a  moderate 
quantity  of  animal  broths.  He  may  drink  liquids  freely,-  especially  water  not  too 
cool,  to  which  spiritus  setheris  nitrosi  is  added.  K  he  be  prostrated  by  the  primary 
disease,  alcoholic  stimulants  should  be  allowed. 

The  indications  are  to  relieve  the  hypertemic  kidneys  by  diaphoresis  and  purga- 
tion. To  produce  the  former  the  patient  should  be  immersed  in  a  warm  bath  at 
about  the  temperature  of  the  body  (98°  to  1U0°),  in  which,  if  he  be  quiet  and  com- 
fortable, he  should  remain  from  fifteen  to  twenty  minutes,  but  a  shorter  time  if 
restless  and  frightened  by  the  Avater,  after  which  he  should  be  placed  in  a  warm 
bed  and  well  covered  by  blankets.  If  perspiration  result,  the  bath  has  been  useful, 
and  it  may  be  employed  in  grave  cases  two  or  three  times  daily.  If  perspiration 
do  not  result,  it  may  be  produced  by  surrounding  the  bod}'^  either  by  hot  dry  or 
moist  air.  Hot  air  may  be  produced  by  burning  alcohol  in  a  thin  layer  upon  a 
plate  under  a  chair,  upon  which  the  patient  sits  while  he  is  surrounded  by  a 
blanket,  or  he  may  be  covered  in  bed  and  the  hot  air  introduced  under  the  bed- 
clothes. In  New  York  a  convenient  apparatus  is  used  for  this  purpose,  consisting 
of  a  small  sheet-iron  pipe  enclosed  in  a  small  box  of  the  same  material.  The  box 
is  in  the  form  of  a  trunk,  with  a  handle  for  convenience  in  carrying,  and  the  lower 
end  of  the  pipe,  which  extends  nearly  to  the  floor,  contains  an  alcohol  lamp.  Hot 
moist  air  may  be  produced  by  placing  against  the  patient  bottles  of  hot  water  sur- 
rounded by  towels  wrung  out  of  water.  The  steam  arising  from  them  and  envelop- 
ing the  body  and  limbs  produces  a  prompt  sudorific  effect.  There  is  in  use  in  this 
city,  in  the  treatment  of  these  and  similar  cases  requiring  diaphoresis,  a  convenient 
apparatus  for  generating  steam.  It  consists  of  a  cylinder  pierced  with  holes  for  the 
admission  of  air  and  containing  a  spirit  lamp,  over  which  is  a  pan  or  jiail  holding  a 
little  water.  The  patient,  nearly  naked,  is  placed  in  a  chair  with  the  apparatus 
underneath,  and  is  covered  by  a  blanket,  so  that  the  steam  surrounds  the  body. 
This  gives  rise  to  free  perspiration,  Avhich  continues  after  the  patient  is  placed  in 
bed.  This  treatment  should  be  repeated  one  or  more  times  daily,  according  to  the 
gravity  of  the  case. 

The  sudorific  effect  of  tlie  treatment  by  external  warmtli  described  above 
should  be  aided  by  employing  diaphoretics.  Those  which  have  been  most 
used  are  the  acetates  of  ammonium  and  potassium,  the  bi-tartrate  and  citrate 
of  potassium,  and  spiritus  jetheris  nitrosi.  If  employed  when  the  surface  is 
cool  tliey  act  rather  as  diuretics  than  diaphoretics.  These  agents,  being 
simple  in  their  action  and  without  deleterious  effect,  may  be  given  frequently 
and  in  large  proportionate  doses  for  the  age. 

But  lately  a  diaphoretic  which  far  surpasses  these  in  efficiency  has  been 
discovered  in  pilocarpine,  the  active  principle  of  jaborandi.  Being  soluble  in 
water  and  tasteless,  it  is  easily  administered,  and  is  retained  when,  on  account 
of  the  urjemic  poisoning  present  in  scarlatinous  nephritis,  the  stomach  is 
irritable  and  other  medicines,  as  digitalis,  are  rejected.  Ether  may  be 
employed  with  it,  or  the  amount  of  alcoholic  stimulant  may  be  increased 
at  the  time  of  its  exhibition  in  order  to  guard  against  any  depressing  effect. 
To  a  child  of  two  years  one-fortieth  to  one-twentieth  of  a  grain  may  be  given 
every  six  hours  by  the  mouth.  It  may  also  be  employed  hypodermically,  as 
one-twentieth  of  a  grain  to  a  child  of  five  years.  It  has  both  a  diaphoretic 
and  a  diuretic  action,  while  it  stimulates  both  the  salivary  and  mucous  secre- 
tions. According  to  one  observer,  an  adult  when  fully  under  the  influence 
of  pilocarpine  secretes  from  one  pint  to  one  quart  of  saliva  within  two  hours, 
and  Leyden  reports  a  case  of  diphtheritic  nephritis  in  which  the  quantity  of 
urine  rose  from  half  a  pint  to  five  pints  daily.  But  its  most  prompt  and 
certain  action  is  upon  the  sweat-glands.  Hirschfelder  speaks  of  its  beneficial 
action  in  relieving  various  forms  of  dropsy,  and  adds :  "  In  one  morbid  con- 
dition of  the  kidney,  however,  jaborandi  is  the  remedy  par  excellence,  and 
that  is  the  acute  parenchymatous  nephritis  which  frequently  follows  scar- 


SCARLET  FEVER.  295 

latina This  disease  heals  spontaneously  if  the  danger  that  threatens 

life  from  reduction  of  the  urine  and  from  the  effusions  of  fluid  into  the  cav- 
ities of  the  body  be  averted.  In  this  disease  jaborandi  works  wonders."  I 
have  also  found  it  an  invaluable  agent  when  the  older  remedies  failed  and 
death  seemed  imminent.  The  following  cases,  in  which  the  beneficial  action 
of  this  agent  was  apparent,  occurred  in  my  practice : 

Case  1. — G ,  male,  aged  live  years  and  sis  months,  sickened  with  scarlet 

fever  on  June  2,  1882.  It  began  with  vomiting,  and  was  attended  by  a  degree  of 
fever  which  indicated  an  attack  of  rather  more  than  the  average  gravity.  The 
fauces  at  one  time  exhibited  a  slight  exudation  like  that  of  diphtheria.  In  the 
declining  stage  of  the  malady  rheumatic  pain  and  tenderness  occurred  in  the  wrist- 
and  finger-joints,  but  not  in  those  of  the  lower  extremities.  The  case,  however, 
progressed  favorably,  and  during  the  convalescence  my  attendance  ceased.  On 
June  2-ith  my  attention  was  again  called  to  the  child,  when  the  urine  was  found  to 
be  scanty  and  very  albuminous.  External  measures,  such  as  are  described  in  the 
foregoing  pages,  were  employed,  and  the  infusion  of  digitalis  with  potassium  acetate 
ordered  to  be  given  every  three  hours  :  but  this  medicine  was  for  the  most  part 
vomited.  The  "bowels  were  kept  open  by  jalap  and  the  potassium  bitartrate.  The 
urine,  however,  continued  scanty,  and  on  June  28th  severe  convulsions  occurred. 
At  this  time  the  quantity  of  urine  was  only  f^ij  in  twenty-four  hours.  _  The  pulse 
in  the  convulsions  was  quick  and  feeble,  the  skin  very  hot,  and  the  axillary  temp. 
103°.  The  eclampsia  continued  one  hour,  and  was  controlled  by  large  and  repeated 
doses  of  bromide  of  potassium,  aided  by  clysters  of  five  grains  of  hydrate  of  chloral 
in  water.  Muriate  of  pilocarpine  was  now  directed  to  be  given  in  doses  of  one- 
thirty-second  of  a  grain  every  three  hours,  dissolved  in  cold  water.  This  agent 
was  not  vomited,  and  it  must  have  been  given  by  the  parents  in  their  fright 
and  anxiety  in  larger  or  more  frequent  doses  than  were  directed,  for  on  July  1st 
the  bottle  containmg  one  grain  was  empty.  Free  diaphoresis  resulted  from  the 
pilocarpine,  and  the  "quantity  of  urine  was  increased.  The  mother  stated  that  the 
child  had  taken  only  two  doses,  or  one-sixteenth  of  a  grain,  of  pilocarpine  when 
the  diuretic  efl"ect  was  apparent  and  free  diaphoresis  also  occurred.  She  also  stated 
subsequently  that  the  quantity  of  urine  was  larger  when  the  pilocarpine  was  ad- 
ministered every  third  hour  than  when  given  at  a  longer  interval.  .A  flaxseed 
poultice  on  which  mustard  was  dusted  was  also  applied  over  the  kidneys.  On  June 
20th  the  pulse  was  96,  temperature  100.5°  :  occasional  convulsive  attacks  occurred, 
which  were  readily  controlled  by  enemata  of  hydrate  of  chloral.  On  June  30th  the 
symptoms  were  all  better  :  no  more  attacks  of  eclampsia  had  occurred,  and  the  urine 
was  more  abundant  and  less  albuminous.  The  mother  remarked  that  the  new 
medicine  (pilocarpine)  had  settled  the  stomach  and  increased  the  urine.  The 
patient  continued  to  improve,  and  on  July  4th  the  record  states :  "  Now  takes  the 
pilocarpine,  gr.  -^^^  every  six  hours :  passes  urine  freely  since  yesterday  ;  has  not 
vomited  since  he  began  to  take  the  pilocarpine  :  pulse  106,  axillary  temp.  99°;  is 
playful  and  takes  milk  freely,  nearly  three  quarts  in  twenty-four  hours,  with  some 
farinaceous  food.  Digitalis  with  potassium  acetate  is  also  given  in  occasional 
doses."  July  6th,  pulse  92,  temp.  99°;  perspires  much,  and  urine  nearly  normal 
in  quantity  and  character. 

Case  2. — Mary  S ,  aged  five  years,  on  Dec.  22,  1882,  presented  the  symp- 
toms of  severe  nephritis.  Her  brother  had  scarlet  fever  two  weeks  previously,  and 
she  had  sore  throat  at  about  the  same  time,  but  without  eSlorescence  ;  pulse  98, 
temperature  98.5°;  her  urine  highly  albuminous,  and  reduced  to  f^iv  in  twenty- 
four  hours ;    bowels  constipated.     Ordered  a  single  dose  of 

R.  Hydi-arg.  chlor.  mitis,  gr.  iij  ; 

Eesin.  podophylL,  gr.  \. — Misce. 

The  muriate  of  pilocarpine  was  also  ordered,  gr.  ^,  but  the  patient  vomited  soon 
after  taking  it.  Another  dose  was  retained,  and  was  followed  by  considerable  per- 
spiration. Dec.  23d,  had  one  stool  from  the  powder  of  yesterday.  Has  taken  five 
doses  of  pilocarpine,  but  vomited  after  three  of  them.  The  last  dose  was  adminis- 
tered at  10  p.  M.,  and  the  mother  says  she  "  sweat  fearfully  ''  during  the  night.  The 
patient  was  kept  warm  in  bed  ;  stimulating  poultices  of  mustard  and  flaxseed,  one 


296  COXSTTTUTIOXAL  DISEASES. 

to  sixteen,  were  constantly  in  use  over  the  kidneys,  and  the  pilocarpine  was  admin- 
istered three  or  four  times  a  day.  The  record  for  Dec.  26th  states:  "Took  the 
pilocarpine  four  times  since  yesterday  morning,  and  each  dose  is  followed  by  per- 
spiration lasting  from  one  to  one  and  a  half  hours  -.  quantity  of  urine,  from  f5vj 
to  f5viij  daily :  vomited  twice  yesterday,  not  to-day ;  pulse  1U4 :  temp.  97.75° ; 
complains  of  frontal  headache  :  bowels  regular :  has  considerable  salivation.  The 
patient  is  warm  in  bed.  and  the  flaxseed  and  mustard  poultice  over  the  kidneys  is 
continued."  Dec.  2Sth,  specific  gravity  of  urine  1019  :  urine  still  quite  alljuminous 
and  containing  blood-corpuscles  and  granular  casts,  also  crystals  of  oxalate  of  lime. 
Dec.  30th.  takes  gr.  -^  pilocarpine  twice  daily,  and  occasional  doses  of  infusion  of 
digitalis :  urine  more  abundant :  its  specific  gravity  1014.  slightly  albuminous,  and 
containing  very  few  granular  casts  and  blood-corpuscles  :  has  lost  its  smoky  appear- 
ance :  reaction  alkaline  :  perspiration  slight :  patient  convalescent. 

In  another  instance  a  child  of  five  years,  from  three  to  four  weeks  after 
scarlet  fever,  was  noticed  to  have  anasarca  of  the  face  and  extremities,  with 
scanty  and  albuminous  urine.  One  thirty-second  of  a  grain  of  muriate  of 
pilocarpine  was  administered  every  six  hours  without  the  desired  sudorific 
efi'ect.  It  was  then  administered  every  four  hours,  with  an  increase  of  per- 
spiration and  urination,  so  that  the  nephritic  symptoms  were  relieved  and  the 
patient  apparently  out  of  danger  within  three  or  four  days. 

In  a  fourth  patient,  a  girl  of  three  years  having  scarlatinous  nephritis, 
with  symptoms  very  similar  to  those  in  the  last  case,  the  administration  of 
one-twentieth  grain  doses  of  pilocarpine  in  conjunction  with  the  hot-air  bath 
was  followed  by  increased  perspiration  and  urination,  and  progressive  and 
rather  rapid  convalescence.  This  child  had  been  taking  bichloride  of  mercury 
in  one-fiftieth  grain  doses,  prescribed  by  a  homoeopathic  physician,  without 
appreciable  benefit,  it  having  been  for  the  most  part  vomited. 

Cxiven,  as  in  the  above  cases,  in  moderate  doses  and  with  sufiicient  inter- 
val, pilocarpine  has  never  in  my  practice  had  any  deleterious  efi'ect,  and  I 
regard  it  as  a  very  important  addition  to  the  remedies  for  the  relief  of  scar- 
latinous nephritis.  It  is  apparently  the  most  useful  and  important  diaphoretic 
for  this  disease  which  we  possess,  but  .pilocarpine  is  a  dangerous  remedy  if 
not  given  in  the  proper  small  doses  and  at  proper  intervals.  It  has  pro- 
duced a  fatal  bronchorrhcea  by  too  large  a  dose,  of  which  I  was  a  witness ;  so 
that  it  must  be  given  in  small  doses  and  its  eff"ects  closely  watched. 

Cathartics,  especially  those  of  a  hydragogue  nature,  are  also  very  bene- 
ficial. Their  action  is  more  certain  than  that  of  most  diaphoretics  and  diu- 
retics, and  their  employment  is  imperatively  required  in  severe  or  dangerous 
cases  in  which  it  is  necessary  to  remove  as  soon  as  possible  the  serum  or  urea 
which  endangers  life.  Young  children  or  those  with  delicate  stomachs  and 
those  much  enfeebled  by  the  primary  disease  may  take  magnesia,  either  the 
citrate  or  the  calcined.  A  good  cathartic  for  ordinary  robust  cases  is  a  mix- 
ture of  jalap  and  potassium  bitartrate.  the  pulvus  jalap^e  eompositus,  consist- 
ing of  one  part  of  jalap  and  two  of  cream  of  tartar.  Ten  grains  of  the  mixture 
may  be  given  to  a  child  of  five  years,  and  repeated  according  to  circum- 
stances. Its  efi'ect  is  increased  by  dissolving  a  teaspoonful  of  potassium 
bitartrate  in  a  gobletful  of  water  and  allowing  the  patient  to  drink  from  it. 
The  following  cathartic  also  acts  promptly  and  beneficially  in  the  treatment 
of  scarlatinous  nephritis  : 

R.  01.  cinnamomi,  gtt.  v; 

Magnes.  sulphat.,  §j  ; 

Potass,  bitartrat.,  ^ij. — Misce. 

Dose  :  One  teaspoonful  repeated  from  two  to  four  hours  until  catharsis  occurs. 

After  the  use  of  laxative  agents  the  kidneys,  being  less  congested  on 
account  of  the  diversion  that  has  occurred,  often  begins  to  excrete  urine 


SCARLET  FEVER.  297 

more  freely.  But  if  the  patient  be  angemic  or  enfeebled  and  the  symptoms 
are  not  urgent,  it  is  frequently  better  to  avoid  active  catharsis,  which  more 
or  less  reduces  the  strength,  and  employ  remedies  of  a  sustaining  character, 
as  in  the  following  case,  which  occurred  in  my  practice :  A  little  boy,  pallid 
and  scrofulous,  began  to  have  anasarca  after  scarlet  fever,  chiefly  in  the  scro- 
tum, accompanied  by  a  moderate  degree  of  ascites.  The  urine,  which  was 
passed  in  nearly  the  normal  quantity,  contained  albumen,  but  not  in  large 
amount.  This  patient  gradually  and  fully  recovered,  with  no  treatment 
except  the  use  of  an  oil-silk  jacket  over  the  kidneys  and  abdomen  to  pro- 
mote diaphoresis,  and  the  use  of  iron.  Such  a  patient,  treated  by  the  power- 
ful eliminatives  which  we  employ  for  the  more  urgent  and  robust  cases,  would 
probably  have  been  injured  rather  than  benefited.  No  treatment  can  there- 
fore be  recommended  in  a  treatise  on  scarlatinous  nephritis  which  will  be 
strictly  applicable  for  all  cases.  Variations  are  demanded  according  to  the 
state  of  the  patient  and  the  form  and  gravity  of  the  disease. 

Diuretics  which  do  not  stimulate  the  kidneys  are  proper  at  an  early  as 
well  as  late  period  of  the  renal  malady.  The  following  is  a  favorite  diuretic 
in  the  New  York  City  Hospital : 

R.  Potass,  acetat.,  ^ 

"     bicarbonat.,  ^  aa  gij  ; 

"     citrat.,  j 

Infus.  tritici  repentis,  ^iv. — IVIisce. 

Give  one  teaspoonful  every  two  hours. 

One  teaspoonful  of  the  infusion  may  be  given  every  third  hour  to  a  child 
of  five  years.  The  following  formula  is  for  one  of  the  same  age  in  good 
general  condition.     It  should  be  given  in  water : 

R.  Potass,  acetatis,  ^ss  ; 

Infus.  digitalis,  ^5^]- — Misce. 

Give  one  teaspoonful  from  two  to  four  hours. 

Local  treatment  is  important.  In  the  majority  of  cases  instead  of  depletion 
a  poultice  slightly  irritating,  so  as  to  cause  redness  of  the  skin,  should  be 
applied  over  the  kidneys,  or  for  older  children,  not  likely  to  be  frightened  by 
the  process,  the  dry  cups  may  be  applied  daily.  In  subacute  cases,  not 
attended  by  any  alarming  symptoms,  sufficient  redness  may  be  produced  by 
the  external  use  of  one  part  of  ttirpentine  and  two  of  camphorated  oil. 

Eclampsia,  described  in  the  preceding  pages,  is  produced,  as  we  have  seen, 
during  the  course  of  scarlet  fever  by  the  irritating  effect  of  the  scarlatinous 
poison  upon  the  nervous  centres ;  but,  occurring  after  the  decline  of  scarlet 
fever,  it  is  ordinarily  produced  by  the  retained  urea.  The  same  remedies  are 
required  to  control  the  convulsive  movements  as  when  they  occur  under 
other  circumstances.  The  bromide  of  potassium  should  be  immediately 
administered  in  large  doses  whenever  eclamptic  symptoms  arise.  During 
eclampsia  a  child  of  three  years,  should  take  five  grains  of  this  agent  every 
five  to  ten  minutes  till  the  attack  ceases,  and  then  at  longer  intervals.  The 
hydrate  of  chloral  is  a  more  powerful  agent,  and  if  the  eclampsia  be  not 
quickly  controlled,  I  commonly  employ  it  per  rectum,  dissolved  in  one  or  two 
teaspoonfuls  of  water.  For  a  child  of  three  to  five  years. five  grains  should 
be  thrown  into  the  rectum  by  a  small  glass  or  gutta-percha  syringe,  and 
retained  by  pressure.  Properly  administered  and  retained,  it  rarely  fails  to 
control  the  eclampsia  within  ten  or  fifteen  minutes.  Subsequently,  occa- 
sional doses  of  the  bromide  should  be  given  to  prevent  the  occurrence  of 
eclampsia  while  the  measures  described  above  are  being  employed  to  elimi- 
nate the  urea. 


298  CONSTITUTIONAL  DISEASES. 

Khe^^matism,  endocarditis,  and  pericarditis,  arising  as  complications  or 
sequelaj.  require  the  treatment  which  is  appropriate  when  they  occur  under 
other  circumstances,  but  the  remedies  should  not  be  depressing,  as  the  sys- 
tem is  alread}'  enfeebled  by  the  primary  disease.  The  rheumatism,  if  mild, 
usually  abates  in  a  few  days  without  medication,  and  the  affected  joints 
require  only  some  soothing  lotion  and  support  by  a  bandage.  The  following 
liniment  may  be  applied  upon  muslin  and  covered  by  cotton  wadding : 

R.    01.  caryophylli,  ^^^ij  ; 

Tine,  belladoimse,  f3J  ; 

01.  camphorati,  ^o^J- — Misce. 

If  the  rheumatism  be  severe  and  affect  several  joints,  the  sodium  salicylate 
should  be  prescribed,  as  in  the  idiopathic  disease,  with  an  occasional  opiate  to 
procure  rest. 

Endocarditis  and  pericarditis  require  rest  in  the  horizontal  position,  avoid- 
ance of  all  excitement,  the  use  of  the  tincture  or  infusion  of  digitalis  or  the 
tincture  of  strophanthus  to  procure  a  slow  and  steady  action  of  the  heart. 
Three  drops  of  the  tincture  of  digitalis  or  one  to  one  and  a  half  drops  of 
the  tincture  of  strophanthus  may  be  given  every  four  hours  to  a  child  of  five 
years.  The  same  external  measures  should  be  employed  as  in  acute  pleu- 
ritis.  I  prefer  the  application  of  a  thin  poultice  of  flaxseed  containing  one- 
sixteenth  part  of  mustard  and  covered  w^ith  oiled  silk.  The  cardiac  inflam- 
mations, as  well  as  rheumatism,  require  opiates  in  sufficient  doses  to  procure 
rest  and  sleep. 

In  some  instances  strychnia,  gr.  y-^g-  to  a  child  of  eight  years,  is  the  better 
heart  tonic. 

Pleuritis,  which  we  have  stated  is  often  suppurative,  demands  the  same 
treatment  as  the  idiopathic  disease  when  it  occurs  in  cachectic  patients. 


CHAPTER    III. 
KOTHELN. 

This  disease  has  also  been  designated  rubella,  epidemic  roseola,  rosalia^ 
rubeola  notha,  and  German  measles.  Some  recent  writers  incline  to  the 
belief  that  it  occurred  in  Europe  in  the  eighteenth  century,  having  the  name 
rubeola.  Thomas  states  that,  according  to  Formey,  -iST  died  from  rubeola, 
172  from  scarlet  fever,  and  53  from  measles  in  Berlin  in  the  decade  beginning 
with  1784 ;  but  he  also  states  that  many  who  observed  these  epidemics  be- 
lieved that  the  rubeola  was  a  species  of  measles.  We  infer  that  this  was  the 
correct  opinion,  and  that  the  rubeola  of  the  eighteenth  century  was  not  the 
rotheln  of  the  present  time,  since  the  latter  is  almost  never  fatal,  except  from 
complications.  In  Great  Britain,  from  the  year  1840  onward,  various  writers, 
when  treating  of  measles  and  scarlet  fever,  make  statements  which  lead  us  to 
think  that  they  may  have  sometimes  mistaken  epidemics  of  rotheln  for  modi- 
fied forms  of  measles  or  scarlet  fever.  Perhaps  it  is  not  too  much  to  claim 
that  the  first  clear  and  distinct  differentiation  of  rotheln  was  made  in  this 
country.  Cases  of  rotheln  occurring  in  and  about  Boston  were  described  by 
Dr.  Romans,  Sr..  in  1845,  and  at  a  later  date — to  wit,  in  1853  and  1871 — B. 
E.  Cotting  and  Mr.  D.  Howard  saw  cases,  and  described  them  in  papers  read 


ROTHELN.  299 

before  local  societies  {Bost.  Med.  and  Surg.  Journ.,  March  15,  1873).  In 
187-1,  Dr.  Caleb  Green  of  Homer,  Cortland  co.,  New  York,  an  accurate  and 
intelligent  observer,  also  witnessed  an  epidemic  of  this  disease. 

Rotheln  was  not,  however,  noticed  in  American  treatises,  and  it  scarcely 
received  recognition  in  America,  until  an  epidemic  of  it  occurred  in  the  New 
York  Foundling  Asylum  and  in  New  York  City  in  1873-74,  which  furnished 
the  material  for  a  paper  published  in  the  Archives  of  Dermatology  in  187^1:. 
This  epidemic  began  in  the  latter  part  of  1873,  and  attained  its  maximum  in 
March  and  April,  1874.  after  which  it  gradiially  declined.  This,  so  far  as  I 
can  learn,  was  the  first  occurrence  of  rotheln  in  this  locality.  In  a  general 
practice  of  more  than  twenty  years,  extending  over  a  considerable  portion 
of  this  city,  I  had  previously  seen  nothing  like  it,  and  other  older  physicians, 
having  a  large  general  practice,  informed  me  that  they  considered  it  an  en- 
tirely new  disease  with  us.  Those  who  believed  that  they  had  occasionally 
observed  isolated  cases  of  it  previously  to  this  epidemic  probably  referred  to 
roseola. 

The  first  case  which  I  observed  occurred  in  the  middle  of  December, 
1873,  in  West  Seventy-first  street,  in  the  northern  suburbs  of  Xew  York. 
A  few  weeks  later  cases  were  so  numerous  in  the  more  thickly-populated 
section  of  the  city  as  to  attract  the  attention  of  many  physicians.  It  was 
evident  that  a  disease  had  appeared  with  which  we  were  not  familiar,  and 
as  the  eruption  occurred  in  points  and  small  circumscribed  patches,  it  was 
usually  designated  by  the  physicians,  in  want  of  a  more  accurate  name, 
epidemic  roseola,  or  was  spoken  of  as  a  spurious  measles.  Physicians  who 
were  familiar  with  foreign  medical  literature  saw  the  resemblance  between 
these  cases  and  those  of  rotheln  as  described  by  British  and  continental 
writers,  but  in  certain  at  least  of  the  foreign  cases  the  duration  of  the  rash 
was  said  to  be  seven  days  (Liveing,  London  Lancet.,  March  14,  1874,  and 
Med.  Neics  and  Library ^  May,  1874),  whereas  in  the  cases  in  Xew  York  it 
commonly  disappeared  by  the  fourth  day.  This  discrepancy,  however,  was 
not  sufficient  to  invalidate  the  belief  in  the  identity  of  the  New  York  disease 
with  the  foreign  rotheln.  It  was  readily  explained  by  the  difference  in  the 
seasons  in  which  the  cases  occurred,  for  Liveing  observed  his  cases  in  June 
and  July,  and,  as  we  will  see,  the  greater  the  external  heat  the  longer  is  the 
duration  of  the  eruption. 

Between  the  middle  of  December,  1873,  and  May  1, 1874, 1  had  observed 
and  treated  this  malady  in  eighteen  families.  Cases  occurred  in  three  other 
families  living  in  the  same  houses  with  some  of  those  which  I  attended,  and, 
as  they  were  fully  and  clearly  described  to  me,  so  that  there  could  be  no  doubt 
as  to  their  nature,  I  have  included  them  in  my  statistics.  The  total  number 
of  cases  in  these  twenty-one  families  was  48.  During  May,  when  the  epi- 
demic was  declining,  I  saw  6  additional  cases,  occurring  singly,  making  a  total 
of  54.     Their  ages  are  given  in  the  following  table : 

Age.  Cases. 

From  eight  months  to  one  year 2 

' '     one  year  to  two  years 4 

"      two  years  to  five  years 16 

' '      five  years  to  ten  years 23 

"      ten  years  to  fifteen  years 3 

"      fifteen  years  to  thirty  years 6 

Total  number  of  cases 54 

The  age  of  the  youngest  patient  was  eight  months  and  that  of  the  oldest 
thirty  years :  72  per  cent,  of  the  total  number  were  between  the  ages  of  two 
and  ten  years,  so  that  rotheln  is  pre-eminently  a  disease  of  childhood.     Indi- 


300  CONSTITUTIONAL  DISEASES. 

viduals  in  and  beyond  the  middle  period  of  life  seem  to  have  nearly  an  immu- 
nity from  it.  The  age  of  the  oldest  patient  of  whom  I  was  informed  in  the 
epidemic  of  1873  and  1874  was  about  forty  years.  On  March  25, 1873,  during 
my  attendance  in  the  New  York  Foundling  Asylum,  rotheln  appeared  in  a 
boy  of  four  years ;  in  the  following  month  about  thirty  more  cases  occurred 
in  this  institution,  all  children,  while  among  the  large  number  of  female  nurses 
and  employes,  who  were  chiefly  between  the  ages  of  twenty  and  thirty  years, 
all  but  three  escaped. 

From  1874  to  1880  rotheln  did  not  prevail  in  New  York,  unless  now  and 
then  an  isolated  or  sporadic  case,  the  nature  of  which  was  not  recognized 
and  which  was  supposed  to  be  roseola.  On  August  9,  1880,  two  cases 
appeared  in  diff"erent  wards  of  the  New  York  Foundling  Asylum,  when  it 
was  remembered  that  two  weeks  previously  these  children  had  been  exposed 
to  a  patient  in  the  hospital  attached  to  the  institution  who  had  what  the  phy- 
sician in  attendance  supposed  at  the  time  to  be  roseola. 

Commencing  with  these  two  cases,  an  epidemic  occurred  in  the  asylum, 
mild  in  type,  aifecting  only  a  few  at  a  time,  but  extending  over  several 
months,  until  about  sixty  inmates,  chiefly  children,  were  attacked.  Toward 
the  close  of  1880  rotheln  began  to  appear  in  the  northern  part  of  the  city, 
in  which  the  asylum  is  located  and  over  which  my  practice  extends.  Its 
maximum  prevalence  was  attained  in  the  latter  part  of  March  and  April, 
1881,  when  it  particularly  attracted  the  attention  of  physicians.  A  large 
proportion  of  the  children  attending  certain  public  and  private  schools  were 
attacked.  It  occurred  in  seventeen  families  in  my  practice.  The  ages  of  the 
patients  in  these  families  are  given  in  the  following  table : 

Age.  Cases. 

From  one  to  two  years 3 

"      two  to  five  years 8 

"      five  to  ten  years      18 

"     ten  to  fifteen  years 11 

There  were  two  cases  over  fifteen  years,  aged  respectively  twenty -two 

and  forty-two  years .    .  ^ 

Total  number  of  cases 42 

Premonitory  Stage.  —  Premonitory  symptoms  are  in  most  instances 
absent  or  so  mild  as  to  attract  but  little  attention.  It  not  infrequently 
happened  in  the  New  York  epidemics  that  the  parents  or  the  teachers  in  the 
schools  were  first  made  aware  of  the  illness  of  the  children  by  observing  the 
eruption.  In  some  instances  children  were  sent  from  school,  not  because  they 
felt  too  ill  to  remain,  but  on  account  of  the  unusual  appearance  of  the  skin. 
Sometimes,  however,  in  those  old  enough  to  express  their  sensations  a  pre- 
monitory stage  of  some  hours  or  a  day,  or  even  of  longer  duration,  was 
present,  consisting  of  such  symptoms  as  usually  occur  when  one  has  taken 
a  severe  cold,  as  languor,  pain  in  the  head,  trunk,  or  limbs.  The  resident 
physician  of  the  New  York  Foundling  Asylum  was  so  ill  with  rotheln  that 
he  was  confined  to  his  bed  during  the  first  day  of  the  disease.  Now  and  then 
patients  experience  nausea  previously  to  the  eruption  and  in  the  first  and 
second  days  of  the  eruptive  stage.  In  only  one  instance  did  I  observe  grave 
prodromic  symptoms.  A  boy  aged  eight  years  was  suddenly  seized  with  clonic 
convulsions,  and  while  in  a  warm  bath  for  the  relief  of  these  the  rash  appeared 
upon  those  parts  of  the  body  which  were  immersed  in  water. 

Symptoms. —  Tegwnentary  System. — {a)  The  Skin. — ^The  eruption  com- 
monly commences  upon  the  forehead,  around  the  ears,  and  along  the  neck, 
as  in  measles.  Occasionally  it  may  appear  upon  the  back  or  chest,  as  in  the 
above-mentioned   case,  in  which  the  hot  water    accelerated   its  appearance. 


BOTHELN.  301 

Commencing  above,  the  efflorescence  travels  downward,  appearing  after  some 
hours  upon  the  lower  part  of  the  trunk  and  on  the  legs,  resembling  in  this 
respect  the  eruption  of  measles  and  scarlatina.  It  occurs  upon  all  parts  of 
the  integument  except  the  scalp  and  palmar  and  plantar  surfaces.  In  the 
majority  of  the  cases  which  I  have  seen  it  gradually  faded  away,  disappear- 
ing by  the  fourth  day,  but  in  children  who  were  kept  warm  in  bed  or  in 
warm  apartments  it  remained  longer  than  on  others.  In  many  instances 
traces  of  the  rash  were  still  visible  several  days  after  recovery  when  the 
patients  were  heated  by  exercise  or  excitement.  It  reappeared  at  times, 
though  indistinctly,  on  a  girl  of  thirteen  years  for  three  weeks.  In  most 
of  the  cases  in  the  New  York  epidemics  the  eruption  commonly  occurred  in 
points  and  circular  spots  somewhat  smaller  than  those  of  measles.  These 
points  and  spots  were  numerous  and  thickly  set,  so  that,  in  the  aggregate, 
they  covered  at  least  half  of  the  surface,  while  between  them  the  skin  pre- 
sented nearly  or  quite  its  normal  appearance.  The  general  aspect  in  most 
cases  was  more  like  that  of  measles  than  that  of  scarlatina,  but  in  exceptional 
instances  the  skin  between  the  points  and  spots  had  a  redness  similar  to  that 
of  erythema,  and  the  resemblance  was  very  like  the  scarlatinous  efflorescence. 
Thus,  in  a  boy  of  three  years  the  eruption  so  closely  resembled  the  scarlat- 
inous over  the  trunk  that  were  it  not  that  the  temperature  was  constantly 
below  100°,  and  the  fever  entirely  ceased  within  three  or  four  days,  I  would 
probably  have  considered  the  malady  a  mild  scarlatina.  In  certain  patients 
the  eruption,  beginning  in  circumscribed  spots,  like  that  of  measles,  becomes 
in  two  or  three  days  confluent,  so  as  to  resemble  that  of  scarlatina,  while 
over  other  parts  the  spots  remain  discrete.  This  was  the  character  of  the 
eruption  upon  the  third  and  fourth  days  on  the  extremities  of  a  little  boy  in 
the  Foundling  Asylum.  The  rash  is  attended  by  considerable  itching,  from 
which,  indeed,  many  patients  suiFer  more  than  from  all  other  symptoms. 

The  eruption  disappears  on  pressure,  produces  a  slight  roughness  of  the 
surface,  as  ascertained  by  passing  the  fingers  gently  over  it,  and  usually  fades 
away  without  desquamation.  Exceptionally,  there  is  a  slight  branny  exfolia- 
tion, and  in  one  of  my  patients  the  exfoliation  was  as  great  over  the  abdomen 
as  in  cases  of  scarlatina. 

(V)  The  Mucous  Memhrane. — In  connection  with  the  cutaneous  eruption 
a  mild  inflammation  also  occurs  upon  the  mucous  membrane  covering  the 
fauces,  buccal  cavity,  and  nostrils,  and  upon  reflections  of  this  membrane 
over  the  eyes  and  eyelids — i.  e.,  upon  the  conjunctiva.  In  certain  patients 
this  inflammation  is  scarcely  appreciable,  but  in  the  majority  it  arrests  atten- 
tion at  once.  It  produces  a  suff"used,  reddish,  or  weak  appearance  of  the  eyes, 
with  a  moderately  increased  lachrymation.  On  everting  the  eyelids  the  pal- 
pebral conjunctiva  is  seen  to  be  injected.  In  certain  patients  a  moderate  puri- 
form  secretion  collects  at  the  inner  angle  of  the  eyelids.  In  occasional  cases 
the  conjunctivitis  causes  oedema  of  the  lids,  usually  slight  and  likely  to  be 
overlooked  by  the  physician ;  but  in  three  instances  which  I  now  recall  to 
mind  the  mothers  of  the  children  directed  my  attention  to  the  swollen  state 
of  the  lids.  In  one  of  these,  an  infant  of  twenty-three  months,  the  tumefac- 
tion was  so  great,  commencing  about  the  time  the  eruption  began  to  fade, 
that  light  was  totally  excluded  from  the  eyes  and  it  was  impossible  to  ascer- 
tain their  condition.  The  skin  over  the  eyelids  retained  nearly  its  normal 
appearance,  and  a  puriform  secretion  appeared  between  the  lids.  In  three 
or  four  days  the  oedema  of  the  lids  and  the  hypersemia  of  the  conjunctiva 
declined.  The  coryza  is  in  most  cases  sufficient  to  cause  an  unpleasant  sen- 
sation in  the  nostrils  and  provoke  sneezing ;  but  the  flow  from  the  nostrils, 
though  present,  was  in  no  instance  under  my  observation  as  abundant  as  in 
ordinary  cases  of  scarlatina  or  even  of  measles.    The  fauces  present  an  injected 


302  CONSTITUTIONAL  DISEASES. 

appearance,  and  in  severe  cases  there  is  moderate  swelling  of  the  tonsils.  The 
same  catarrhal  hypersemia  is  also  seen  in  spots  or  patches,  more  or  less  diffused, 
upon  the  buccal  surfaces.  Both  the  faucial  and  buccal  catarrh  are  less  in 
degree,  however,  than  in  cases  of  rubeola  and  scarlatina,  which  have  an  equal 
intensity  of  cutaneous  eruption ;  and  this  fact  aids  in  differential  diagnosis. 

Th(^  Respiratory  System. — In  both  the  epidemics  which  I  have  witnessed 
the  mucous  membrane  of  the  larynx,  trachea,  and  bronchial  tubes  participated 
only  slightly  in  the  inflammation  which  involved  the  nasal,  buccal,  and  faucial 
surfaces.  Many  of  my  patients  had  no  cough,  but  others  had  a  mild  cough, 
lasting  a  few  days,  but  with  normal  respiration.  It  was  due  apparently  to  a 
very  mild  catarrh  of  the  respiratory  ti'act  at  the  time  when  the  nasal  and 
conjunctival  surfaces  were  the  most  affected.  It  subsided  in  a  few  days 
without  treatment.     In  no  case  do  I  recollect  that  there  was  any  hoarseness. 

The  Digestive  System. — The  tongue  in  rotheln  is  moist  and  of  normal 
appearance  or  covered  by  a  slight  fur.  The  appetite  may  be  impaired,  but 
is  not  wanting  in  uncomplicated  cases.  The  patients  sometimes  say  that  it  is 
nearly  the  same  as  in  health  ;  the  thirst  is  slight,  and  the  bowels  are  regular. 

^'ausea  is  not  infrequent,  and  vomiting  was,  in  several  cases  in  my  prac- 
tice, one  of  the  initial  symptoms.  In  certain  patients  it  also  occurred  on  the 
first  or  second  day  of  the  eruption.  In  others  there  was  no  nausea,  so  far  as 
I  could  learn,  either  immediately  before  or  during  the  prevalence  of  the 
disease.  This  symptom  is  less  frequent  in  rotheln  than  in  scarlet  fever,  but 
is  as  common  apparently  as  in  measles.  I  have  never  found  albumen  in  the 
urine,  though  I  have  examined  that  passed  by  several  patients.  This  secre- 
tion did  not  appear  to  be  abnormal  except  as  it  contained  urates,  so  common 
in  febrile  states. 

The  Pulse  and  Temperature. — The  largest  number  of  accurate  daily  obser- 
vations relating  to  the  temperature  was,  I  think,  that  of  Dr.  Reid  in  the  New 
York  Foundling  Asylum  during  the  month  of  March,  1874.  He  has  kindly 
furnished  me  with  his  statistics  relating  to  this  symptom,  as  follows:  "The 
number  of  closely-observed  cases  in  which  the  temperature  was  taken  was 
24.  In  17  of  the  cases  the  temperature  ranged  from  97°  to  99°  ;  in  6  it 
reached  100°,  100J°,  and  100|°  ;  in  1  it  reached  103J°  on  the  second  day 
of  the  eruption,  but  remained  so  elevated  only  one  day."  In  certain  patients 
Dr.  Eeid  observed  what  he  designates  "  a  tendency  to  the  development  of  an 
ephemeral  fever."  These  observations  correspond  closely  with  those  made  by 
myself  during  the  same  epidemic.  Thus,  in  16  cases  I  found  the  axillary 
temperature  taken  each  day  to  be  constantly  between  98°  and  100°,  with  a 
pulse  under  110,  except  in  1  case,  in  which  it  numbered  124.  In  certain 
other  patients  a  more  decided  rise  in  temperature  from  one  to  two  or  three 
days  occurred,  usually  in  the  commencement  of  the  malady.  Thus,  a  girl 
aged  three  and  a  half  years  had  a  temperature  of  101 1°  and  a  pulse  of  128.  In 
another  instance  the  pulse  was  124  and  the  temperature  102°.  In  another, 
a  girl  of  three  and  a  half  years,  considerable  fever  occurred  without  apparent 
cause  on  Saturday  night,  but  it  abated  on  the  subsequent  day.  She  seemed 
well  until  the  following  Tuesday,  when  the  fever  returned  and  the  eruption 
appeared.  On  Thursday  the  temperature  from  102°  to  103°  fell  to  99*°, 
and  within  a  day  or  two  she  was  convalescent.  In  two  other  patients  from 
two  to  four  days  after  the  disappearance  of  the  eruption  an  accession  of  fever 
occurred,  lasting  about  one  day,  and  attended  by  pain  and  distress  in  the 
epigastric  region,  but  without  vomiting  or  diarrhoea.  In  one  of  these  the 
temperature  was  103f  °,  the  pulse  130  per  minute.  In  the  other  case  the  tem- 
perature and  pulse  did  not  seem  to  be  under  these  figures,  but  were  not 
accurately  ascertained.  Occasionally  the  fever  is  due  more  to  complications 
than  to  the  primary  disease.     Thus,  in  two  of  my  patients  the  rise  of  tern- 


r'Otheln.  303 

perature  was  mainly  attributable  to  diphtheritic  inflammation  which  had 
attacked  the  fauces.  But  while  the  fever  in  rotheln  is  ordinarily  of  short 
duration,  in  certain  patients  temporary  exacerbations  may  occur  in  which  the 
temperature  is  as  high  as  in  scarlet  fever  or  measles. 

Complications  ;  Prognosis. — The  only  complications  which  occurred  in 
cases  in  my  practice  have  already  been  alluded  to — to  wit,  diphtheria,  which, 
when  prevalent,  usually  attacks  surfaces  already  inflamed.  In  the  Fou.ndling 
Asylum  varicella  complicated  one  case  and  pneumonia  another.  In  a  third 
pneumonia  occurred  about  three  days  after  the  disappearance  of  the  eruption. 
The  prognosis  in  uncomplicated  cases  is  always  very  favorable,  and  there  is 
no  liability  to  sequelae  more  than  in  mild  catarrhal  inflammations  of  a  non- 
specific character.  The  duration  of  rotheln  is  short,  not  ordinarily  extending 
beyond  three  to  five  days. 

Nature  ;  Incubative  Period  ;  Contagiousness. — Is  rotheln  a  distinct 
malady,  or  one  with  which  we  are  familiar,  but  the  form  and  character  of 
which  are  modified  by  unusual  meteorological  conditions  ?  Is  it  roseola 
■assuming  at  certain  periods  an  epidemic  character  and  appearing  to  be  con- 
tagious ?  Or  is  it  at  all  times  infectious,  possessing  a  specific  principle,  and, 
like  other  infectious  diseases,  self-propagating?  Should  it  in  nosological 
classification  be  placed  among  the  non-contagious  and  local  or  among  the 
constitutional  and  infectious  maladies  ?  Let  us  consider  the  facts  observed 
in  the  New  York  epidemics. 

The  first  cases  of  rotheln  in  this  city  were  often  designated  roseola  by  the 
physicians  called  to  treat  them,  since  they  seemed  to  resemble  more  closely 
this  disease  than  any  other  with  which  they  were  familiar.  But  rotheln' 
difi"ers  widely  from  the  peculiar  form  of  dermatitis  known  as  roseola.  The 
successive  occurrence  of  the  eruption  over  the  upper  and  then  the  lower 
parts  of  the  body,  but  covering  the  whole  surface,  and  the  definite  duration 
of  three  to  five  days,  are  points  of  difi'erence.  Moreover,  roseola  would  not, 
without  so  great  a  change  in  its  character  as  to  become  virtually  a  distinct 
disease,  occur  in  the  cool  months,  without  any  appreciable  dietetic  cause,  as 
an  epidemic  over  a  certain  area  and  for  a  limited  time,  aff"ecting  whole  house- 
holds and  sparing  other  households  as  well  as  individuals  of  a  certain  age. 
We  therefore  consider  it  distinct  from  roseola. 

Most  of  the  cases  of  the  New  York  epidemics  bore  considei'able  resem- 
blance to  measles,  both  as  regards  the  appearance  and  duration  of  the  erup- 
tion and  the  catarrh  of  the  mucous  surfaces.  Parents  often  diagnosticated 
measles  before  the  arrival  of  the  physician,  and  the  physician  himself,  at  first 
glance,  sometimes  made  the  same  diagnosis.  But  in  rotheln  the  shortness 
and  mildness  of  the  stage  of  invasion,  the  absence  of  cough  or  the  presence 
of  one  trivial  and  scarcely  noticed,  appetite  good  or  but  slightly  impaired — 
in  fine,  symptoms  that  are  transient  or  slight — afi"ord  a  striking  contrast  to 
the  graver  symptoms  of  measles.  But  the  decisive  proof  that  rotheln  is  not 
a  modified  measles  is  found  in  the  fact  that  one  does  not  prevent  the  other. 
Of  the  48  cases  observed  by  myself  prior  to  May  1st  in  the  epidemic  of 
1874,  19  at  least  had  had  measles,  and  1  who  had  rotheln  took  measles  sub- 
sequently. I  have  already  stated  that  in  the  New  York  Foundling  Asylum 
rotheln  in  1873  and  1874  closely  followed  an  epidemic  of  measles.  A  con- 
siderable number  of  the  children  attacked  by  the  former  disease  had  recently 
recovered  from  the  latter.  During  the  epidemic  of  1880  and  1881  the  same 
fact  was  observed — namely,  that  a  previous  attack  of  measles  as  well  as 
scarlet  fever  afforded  no  protection  from  rotheln.  Dr.  Chadbourne,  the  resi- 
dent physician,  writes  of  the  cases  in  the  Foundling  Asylum  in  1880  and 
1881 :  "  Eight  children  had  rotheln  who  had  had  both  scarlet  fever  and 
measles  within  six  months  under  my  observation,  while  certain  others  had 


304  CONSTITUTIONAL  DISEASES. 

had  these  diseases  at  some  previous  time.'  Of  the  cases  observed  \>\  myself 
in  family  practice  in  the  same  epidemic,  it  is  stated  in  my  notes  that  ten  had 
had  measles.  These  statistics  are  sufficient  to  show  that  rotheln  is  a  distinct 
disease  from  measles,  however  close  the  kinship. 

That  rotheln  is  not  a  form  of  scarlet  fever  is  evident  from  the  fact  that 
as  resards  at  least  the  Xew  York  epidemics  the  rash  was  in  most  instances 
quite  distinct  from  the  scarlatinous  efflorescence,  occurring,  as  we  have  said, 
in  small  more  or  less  circular  points  and  patches.  Moreover,  as  we  have 
remarked  above,  there  is  in  rotheln  a  slight  febrile  movement  and  general 
mildness  of  symptoms  which  contrast  with  the  high  fever  and  other  pro- 
nounced symptoms  of  scarlatina,  or  if  there  be  considerable  febrile  move- 
ment its  duration  is  brief.  But  the  conclusive  proof  of  an  essential  differ- 
ence between  these  two  diseases  is  found  in  the  fact  already  stated  in  refer- 
ence to  measles,  that  the  attack  of  the  one  malady  does  not  prevent  the 
occurrence  of  the  other.  There  are,  it  is  true,  cases  in  which  it  is  difficult  at 
first  to  make  the  differential  diagnosis  between  rotheln  and  mild  measles  or 
mild  scarlet  fever,  but  when  the  course  of  the  malady  has  been  closely 
observed  for  three  or  four  days,  it  will  rarely  happen,  I  think,  that  we  will 
be  unable  to  make  out  its  character. 

Those  cases  of  an  epidemic  which  arise  when  the  causes  or  conditions 
from  which  it  has  developed  are  most  strongly  operative,  and  which  at  this 
time  are  likely  to  be  typical,  obviously  afford  the  best  data  for  studying  its 
nature.  Such  were  the  48  cases  which  I  saw  in  the  epidemic  of  1873  and 
1874,  and  the  42  in  that  of  1880  and  1881.  As  regards  the  former  epi- 
demic, in  thirteen  of  the  twenty-one  families  embraced  in  my  statistics  the 
first  cases  were  children  who  up  to  the  time  of  the  seizure  were  attending 
public  and  private  schools,  and  in  certain  instances  those  who  were  nearly 
simultaneously  attacked,  living  perhaps  in  streets  widely  separated,  were 
attending  the  same  school.  During  the  epidemic  of  1880  and  1881  the  first 
patients  in  thirteen  of  the  eighteen  families  in  which  rotheln  occurred  in  my 
practice  were  school-children  between  the  ages  of  six  and  twelve  years,  and 
in  most,  if  not  all,  the  different  schools  which  they  attended  rotheln  was  at 
the  time  prevailing  as  an  epidemic,  as  I  ascertained  on  inquiry.  It  therefore 
seemed  probable  that  these  children  whom  I  attended  had  contracted  it  from 
others  in  the  schools. 

In  both  the  New  York  epidemics  during  the  time  that  rotheln  was  at  its 
maximum  prevalence,  in  most  of  the  families  containing  two  or  more  chil- 
dren the  cases  were  multiple,  not  occurring  simultaneously,  but  in  succes- 
sion, as  if  the  malady  were  contracted  from  those  first  affected.     This  is  what 

we  daily  witness  in  the  spread  of  exanthematic  fevers.     Thus  in  Mr.  E 's 

family  a  girl  attending  one  of  the  public  schools  took  rotheln  in  the  middle 
of  December.  1873 ;  the  two  remaining  children  sickened  with  it  one  week 
and  two  weeks  later.  A  niece  visiting  in  the  family  at  the  time  when  the 
first  child  was  sick,  but  returning  home  to  another  street,  also  had  the  erup- 
tion on  December  27th.     Alice  R ,  aged  ten  years,  a  frequent  visitor  at 

Mr.  E 's,  living  in  the   same   street,  and  several   times   exposed  to  his 

children  during  their  illness,  also  took  rotheln  about  January  4th.  West 
Seventy-first  street,  where  these  cases  occurred,  was  thinly  settled  and  subur- 
ban, and  I  could  learn  of  no  other  cases  in  the  vicinity.     A  child  of  Mr. 

P ,  aged  five  and  a  half  years,  had  been  in  the  habit  of  playing  with  two 

children  two  doors  away,  who  became  affected  with  rotheln  in  the  beginning 
of  April,  1881.  On  April  14th  he  was  supposed  to  have  a  mild  coryza  from 
taking  cold,  as  he  sneezed  often,  but  in  a  few  hours  the  efflorescence  appeared. 
Four  days  subsequently,  on  the  18th,  an  infant  was  affected  in  the  same  way, 
and  thirteen  days  later  another  child  in  the  family,  aged  twelve  years.     In  a 


BOTHELN.  305 

similar  manner  rotheln  occurred  in  the  families  of  two  brothers  living  in 
adjoining  houses  in  West  Fifty-first  street.  The  first  patient  was  a  boy  pf 
twelve  years.  It  appeared  successively  in  the  children  of  these  two  families 
until  ten  had  been  afi'ected.  In  a  family  in  West  Forty-sixth  street  the  first 
case  was  a  boy  attending  a  school  in  which  rotheln  was  prevalent.  Within 
twenty  days — namely,  between  March  31st  and  April  20th— four  other  chil- 
dren were  attacked  in  succession. 

These  facts  and  cases  seem  to  demonstrate  the  contagiousness  of  rotheln, 
at  least  during  the  time  in  which  the  conditions  are  most  favorable  for  its 
development  or  during  the  time  in  which  the  epidemic  influence  is  most  pro- 
nounced. In  the  declining  period  of  both  the  Xew  York  epidemics  the  cases 
which  I  observed  occurred  for  the  most  part  singly,  although  there  was  no 
attempt  to  isolate  the  patients,  so  that  the  contagiousness  of  the  disease 
must  be  slight. 

Kbtheln  is,  in  my  opinion,  an  exanthematic  fever  feebly  contagious. 
It  resembles  varicella  in  general  mildness  of  symptoms,  in  the  absence 
of  dangerous  complications  or  sequelse,  and  in  the  uniformly  favorable 
prognosis,  while  its  symptoms  show  a  resemblance  to  measles  and  scarlet  fever. 

If  the  above  view  be  correct,  rotheln  must  possess  an  incubative  period 
which,  in  the  cases  observed  in  both  epidemics,  apparently  varied  between 
seven,  or  perhaps  less  than  seven,  and  twenty-one  days.  Its  incubation, 
therefore,  like  that  of  scarlet  fever  and  diphtheria,  apparently  varies  in 
different  patients.  In  the  cases  which  came  under  my  notice  the  incubative 
period,  when  it  could  be  accurately  ascertained,  was  more  frequently  about 
two  weeks  than  a  longer  or  shorter  period.  The  resident  physician  of  the 
Xew  York  Foundling  Asylum,  when  the  epidemic  was  prevailing  in  that 
institution,  returned  to  his  home  in  the  State  of  Maine  to  a  locality  where 
rotheln  was  unknown.  Fourteen  days  from  the  date  of  his  departure  he  was 
himself  affected  with  the  disease  in  its  typical  form.  No  other  case  occurred 
at  his  home,  where  probably  the  atmospheric  conditions  were  unfavorable. 

Minnie  B ,  attending  a  school  in  which  there  were  many  cases,  had  the 

rash  on  April  5th.     On  the  23d  of  the  same  month,  eighteen  days  afterward, 
it  appeared  upon  the  servant  who  was  frequently  in  Minnie's  room.    Elizabeth 

C ,  attending  a  school  in  which  rotheln  was  prevailing,  had  the  eruption 

on  April  17th.     It  commenced  upon  her  sister  thirteen  days,  and  upon  her 
mother  fourteen  days,  subsequently. 

Other  cases  might  be  cited  of  an  apparently  shorter  as  well  as  longer 
incubative  period.  The  following  note  from  Dr.  Chadbourne  of  the  New 
York  Foundling  Asylum,  bearing  upon  the  subject,  is  interesting:  "I  am 
led  to  believe  from  my  observations  that  the  period  of  incubation  was,  in  the 
majority  of  cases,  from  twelve  to  fifteen  days.  The  disease  has  been  very 
feebly  contagious.  In  some  cases  one  child  would  have  rotheln,  while  the 
other,  nursed  by  the  same  woman,  escaped.  In  two  instances  women  had 
the  disease,  and  though  each  suckled  two  infants,  the  latter  escaped."  Osborn 
states  that  enlargement  of  the  small  glands  at  the  edge  of  the  hair  on  the 
postero-lateral  sides  of  the  neck  has  been  present  in  all  the  cases  which  he 
has  observed,  and  he  therefore  considers  it  an  important  diagnostic  sign 
(  ^yeeMy  Med.  Rev.,  Dec.  24,  1887).  Several  other  writers  have  also  observed 
this  glandular  enlargement,  and  some  have  stated  that  it  occasionally  pre- 
cedes the  efilorescence.  Swelling  of  the  lymphatic  glands  in  other  parts  of 
the  system  has  also  been  recorded  by  different  observers,  and  it  rarely  goes 
on  to  suppuration.  It  usually  subsides  with  the  disappearance  of  the  rash, 
but  Golson  has  observed  the  occurrence  of  abscesses  in  the  site  of  the  sub- 
maxillary lymphatic  glands.  Curtman  has  also  observed  the  formation  of 
abscesses  in  various  parts  of  the  body. 
20 


306  CONSTITUTIONAL  DISEASES. 

Complications. — Recent  writers  have  recorded  a  considerable  number 
of  complications  and  sequelae,  the  more  important  of  which  we  will  briefly 
enumerate  as  follows,  but  the  occurrence  of  some  of  them  was  a  coincidence  : 
Severe  bronchitis,  pneumonia,  pleurisy,  enteritis,  entero-colitis,  colitis,  icterus, 
stomatitis,  rheumatism,  meningitis,  abscesses,  miliaria,  pemphigus,  erysipelas, 
oedema,  enlargement  of  the  thyroid,  otorrhoea,  earache,  and  keratitis.  Some 
of  these  complications  are  such  as  frequently  occur  in  measles,  to  which,  as 
we  have  seen,  rotheln  bears  considerable  resemblance. 

Diagnosis.— Rotheln  might  readily  be  mistaken  for  roseola  if  only  a  few 
and  isolated  cases  occur,  but  the  longer  continuance  of  the  eruption,  the 
catarrhal  symptoms,  though  slight,  and  in  most  instances  the  evidence  of 
contagion,  enable  us  to  make  the  diagnosis.  From  measles  this  disease  is 
distinguished  by  the  absence  of,  or  slight  and  transient  character  of,  the 
prodromal  stage.  The  fever  with  evening  exacerbations,  the  cough,  and  pro- 
nounced catarrhal  symptoms,  which  precede  the  rash  in  measles  three  or  four 
days,  do  not  occur  in  rotheln.  The  diagnosis  from  mild  scarlet  fever  in  the 
commencement  of  an  epidemic,  when  only  a  few  cases  are  observed,  may  be 
difficult,  but  no  epidemics  of  scarlet  fever  occur  in  which  the  type  remains 
so  mild  as  in  rotheln.  The  shorter  duration  of  the  rash,  the  absence  of  the 
initial  vomiting  and  of  the  strawberry  tongue,  the  usual  roseolar  rather  than 
erythematous  character  of  the  rash,  the  mildness,  sometimes  scarcely  appre- 
ciable, of  the  stomatitis  and  pharyngitis,  the  slight  indisposition,  so  that  the 
child,  if  it  followed  its  inclination,  would  not  be  under  restraint,  and  the 
absence,  with  few  exceptions,  of  complications  and  sequelae,  usually  render 
the  diagnosis  from  scarlet  fever  clear  and  unmistakable. 

Prognosis.  —  Death  does  not  occur  except  from  some  complication  or 
intercurrent  disease.  When  Forney  stated  that  in  Berlin  during  the  decade 
ending  with  1794,  457  died  from  rubeola,  172  from  scarlet  fever,  and  53  from 
measles,  he  could  not  by  the  term  "  rubeola  "  have  referred  to  rotheln,  as 
some  have  supposed,  or  the  nature  of  the  disease  has  totally  changed.  More- 
over, in  the  literature  of  rotheln  the  assigned  causes  of  death  have  been,  in 
my  opinion,  in  some  instances,  concurrent  or  accidental  maladies  which  did 
not  result  from  this  disease. 

Treatment. — In  the  majority  of  cases  the  medicinal  treatment  should 
be  of  the  mildest  kind  or  none  at  all.  As  death  has  occurred  from  bronchitis 
and  pneumonia  supervening  upon  rotheln,  the  patient  should  remain  in  a 
room  of  equable  temperature,  and  not  be  exposed  to  currents  of  air.  Any 
local  ailment  which  may  arise  or  any  intercurrent  disease  should  of  course 
be  promptly  treated,  since  death  may  occur  from  them,  while  the  primary 
disease  is  not  fatal  and  is  even  trivial. 


CHAPTER    IV. 

VARIOLA— VAKIOLOID. 


Variola,  or  smallpox,  is  a  specific  febrile  aiFection,  accompanied  by  a 
vesiculo-pustular  eruption  upon  the  skin.  Since  the  discovery  of  the  pro- 
tective power  of  vaccination  it  has  been  shorn  of  much  of  its  terror,  but  it 
is  still  the  most  loathsome  and  most  dreaded  of  all  the  fevers.  Two  forms 
of  this  disease  are  recognized,  depending  on  the  fact  whether  there  have  been 
previous  vaccination.     If  the  patient  have  been  vaccinated  at  some  period  in 


VABIOLA — VARIOLOID.  307 

his  life,  the  disease,  which  is  rendered  milder  in  consequence,  is  designated 
varioloid.  If  there  have  been  no  vaccination,  it  is  called  variola  or  smallpox. 
Both  forms  are  identical  in  nature,  the  one  communicating  the  other ;  they 
differ  only  in  gravity. 

From  accounts  still  extant — which,  however,  are  vague — this  disease 
appears  to  have  prevailed  at  a  remote  period  in  China  and  Hindostan.  It 
was  carried  across  the  Asiatic  continent  by  caravans  engaged  in  the  silk-trade, 
reaching  Europe  in  the  sixth  century.  Its  extension  to  countries  previously 
free  from  it  has  been  mainly  through  commerce  and  invading  armies.  It  is 
stated  that  it  reached  England  in  the  thirteenth  century  and  Germany  and 
Sweden  in  the  fifteenth  century.  It  was  introduced  into  Mexico  by  the 
invading  army  of  Cortez,  where  for  years  afterward  heaps  of  skeletons  of 
those  who  had  perished  by  it  were  found  in  shaded  localities. 

Etiology. — Although  pathologists  do  not  doubt  the  microbic  origin  of 
variola,  the  microbe  which  causes  it  has  not  yet  been  clearly  ascertained. 

Smallpox  presents  four  stages :  the  initial,  or  that  of  invasion ;  the  erup- 
tive ;  that  of  desiccation ;  and,  lastly,  that  of  desquamation.  It  is  termed 
discrete  when  the  pustules  remain  separated  from  each  other  ;  confluent  when 
they  unite.  This  division  is  made  according  to  the  charactor  of  the  eruption 
upon  the  face  and  hands.  There  are  parts  of  the  surface,  as  the  abdomen, 
where  the  pustules  are  always  discrete,  even  in  the  confluent  form. 

Incubative  Period. — During  the  last  half  of  the  last  century  inocula- 
tion with  variolous  matter  was  extensively  practised  in  Great  Britain  and  on 
the  Continent,  as  it  was  found  that  smallpox  thus  communicated  was  milder 
than  when  received  by  infection.  This  operation  enabled  physicians  to  deter- 
mine the  period  of  incubation,  which  was  found  to  be  from  eight  to  eleven 
days.  When  variola  is  communicated  through  the  air  the  incubative  period 
is  somewhat  longer — to  wit,  from  twelve  to  fourteen  days. 

Stage  of  Invasion. — Smallpox  begins  abruptly  with  chilliness.  In 
children  of  an  advanced  age  there  is  often,  as  in  the  adult,  a  distinct  chill. 
This  is  followed  by  fever  and  such  symptoms  as  usually  accompany  a  high 
temperature — to  wit,  lassitude,  anorexia,  and  thirst.  In  addition,  certain 
symptoms  arise  which,  though  not  peculiar  to  smallpox,  are  so  marked  in 
the  commencement  of  this  disease  that  they  possess  considerable  diagnostic 
value.  These  symptoms,  which  pertain  to  the  nervous  system  and  occur  in 
the  initial  stage  of  varioloid  as  well  as  variola,  are  severe  frontal  headache, 
pain  in  the  small  of  the  back,  and  great  drowsiness,  sometimes  with  delirium. 
In  many  children  convulsions  occur,  preceded  and  followed  by  a  degree  of 
stupor  which  is  almost  as  profound  as  coma.  Trousseau  suggests  the  name 
rachialgia  for  the  pain  in  the  back,  since  he  believes  that  it  is  located  in  or 
around  the  spinal  cord.  This  belief  is  based  on  the  fact  which  he,  and  other 
observers  have  noticed,  namely,  that  there  is  sometimes  in  connection  with  this 
symptom  an  incomplete  paraplegia,  indicated  by  numbness  of  the  legs  or  even 
inability  to  use  them,  and  sometimes  more  or  less  paralysis  of  the  bladder. 
These  paraplegic  symptoms  pass  off  in  a  few  days.  Vomiting  is  also  a  com- 
mon symptom  in  this  stage,  and  one  also  of  diagnostic  value.  It  occurs  at 
short  intervals  for  twenty-four  to  thirty-six  hours,  The  same  symptom  is 
common  in  scarlet  fever,  and  not  infrequent  in  measles,  but  in  both  these 
maladies  irritability  of  stomach  is  much  less  persistent  than  in  smallpox  ; 
vomiting  does  not  occur  in  normal  rubeolous  and  scarlatinous  cases  more  than 
once  or  twice. 

The  tongue  is  covered  with  a  moist  fur.  If  the  disease  is  to  be  discrete, 
constipation  is  commonly  present  in  the  stage  of  invasion ;  if  confluent,  diar- 
rhoea is  a  common  symptom,  continuing  till  the  fourth  or  fifth  day,  or  even 
longer.     Roseola  or  erythema  sometimes  occurs  in  this  stage,  and  this  may 


308  CONSTITUTIONAL  DISEASES. 

lead  to  error  of  diagnosis,  the  disease  being  mistaken  for  one  of  these  cutane- 
ous affections  or  even  for  scarlet  fever.  The  symptoms  in  the  stage  of  inva- 
sion are  usually  more  violent  in  confluent  than  in  discrete  variola,  but  there 
are  exceptions. 

Stage  of  Eruption. — The  eruption  commences  about  the  third  day, 
earlier  in  some  cases,  later  in  others.  The  average  duration,  therefore,  of 
the  first  stage  is  somewhat  shorter  than  in  measles,  but  considerably  longer 
than  in  scarlet  fever.  Sydenham  has  stated — and  observations  show  the 
truth  of  the  remark — that  the  shorter  the  first  stage  the  more  severe  the  dis- 
ease will  prove  to  be ;  and,  conversely,  the  longer  the  period  the  milder  will 
be  its  form.  Therefore,  if  the  eruption  begin  on  the  second  day,  it  will,  as  a 
rule,  be  confluent ;  if  not  till  the  fifth  or  sixth  day,  it  will  be  scanty  and  the 
disease  light. 

The  eruption  commences  in  minute  red  spots,  somewhat  like  those  of 
lichen,  which  gradually  enlarge.  It  is  first  observed  around  the  lips  and 
upon  the  neck,  then  upon  the  face,  scalp,  upper  part  of  chest,  arms,  and 
finally  upon  the  lower  part  of  the  chest,  the  abdomen,  and  legs.  It  is  some- 
times, especially  in  young  children,  first  observed  in  the  folds  of  the  skin,  as 
about  the  genitals  or  in  the  groin.  If  the  cuticle  be  irritated,  as  by  a  sina- 
pism, the  eruption  often  appears  first  upon  this  part  of  the  surface  and  in 
greater  abundance  than  elsewhere.  Commencing  in  a  minute  reddish  point, 
as  stated  above,  it  rapidly  enlarges,  and  soon  its  central  part  begins  to  be 
indurated  and  raised.  It  feels  round  and  hard  to  the  finger,  is  tender,  and 
its  diameter  does  not  ordinarily  exceed  two  lines.  This  is  the  papular  stage. 
The  papulae  increase  and  become  more  elevated,  and  in  twenty-four  to  forty- 
eight  hours  from  the  commencement  of  the  eruptive  stage  they  become  vesic- 
ular. On  the  fifth  day  of  the  eruption,  or  eighth  of  the  disease,  the  vesicle 
has  attained  its  full  size.  Its  diameter  is  then  about  one-fourth  of  an  inch 
and  its  elevation  is  two  or  three  lines.  Its  base  is  circular  and  indurated, 
and  it  is  surrounded  by  a  narrow  zone  of  inflammation,  indicated  by  redness 
and  tenderness  of  the  skin.  The  pock  commonly,  as  it  passes  from  the  papu- 
lar to  the  vesicular  stage,  loses  its  acuminate  form,  and  becomes  depressed  in 
the  centre,  but  in  most  cases  mixed  with  the  umbilicated  vesicles  are  some 
which  remain  acuminate. 

In  proportion  as  the  eruption  becomes  developed  in  discrete  variola  and  in 
varioloid,  the  symptoms  which  accompanied  the  stage  of  invasion  abate ;  the 
fever,  headache,  pain  in  the  back,  and  thirst  cease,  and  the  appetite  returns. 
In  the  confluent  form  the  fever  continues  with  little  abatement. 

Simultaneously  with  the  eruption  upon  the  skin  an  eruption  also  occurs 
upon  the  buccal  and  faucial  surfaces,  and  often  upon  that  of  the  air-passages. 
It  occurs  sometimes,  also,  upon  the  conjunctiva,  producing  dangerous  oph- 
thalmia, and  even  ulceration  with  loss  of  sight,  and  upon  the  mucous  sur- 
face of  the  genital  organs.  The  form  which  it  presents  upon  mucous  sur- 
faces is  somewhat,  different  from  that  upon  the  skin.  There  is  at  first  a 
deposit  of  fibrin,  producing  a  small,  round,  grayish  spot  at  the  point  of  erup- 
tion— firm,  slightly  elevated,  and  covered,  if  not  by  the  entire  mucous  mem- 
brane, at  least  by  its  epithelial  layer.  Ulceration  soon  occurs,  as  in  ulcerous 
stomatitis,  and  if  the  patient  live  the  reparative  process  succeeds,  as  in  simple 
ulcers.  The  eruption  upon  mucous  surfaces  increases  considerably  the  suffer- 
ing of  the  patient,  in  consequence  of  the  tenderness  of  the  ulcers  ;  and  if  its 
seat  be  the  surface  of  the  larynx  or  trachea,  it  may  be  the  immediate  cause 
of  death,  especially  in  young  children,  by  obstructing  respiration. 

The  cutaneous  eruption  has  been  traced  to  the  vesicular  stage.  On  or 
about  the  fifth  day  of  the  eruptive  period,  or  eighth  of  smallpox,  the  ves- 
icles gradually  change  their  character,  their  contents  becoming  thicker  and 


VARIOLA— VARIOLOID.  309 

turbid.  At  the  same  time  they  increase  still  more  in  size  and  the  central 
depression  disappears.  This  is  designated  the  stage  of  maturation  or  of  sup- 
puration, though  it  is  known  that  the  turbidity  is  due  chiefly  to  another 
substance  than  pus.  The  pock,  having  undergone  these  changes,  is  termed 
the  pustule. 

In  discrete  variola  and  in  varioloid  the  fever  returns  during  the  pustular 
stage,  or  if  the  form  of  the  disease  be  confluent  and  the  fever  have  continued, 
it  now  becomes  more  intense.  The  return  of  the  fever  or  its  increase  is 
denoted  by  increased  frequency  of  pulse,  elevation  of  temjaerature,  dryness 
of  skin,  anorexia,  and  thirst.  A  tendency  to  constipation  remains  throughout 
in  varioloid  and  discrete  variola ;  in  the  confluent  form  diarrhoea  more  fre- 
quently occurs,  which,  if  it  continue,  is  an  unfavorable  prognostic  sign. 

Other  changes  occur.  The  pustules  increase  somewhat  in  size  and  become 
more  globular.  Some  of  them,  when  most  distended,  break  through  friction 
of  the  clothes  or  scratching  of  the  child,  and  their  contents,  escaping,  add  to 
the  loathsomeness  of  the  disease.  There  is  in  the  pustular  stage  more  or  less 
redness  of  the  surface  between  the  eruptions,  and,  except  in  the  mildest  cases, 
tumefaction  from  subcutaneous  infiltration  occurs.  In  the  confluent  form  at 
this  period  the  features  are  often  so  swollen  that  the  friends  would  not  recog- 
nize the  patient.  The  eyelids  may  be  so  oedematous  that  the  eyes  are  for  a 
time  concealed  from  view.  This  oedema  of  the  surface  is  not  altogether  absent 
in  the  vesicular  stage,  but  it  increases  during  the  time  of  maturation,  after 
which  it  subsides. 

Stage  or  Desiccation. — This  immediately  succeeds  the  full  development 
of  the  pustules.  The  liquid  portion  of  the  contents  of  the  pustules  which 
are  broken  evaporates,  leaving  a  crust.  If  there  be  no  rupture,  the  liquid  is 
absorbed  and  a  scab  results,  which,  though  smaller,  preserves  in  a  measure 
the  form  of  the  pustule.  While  the  pustule  desiccates  the  surrounding  inflam- 
mation rapidly  abates.  The  crusts  occur  first  upon  the  face,  and  on  other 
parts  in  the  order  in  which  the  eruption  appeared.  The  odor  from  the  patient 
at  this  time  is  peculiar.  In  the  confluent  form  especially  it  is  very  ofiensive, 
and  can  be  noticed  at  a  distance  from  the  bedside.  Rilliet  and  Barthez  call 
it  nauseous  and  fetid.  As  desiccation  progresses  the  symptoms,  local  and 
general,  abate.  The  pulse  and  temperature,  if  the  case  be  favorable,  return 
to  the  normal ;  the  cough,  hoarseness,  and  thirst  disappear,  while  the  appetite 
returns ;  the  sleep  is  more  tranquil,  and  the  functions  generally  are  more 
regularly  performed. 

The  last  stage  is  that  of  desquamation  ;  it  commences  between  the 
eleventh  and  sixteenth  days.  The  scabs,  which  present  a  dark  or  brownish 
appearance,  are  successively  detached.  This  period  lasts  several  days;  some- 
times two  or  three  weeks  even  elapse  before  all  the  crusts  separate.  In  the 
meantime,  the  patient  gradually  recovers  his  health  and  former  strength. 
After  the  fall  of  the  crust  the  cicatrix  underneath  presents  a  reddish  appear- 
ance. The  color  gradually  fades,  and  there  remains  an  irregular  depression, 
or  pit,  of  a  lighter  color  than  the  surrounding  surface,  and,  if  there  have 
been  a  full  development  of  the  eruption,  it  disfigures  the  patient  for  life. 

Such  is  the  clinical  history  of  variola  when  it  is  favorable  and  its  course 
is  regular.  The  disease  is  sometimes  irregular.  In  rare  instances  the  erup- 
tion occurs  almost  at  the  commencement  of  the  attack.  The  form  is  then 
likely  to  be  confluent.  There  are  irregularities  also  in  consequence  of  diarrhoea, 
hemorrhages,  or  other  complications.  I  have  known  the  eruption  appear  first 
on  the  limbs,  and  last  on  the  trunk  and  face,  and  the  appearance  of  the  erup- 
tion is  not  always  the  same.  In  the  anaemic  and  feeble  child  it  often  presents 
a  pale  color,  with  some  induration  at  its  base,  but  without  the  red  areola 
around  it  or  with  this  quite  indistinct.     In  rare  instances  the  vesicles  have  a 


310  COXSTITUTIOXAL  DISEASES. 

reddish  color,  their  contents  being  tinged  with  blood.  This  form  of  variola 
is  designated  hemorrhagic.  It  indicates  a  profoundly  altered  state  of  the 
blood.  The  eruption  in  this  form  is  of  small  size,  and  if  the  pock  is  broken 
blood  oozes  from  it. 

I  have  met  one  case,  perhaps  two,  of  malignant  hemorrhagic  smallpox,  as 
described  by  Hebra,  among  the  rare  forms  of  this  malady.  The  second  case 
died  so  soon  that  we  were  undecided  whether  he  had  smallpox  or  scarlatina. 
A  man  aged  thirty-six  years,  previously  healthy,  became  suddenly  and  severely 
sick  in  June,  1881,  with  fever,  intense  headache  and  backache,  great  depres- 
sion of  the  vital  powers,  sleeplessness,  and  a  sensation  of  sinking  or  depression 
in  the  epigastrium.  He  had  a  mai'ked  foreboding  of  coming  evil,  and  begged 
almost  constantly  for  relief.  Within  forty-eight  hours  a  heavy  and  continuous 
dusky  scarlatiniform  eruption  covered  the  whole  surface,  except  below  the 
knees,  disappearing  on  pressure  ;  fauces  at  first  but  moderately  injected.  On 
the  following  day,  the  third  of  his  sickness,  with  a  temperature  of  104.5°, 
the  efflorescence  became  a  dark  red,  numerous  small  extravasations  of  blood 
had  occurred  under  the  skin,  the  urine  contained  blood,  and  finally  it  seemed 
to  consist  almost  entirely  of  dark  blood ;  a  large  efi'usion  of  blood  under  the 
entire  conjunctiva  of  either  eye  prevented  closure  of  the  eyelids,  and  probably 
hemorrhages  had  occurred  within  the  eyes,  as  the  sight  was  nearly  lost.  Death 
took  place  on  the  following  day.  In  Hebra's  article  on  smallpox  is  the  descrip- 
tion of  precisely  such  cases,  but  the  death  of  my  patient  was  too  early  for 
exact  diagnosis. 

Varioloid. — The  course  of  varioloid  is  similar  to  that  of  variola,  but  it  is 
somewhat  shorter.  It  commences  with  rigors,  followed  by  fever,  headache, 
pain  in  the  back,  vomiting,  drowsiness,  and  sometimes  delirium,  or  even  con- 
vulsions. The  symptoms  in  the  stage  of  invasion  are,  indeed,  the  same  in 
character,  and  often  nearly  as  severe  as  in  variola.  With  the  initial  symp- 
toms there  is  also  sometimes  a  scarlatiniform  eruption,  so  that  the  disease 
may  at  first  be  mistaken  for  scarlatina.  On  the  third  or  fourth  day  the  vario- 
lous eruption  commences.  The  number  of  pocks  is  commonly  few,  often  not 
more  than  twelve  to  twenty.  In  the  mildest  form  of  varioloid,  if  the  phy- 
sician be  not  summoned  in  the  stage  of  invasion,  he  may  not  be  called  at  all, 
so  that  the  patient  passes  through  the  disease  in  ignorance  of  its  nature.  The 
true  character  of  the  malady  is  not  ascertained  till  others  are  affected  either 
with  variola  or  varioloid. 

The  eruption  pursues  a  more  rapid  course  in  varioloid  than  in  the  unmod- 
ified disease.  By  the  fifth  or  sixth  day  the  pustules  are  fully  developed, 
though  often  smaller  and  less  likely  to  be  ruptured  than  in  variola.  Often 
in  varioloid  the  eruption  aborts.  It  remains  papular  two  or  three  days,  and 
then  declines,  or  it  may  reach  the  vesicular  stage  and  decline  without  pustu- 
lation. 

The  constitutional  symptoms  in  varioloid  abate  with  the  commencement 
of  the  eruptive  stage.     The  secondary  fever  is  slight  or  absent. 

Such  is  the  usual  mild  course  of  varioloid,  but  not  always.  If  several 
years  have  elapsed  since  the  vaccination,  its  protective  power  is  greatly 
impaired,  and  varioloid  may  then  exhibit  as  severe  a  form  as  ordinary  small- 
pox.    In  some  instances  it  is  fatal. 

The  term  varioloid  is,  as  has  been  stated,  applied  to  cases  of  variolous 
disease  if  there  have  been  previous  vaccination.  It  is  also  applied  by  writers 
to  second  attacks,  whether  the  first  occurred  from  infection  or  from  variolous 
inoculation,  but  such  cases  are  rare. 

Mode  of  Death. — Death  in  smallpox  occurs  in  several  different  ways. 
The  most  fatal  period  is  the  pustular.  Feeble  children  not  infrequently  die 
from  exhaustion  at  or  about  the  time  that  the  pustules  attain  their  greatest 


VAEIOLA — VARIOLOID.  311 

size.  The  eruption  appears  and  becomes  developed  as  usual,  but  there  are 
evidences  of  weakness  in  the  patient,  and  suddenly  the  progress  of  the  vesicle 
or  pustule  ceases.  It  begins  to  subside  and  its  walls  shrivel.  There  is  evi- 
dently absorption,  in  part,  of  the  liquid  contents.  These  phenomena  are  of 
the  gravest  character.  Death  is  the  common  result,  and  within  twenty-four 
hours.  In  other  cases  death  occurs  from  apnoea.  The  pock,  increasing  in 
size  in  the  larynx  and  trachea,  obstructs  inspiration,  or  there  may  be  the 
formation  of  a  pseudo-membrane,  as  in  true  croup.  This  is  not  an  unusual 
mode  of  death  in  young  children,  in  whom  the  calibre  of  the  larynx  and 
trachea  is  small.  Sometimes  convulsions  and  coma  occur  in  the  last  houi's 
of  life.  In  other  cases  the  stage  of  desquamation  is  reached,  but  convales- 
cence does  not  occur.  The  patient  each  day  becomes  more  anasmic  and 
feeble,  and  finally  death  results  from  failure  of  the  vital  powers.  Again, 
after  smallpox  has  run  its  course  purpura  haemorrhagica  may  be  developed. 
Hemorrhages  occur  from  the  gums,  throat,  nostrils.  Blood  is  vomited,  and 
evacuated  in  the  stools.  I  have  known  death  to  occur  in  all  these  ways,  but 
that  from  purpura  is  least  frequent.  Sometimes,  as  in  scarlet  fever,  death 
occurs  suddenly  and  unexpectedly  in  confluent,  and  even  in  discrete,  variola, 
when  the  j)revious  symptoms  had  apparently  been  favorable.  The  patient  is 
overpowered  by  the  intensity  of  the  virus. 

Anatomical  Characters. — In  those  who  have  died  of  variola  without 
inflammatory  or  other  complication  the  heart-clots  have  been  found  small, 
dark,  and  soft.  The  blood  is  dark  and  thin.  The  vessels  of  the  brain  and 
its  membranes  are  injected,  so  that  numerous  red  points  appear  on  the  cut 
surface  of  this  organ.  The  vessels  of  the  lungs  and  the  abdominal  organs 
are  congested,  while  the  muscles  present  a  deep-red  color.  The  variolous 
eruption  penetrates  more  deeply  than  that  of  any  other  exanthematic  fever. 
It  has  been  stated  elsewhere  that  it  occurs  not  only  on  the  skin,  but  often 
on  the  surface  of  the  mouth,  fauces,  and  air-passages.  The  mucous  mem- 
brane in  these  situations  is  frequently  also  the  seat  of  catarrhal  inflammation, 
being  thickened  and  softened,  and  in  some  parts,  as  the  larynx,  a  pseudo- 
membrane  is  occasionally  produced,  as  in  croup. 

The  eruption  very  seldom,  perhaps  never,  appears  upon  the  gastro-intes- 
tinal  surface,  but  the  solitary  follicles  and  patches  of  Peyer  are  often 
enlarged,  as  in  some  other  zymotic  affections.  The  liver,  spleen,  and  kidneys 
are  commonly  congested  in  those  who  have  died  of  variola.  The  spleen 
especially  is  increased  in  volume  and  softened ;  the  kidneys  are  enlarged,  as 
from  commencing  nephritis,  and  sometimes  softened. 

The  minute  structure  of  the  pock  is  described  by  Rilliet  and  Barthez  and 
others.  The  vesicle  is  multilocular,  consisting  of  at  least  five  or  six  compart- 
ments with  distinct  partitions.  Its  centre  is  united  by  fibrous  bands  to  the 
derm  beneath,  which  union  gives  rise  to  the  umbilicated  appearance.  The 
giving  way  of  these  minute  bands  in  the  pustular  stage  occurs  when  the  form 
changes  from  the  umbilicated  to  the  convex.  In  the  pustular  stage  also, 
according  to  some,  a  fibrous  formation  occurs  within  the  pustule  ;  according 
to  others,  this  substance  is  of  the  nature  of  the  epidermis,  presenting  the 
appearance  of  the  cuticle  when  macerated.  Mixed  with  this  epidermic  or 
fibrinous  formation  are  pus-cells. 

Complications. — There  are  several  different  complications  of  variola. 
One  is  salivation.  This  is  common  in  the  adult,  but  rare  in  the  child. 
When  it  occurs  in  the  child  it  is  slight,  commencing  with  or  about  the  time 
of  the  eruption,  and  disappearing  in  from  one  to  four  or  five  days.  Oph- 
thalmia is  another  complication.  Simple  conjunctivitis,  often  quite  intense, 
may  occur  in  consequence  of  pustules  developed  under  the  lids.  This  inflam- 
mation subsides  without  injury  to  the  eye  as  the  primary  disease  abates.     A 


312  COXSTITUTIONAL  DISEASES. 

more  serious  inflammation  occurs  at  an  advanced  stage  of  variola,  commen- 
cing in  or  near  the  desquamative  period.  This  produces  more  or  less  chemosis, 
and  sometimes  opacity  or  ulceration  of  the  cornea.  A  similar  inflammation 
may  occur  in  the  ear,  giving  rise  to  otorrhoea,  and  even,  in  some  patients,  to 
rupture  of  the  drum  of  the  ear.  Abscesses  in  the  subcutaneous  connective 
tissue  have  been  occasionally  observed,  especially  in  the  confluent  form. 
Subcutaneous  infiltration  and  feebleness  of  constitution  favor  their  occur- 
rence. Suppuration  within  the  joints  is  a  somewhat  rare  complication  or 
sequel,  rendering  convalescence  protracted,  if,  indeed,  the  case  be  not  fatal. 

M.  Beraud  has  published  a  memoir  to  show  that  orchitis  in  the  male  and 
ovaritis  in  the  female  may  complicate  variola.  These  inflammations  are 
believed  to  be  accompanied  by  a  small  and  imperfect  variolous  eruption 
upon  the  tunica  vaginalis  and  the  peritoneal  covering  of  the  ovary.  Trous- 
seau states  that  he  has  often  met  this  complication  in  the  male  since  his 
attention  was  called  to  it.  It  is  mild,  and  subsides  with  the  disappearance 
of  the  eruption.  Laryngitis,  simple  or  diphtheritic,  bronchitis,  pneumonia, 
pharyngitis,  purpuric  hemorrhages,  gangrene  of  the  mouth  or  other  parts, 
oedema  pulmonum,  and  oedema  glottidis  are  occasional  complications,  some 
of  which  are  frequent,  others  rare. 

Prognosis. — This  depends  on  the  age,  vigor  of  system,  form  of  the 
disease,  and  the  presence  or  absence  of  complications.  The  younger  the 
child  the  greater  the  danger.  Trousseau  says  :  "  Confluent  variola,  and  even 
discrete  variola,  are  almost  always  fatal  in  individuals  less  than  two  years 
old."  Above  the  age  of  three  or  four  years  discrete  variola  usually  ends 
favorably,  but  the  confluent  form  is  still,  as  a  rule,  fatal.  Varioloid  in  the 
child  is  a  mild  disease,  terminating  favorably  in  a  large  proportion  of  cases. 
It  is  milder  at  this  age  than  in  the  adult,  on  account  of  the  more  recent 
period  of  vaccination.  If  varioloid  be  severe  and  the  eruption  abundant 
in  a  child  who  has  been  vaccinated,  it  is  probable  that  the  vaccination  was 
spurious. 

It  is  not  necessary,  from  what  has  been  said,  to  specify  the  favorable 
prognostic  signs.  The  unfavorable  prognostics  are — great  violence  of  the 
initial  symptoms ;  early  appearance  of  the  eruption ;  an  abundant  eruption, 
especially  if  pale  and  without  swelling  of  the  surface ;  rapid  decline  of  the 
eruption  in  the  vesicular  or  pustular  stage  ;  hemorrhagic  eruption  or  hemor- 
rhages from  the  surfaces ;  fever  continuing  after  the  appearance  of  the  erup- 
tion ;  diarrhoea  persisting  beyond  the  third  or  fourth  day  ;  delirium  or  great 
drowsiness;  a  frequent  and  feeble  pulse :  and,  finally,  obstructed  respiration 
— if  slow,  indicating  a  pseudo-membrane  or  variolous  eruption  in  the  larynx 
or  trachea ;  if  rapid,  indicating  bronchitis  or  pneumonia. 

Diagnosis. — The  diagnosis  cannot  be  made  with  certainty  prior  to  the 
eruptive  stage.  If,  however,  smallpox  be  prevalent,  if  the  patient  have  not 
been  vaccinated,  and  the  symptoms  which  pertain  to  the  period  of  invasion 
be  present,  as  headache,  pain  in  small  of  back,  repeated  vomiting,  drowsiness, 
and  perhaps  convulsions,  there  is  ground  for  the  gravest  suspicion.  If  in 
addition  to  these  symptoms  reddish  points  begin  to  appear  on  the  second  or 
third  day,  the  diagnosis  may  be  made  with  confidence.  At  this  early  period, 
even  before  there  is  any  distinct  cutaneous  eruption,  ash-colored  spots  may 
sometimes  be  observed  on  the  buccal  or  faucial  surface,  the  commencement 
of  the  variolous  eruption ;  these  possess  considerable  diagnostic  value. 

The  scarlatiniform  efflorescence  in  the  first  stage  of  variola  sometimes 
leads  to  the  belief  that  the  disease  is  scarlet  fever.  The  absence  of  the 
pharyngitis  and  the  appearance  of  the  variolous  eruption  soon  after  the 
efflorescence  correct  the  diagnosis.  Smallpox  has,  in  the  beginning  of  the 
eruptive  period,  sometimes  been  mistaken  for  measles.     The  points  involved 


VARIOLA—  VARIOL  OID. 


313 


in  the  differential  diagnosis  have  been  presented  in  treating  of  that  disease. 
After  the  development  of  the  eruption  it  may  be  mistaken  for  varicella.  The 
eruption  of  varicella  is,  however,  preceded  by  symptoms  which  are  milder 
and  of  shorter  duration,  and  its  appearance  is  different.  It  is  irregular, 
instead  of  round,  is  not  umbilieated,  and  it  does  not  have  the  round,  inflamed, 


Fig.  42. 


>'l    ^ 


Variola :  first  and  second  days  of  the  eruption. 
Fig.  43. 


Variola ;  fifth  day  of  the  eruption. 
Fig.  44. 


Varfola:  eleventh  day  of  the  eruption. 

and  indurated  base  which  characterizes  the  variolous  eruption.  The  erup- 
tion of  ecthyma  is  sometimes  umbilieated,  but  the  symptoms  of  ecthyma 
and  variola  and  the  progress  of  the  eruptions  in  the  two  diseases  are  very 
different. 

There  is  no  disease  in  which  it  is  more  imperatively  the  duty  to  make  an 
early  and  correct  diagnosis  than  in  variola  and  its  modified  form,  varioloid. 


314  CONSTITUTIONAL  DISEASES. 

Smallpox  seldom  occurs  in  the  eastern  part  of  the  United  States,  notwith- 
standing the  very  great  immigration.  Therefore  when  it  does  occur  and  comes 
under  observation  it  is  more  likely  to  be  overlooked  or  wrongly  diagnosticated 
than  if  it  were  more  common.  Thus  in  a  prominent  medical  college  the  mis- 
take was  recently  made  of  not  diagnosticating  varioloid,  and  several  of  the 
physicians  not  fully  protected  sufiered  the  consequence  of  infection  by  this 
loathsome  disease,  and,  while  others  received  cicatrices  for  life,  one  died.  I 
trust  that  no  one  who  examines  the  illustrations  kindly  furnished  me  by 
N.  E.  Vaccine  Co.  will  ever  make  such  a  sad  error. 

Treatment. — Smallpox,  like  the  other  essential  fevers,  is  self-limited, 
and  therefore  the  constitutional  treatment  should  be  sustaining  and  pallia- 
tive. In  the  first  stages  of  the  disease  the  diet  should  be  simple ;  gentle 
laxatives  and  refrigerant  drinks  are  required  if  there  be  much  febrile  excite- 
ment. Lemonade  is  a  grateful  drink,  and  may  be  given  in  moderate  quantity. 
Spiritus  mindereri  in  carbonic-acid  water  may  be  allowed.  As  the  disease 
advances  more  nutritious  food  should  be  recommended,  and  in  severe  cases 
carbonate  of  ammonium,  and  even  alcoholic  stimulants,  are  required. 

As  confluent  smallpox  is  nearly  always,  and  the  discrete  form  often,  fatal 
in  infancy,  the  physician  should  carefully  watch  the  progress  of  the  case  in 
the  infant.  By  judicious  treatment  some  in  this  period  of  life  may  be  saved 
who  otherwise  would  perish.  In  the  infant  depressing  measures  should  be 
avoided.  A  laxative  may  be  given  at  first  if  there  be  much  fever  and  the 
bowels  are  constipated ;  but  the  diet  should  be  nutritious,  and  many  soon 
require  tonics  and  stimulants.  If  the  pulse  become  more  frequent  and 
feeble,  or  if,  with  frequency  of  the  pulse,  the  face  and  extremities  become 
cool,  or  in  the  vesicular  or  pustular  stage  the  eruption  suddenly  subside, 
alcoholic  stimulants  must  be  immediately  employed  or  the  patient  dies. 

Such  is  an  outline  of  the  constitutional  treatment  required  in  smallpox. 
Sydenham  inculcated  a  mode  of  treatment  which  experience  has  shown  to 
be  injurious  in  infancy  and  childhood.  He  had  observed  that  the  severity 
of  the  disease  was  ordinarily  proportionate  to  the  amount  of  eruption,  and 
concluded  from  this  fact  that  measures  which  retarded  the  development  of 
the  eruption  were  salutary :  cold  drinks,  a  cold  apartment,  scanty  covering 
of  the  body,  cathartics  that  caused  derivation  of  the  blood  from  the  surface, 
even  sometimes  the  abstraction  of  blood,  were  considered,  according  to  Syden- 
ham's theoi-y,  to  be  useful  as  means  of  preventing  full  development  of  the 
eruption. 

Sydenham's  treatment,  however  appropriate  it  might  sometimes  be  in  the 
case  of  robust  adults,  is  unsuitable  for  children,  because  they  do  not,  as  a  rule, 
tolerate  in  this  disease  measures  which  reduce  the  strength.  Moreover,  small- 
pox is  rendered  more  dangerous  by  what  Killiet  and  Barthez  designate  per- 
turbating  treatment — treatment  which  renders  it  abnormal.  The  regular 
appearance  and  development  of  the  eruption  are  requisite  in  order  that  the 
case  may  progress  favorably.  On  the  other  hand,  the  opposite  plan  of  treat- 
ment, which  families,  if  left  to  themselves,  frequently  adopt  — to  wit,  the 
employment  of  measures  to  promote  perspiration,  as  hot  drinks  and  confine- 
ment in  a  heated  room — is  also  injurious. 

The  patient  should  be  kept  in  a  temperature  such  as  he  has  been  accus- 
tomed to  and  such  as  is  agreeable  to  him — a  temperature  at  66°  to  70°  ;  his 
diet  should  be  simple  and  nutritious ;  laxative  medicine  should  only  be  given 
to  procure  the  natural  evacuations.  In  smallpox,  as  in  all  infectious  diseases, 
free  ventilation  of  the  apartment  is  required.  The  room  should  be  dark,  for 
a  strong  light  perhaps  increases  the  pitting. 

While  the  general  eruption  should  not,  as  a  rule,  be  interfered  with,  it  is 
proper  to  endeavor  to  diminish,  so  far  as  possible,  the  size  of  the  pocks  on 


VARIOLA— VARIOLOID.  315 

parts  exposed  to  view,  so  as  to  prevent  disfigurement.  Professor  Flint,  in  his 
Treatise  on  the  Practice  of  Medicine^  has  published  an  excellent  summary  of 
the  various  measures  which  have  been  recommended  for  accomplishing  this 
end.  First :  The  opening  and  breaking  up  of  the  vesicle  by  means  of  a  fine 
needle.  This  is  tedious  practice  in  confluent  variola,  but  it  can  readily  be 
performed  in  the  discrete  form — at  least  as  regards  the  vesicles  upon  the  face. 
This  treatment  was  proposed  by  Rayer,  and  it  is  recommended  by  many  who 
have  tried  it.  Secondly  :  After  the  evacuation  of  the  liquid  the  cauterization 
of  the  vesicle  by  a  pointed  stick  of  nitrate  of  silver.  Eilliet  and  Barthez 
say,  in  reference  to  this  mode  of  treatment,  "  Individual  cautei'ization  of  the 
pustules  is,  on  the  other  hand,  an  almost  infallible  means  of  causing  them  to 
abort.  To  be  successful,  it  is  necessary  to  penetrate  into  the  interior  of  the 
pustule  with  a  pointed  crayon  of  nitrate  of  silver  in  order  to  cauterize  the 
derm  ....  It  is  only  the  first  or  second  day  of  the  eruption  that  it  (cau- 
terization) has  certain  success ;  nevertheless,  we  have  often  seen  it  succeed 
the  third  or  the  fourth  day,  or  even  the  fifth."  Thirdly  :  The  application  of 
tincture  of  iodine  once  or  twice  daily  over  the  eruption  when  in  the  papular 
stage.  Some  writers  who  have  employed  iodine  state  that  it  does  not  prevent 
pitting,  but  diminishes  it.  Its  favorable  efi'ects  are  produced  by  coagulating 
the  contents  of  the  papule.  Fourthly :  The  exclusion  of  light  and  air  by 
means  of  a  plaster.  A  mixture  containing  tannate  of  iron  has  been  employed 
for  this  purpose  in  one  of  our  hospitals.  This  produces  a  black  mask.  Light 
and  air  may  be  excluded  by  smearing  the  face  with  sweet  oil  and  dusting 
twice  daily  upon  the  oiled  surface  a  powder  containing  equal  parts  of  sub- 
nitrate  of  bismuth  and  prepared  chalk.  Fifthly :  The  application  of  mild 
mercurial  ointment  upon  the  face  or  other  parts  of  the  surface  where  it  is 
desirable  to  render  the  eruption  abortive.  This  mode  of  treatment  does 
diminish  the  size  of  the  vesicles  and  the  pitting,  but  I  should  not  recom- 
mend it  for  children.  I  have  known  in  the  adult  severe  mercurialization 
from  its  employment  for  four  or  five  days,  and,  though  young  children  do 
not  exhibit  so  readily  the  effects  of  mercury,  the  use  of  the  ointment,  unless 
for  a  very  limited  period,  increases,  in  my  opinion,  their  feebleness  and  dimin- 
ishes the  chance  of  their  recovery.  Calamine  made  into  a  paste  with  sweet 
oil  is  said  to  be  equally  effectual  with  mercurial  ointment,  and  it  produces  no 
constitutional  effect.  Its  effect  is  obviously  similar  to  that  of  bismuth  and 
chalk  employed  with  sweet  oil  as  stated  above.  Also,  I  have  employed  pul- 
verized charcoal  made  into  a  thin  paste  with  sweet  oil  or  glycerin,  and 
applied  daily  or  twice  daily  to  the  face.  It  effectually  excludes  the  light, 
and  the  result  appeared  to  be  good  as  regards  pitting,  but  it  is  a  disagreeable 
application.  Curschmann  recommends  as  preferable  to  any  of  these  methods 
the  use  of  iced  compi-esses  to  the  face  and  hands.  The  pain,  redness,  and 
swelling  are  diminished  by  their  use,  but  without  change  in  the  copiousness 
of  the  eruption  (^Ziemssens  Enct/cloj?.).  If  fissures  or  excoriations  occur,  an 
application  may  be  made  of  oxide  or  carbonate  of  zinc  in  glycerin,  one  drachm 
to  the  ounce. 

Dr.  Tomkyns  of  the  Fever  Hospital,  Manchester,  England,  states  that  he 
has  used  with  good  results  the  following  mixture,  applied  from  time  to  time 
over  the  surface : 

R.  Glycerini,  ^ss ; 

Tine,  iodini,  ^ij  ; 

Mucil.  amyli,  Oss. — Misce. 

The  intense  itching  and  the  fetid  odor  are,  according  to  my  observations, 
best  relieved  by  frequent  bathing  with  the  following  wash  : 


316  CONSTITUTIONAL  DISEASES. 


R.  Acidi  carbolic, 

.^j; 

Tine,  camphor., 

5y; 

Aquse, 

Oj. — jVIisce. 

Shake  bottle  before  using. 

The  prevention  of  smallpox,  so  far  as  practicable,  is  one  of  the  important 
incidental  duties  of  the  physician.  Isolation  of  the  patient  and  precautions 
in  reference  to  his  clothes  and  bedding  are  imperatively  required,  so  great  is 
the  contagiousness  of  this  disease.  The  only  certain  means  of  prevention  is 
vaccination,  and  providentially  the  incubative  period  of  the  vaccine  disease 
is  less  than  that  of  variola.  Therefore,  smallpox  may  be  prevented  after  the 
virus  is  received  in  the  system  by  timely  and  successful  vaccination.  Vac- 
cination, at  any  period  between  the  time  of  exposui-e  and  the  commencement 
of  the  symptoms  of  invasion,  will  either  prevent  the  occurrence  of  smallpox 
or  modiipy  it.  If  the  symptoms  of  invasion  have  already  commenced,  it  is 
uncertain  whether  it  produces  any  modifying  effect. 

Variola  is  so  very  contagious  that  there  is  danger  that  the  physician  and 
attendants  may  communicate  it  through  their  persons  or  clothing.  The  virus 
adheres  tenaciously  to  objects,  and  may  be  conveyed  by  them  long  distances. 
Therefore  the  room  occupied  by  the  patient  should  contain  no  unnecessary 
articles,  as  books  or  writing  material,  and  the  physician  attending  a  case 
should  bathe  and  change  his  clothing  before  going  elsewhere.  A  disinfectant 
should  also  be  constantly  used  in  the  room,  as  the  following,  which  I  have 
recommended  in  the  treatment  of  diphtheria  and  scarlet  fever : 

R.  01.  eucalypti, 

Acidi  carbolic,  da.  ,^j  ; 

Spts.  terebinth.,  5"^iij- — Misce. 

Two  teaspoonfuls  in  a  quart  of  water,  placed  in  a  tin  vessel,  shallow  and  with 
broad  surface,  and  maintained  in  a  state  of  constant  simmering. 


CHAPTER  V. 

VACCINIA. 

Vaccinia  is  a  mild  eruptive  disease  which  occasionally  occurs  among 
cattle  and  has  been  propagated  from  them  to  man.  It  is  characterized  by 
the  appearance  upon  the  surface  of  one  or  more  papules,  which  soon  become 
vesicular  and  then  pustular.  It  is  communicable  by  contact,  but,  unlike  the 
other  eruptive  fevers,  it  is  not  contagious  through  the  air.  It  is  inoculable, 
both  by  the  liquid  contained  in  the  vesicle,  which  is  designated  vaccine  lymph, 
and  by  the  scab  which  results  from  the  desiccation  of  the  pustule. 

To  Gloucestershire,  England,  the  honor  belongs  of  discovering  and  utiliz- 
ing the  fact  that  vaccinia,  a  mild  and  comparatively  harmless  disease,  is  trans- 
missible from  the  cow  to  man,  and  that  it  affords  protection  from  smallpox. 
It  appears  that  a  vague  opinion  prevailed  among  the  farmers  of  this  dairying 
section  that  a  disease  which  has  since  been  designated  vaccinia  was  occasion- 
ally received  from  the  cow  in  milking,  the  virus  passing  from  a  pustule  on 
the  teat  to  a  sore  or  chap  on  the  hand  of  the  milker,  and  that  those  who  thus 
contracted  the  disease  received  immunity  from  smallpox.  As  usually  happens 
with  important  discoveries,  so  slow  of  apprehension  is  the  human  intellect, 
these  people,  to  whom   Providence  had  revealed  a  most  important  fact,  were 


VACCINIA.  317 

blind  to  its  real  value.  Finally,  in  the  year  1724,  Benjamin  Jesty,  whom  the 
world  has  not  sufficiently  honored,  "  an  honest  and  upright  man,"  according 
to  his  epitaph,  a  farmer  of  Gloucestershire,  had  the  courage  to  vaccinate  his 
wife  and  two  children.  His  excellent  moral  character  did  not  shield  him. 
He  was  regarded  by  his  neighbors  as  an  inhuman  brute,  who  had  performed 
an  experiment  on  his  own  family  the  tendency  of  which  might  be  to  trans- 
form them  into  beasts  with  horns. 

This  first  essay  in  vaccination  appears  to  have  been  entirely  successful,  but 
the  prejudice  against  the  operation  continued.  A  fifth  of  a  century  passed, 
during  which  there  was  no  extension  of  the  benefits  of  this  great  discovery. 
At  last,  toward  the  close  of  the  last  century.  Dr.  Edward  Jenner,  a  physician 
of  Grloucestershire,  an  inoculator  of  his  district,  began  to  investigate  this  dis- 
ease of  the  cow,  about  which  little  was  known,  and  the  grounds  for  the  belief 
that  it  aff"orded  protection  from  smallpox.  Fortunately  for  the  world,  Jenner 
had  been  educated  under  John  Hunter,  and  had  learned  from  his  great  mas- 
ter to  study  nature  rather  than  books — to  be  guided  by  experience  and  obser- 
vation rather  than  by  the  dogmas  of  his  predecessors  or  of  the  schools. 

Jenner  performed  his  first  vaccination  on  the  14th  of  May,  1796.  twenty- 
two  years  after  Benjamin  Jesty  had  lost  his  good  name  among  his  neighbors 
by  vaccinating  his  own  family.  The  popularizing  of  vaccination,  mainly 
through  Jenner's  pei'severance,  affords  one  of  the  most  interesting  and  in- 
structive chapters  in  the  discovery  of  medical  science — how  he  went  to  London 
full  of  the  importance  of  the  discovery,  and  was  there  advised  by  his  medical 
friends  to  desist  from  his  wild  schemes,  lest  he  should  injure  the  reputation 
which  he  had  gained  from  a  creditable  paper  on  the  habits  of  the  cuckoo ; 
how  he  was  finally  allowed  to  vaccinate  in  hospital  wards,  and  gained  some 
adherents  to  the  new  faith  among  the  leading  physicians  of  the  metropolis ; 
and,  finally,  how,  as  the  claims  of  vaccination  began  to  be  recognized  at  the 
close  of  the  last  century  and  commencement  of  the  present,  a  most  acrimo- 
nious discussion  arose  which  filled  all  the  medical  journals  of  that  period. 
The  opponents  of  vaccination  resorted  to  every  device  to  prevent  the  accept- 
ance of  Jenner's  views.  They  attempted  to  prejudice  the  people  against 
them  by  specious  arguments,  by  ridicule,  and  even  by  caricatures.  One  of 
the  leading  journals  contained  the  picture  of  a  cow  covered  with  sores  and 
devouring  children,  and  it  was  urged  that  vaccination  was  a  bestial  operation, 
degrading  man  to  the  level  of  the  brute.  But  the  truth  had  gained  a  firm 
hold  and  the  practice  of  vaccination  extended. 

The  discovery  of  vaccinia  and  of  its  protective  power  cannot  be  too  highly 
appreciated.  It  has  probably  done  more  to  relieve  human  suff"ering  than  any 
other  discovery  of  the  last  one  hundred  years,  unless  we  except  that  of  anses- 
thetics,  and  more  to  save  human  life  than  any  other  instrumentality  of  a 
purely  physical  kind. 

The  fact  was  established  in  the  time  of  Jenner  that  the  virus  of  small- 
pox inoculated  in  the  cow  produces  vaccinia,  which  in  its  propagation  back 
to  man  never  returns  to  its  original  form,  but  always  remains  vaccinia. 
Moreover,  Jenner  believed  that  the  disease  known  in  the  horse  as  the  grease 
was  identical  in  nature  with  vaccinia  in  the  cow.  He  failed,  however,  in  his 
experiment  to  communicate  vaccinia  from  the  horse,  but  other  experiments 
have  been  more  successful.  In  1801  a  Dr.  Loy  of  the  county  of  York,  Eng- 
land, met  two  cases  of  vaccinia  in  persons  who  had  taken  care  of  a  horse 
aff"ected  with  the  grease,  and  from  the  lymph  which  he  obtained  was  able  to 
produce  vaccinia  in  the  cow.  In  1805,  Viborg,  a  Danish  veterinary  surgeon, 
after  many  failures,  succeeded  also  in  communicating  vaccinia  to  the  cow  by 
means  of  the  virus  taken  from  a  horse. 

From  this  time  little  light  was  thrown  on  this  subject  till  within  the  last 


318  CONSTITUTIONAL  DISEASES. 

twenty  years.  Although  Loy  and  Viborg,  and  perhaps  a  few  others,  had 
recorded  their  success,  other  experimenters  had  failed  to  communicate  vac- 
cinia from  the  horse.  In  the  absence  of  additional  cases  the  pi'ofession  began 
to  question  whether  there  might  not  have  been  some  error  in  the  observations 
of  the  gentlemen  whose  names  I  have  mentioned,  and  whether  a  disease  iden- 
tical with  vaccinia,  or  a  disease  which  may  communicate  vaccinia  to  the  cow 
or  to  man,  occurs  in  the  horse. 

Observations  confirmatory  of  those  of  Loy  and  Viborg  were  at  length, 
however,  made,  which  must  be  regarded  as  conclusive.  In  1856,  in  the 
department  of  L'Eure-et-Loir,  France,  M.  Pichot  was  consulted  by  a  boy 
who  had  on  the  back  of  his  hands  vaccine  pustules  which  had  apparently 
reached  the  eighth  or  ninth  day.  He  had  not  taken  care  of  nor  been  in  con- 
tact with  a  cow,  but  had  a  few  days  before  taken  care  of  a  horse  affected  with 
the  grease.  Vaccination  was  performed  by  means  of  the  lymph  taken  from  the 
pustules,  and  genuine  vaccinia  was  produced. 

Again,  in  1860  an  epidemic  prevailed  among  the  horses  in  Riemes  and 
Toulouse,  France.  A  mare  sickened  with  the  disease,  and  there  was  swelling 
of  the  hough,  with  discharge  of  sanious  matter.  M.  Delafosse  vaccinated  two 
cows  with  this  matter  and  communicated  genuine  vaccinia.  This  epidemic 
was  believed  by  the  veterinary  surgeons  to  be  an  erviptive  fever,  differing  in 
its  nature  somewhat  from  the  disease  or  diseases  which  have  ordinarily  been 
designated  the  grease.  It  has  been  conjectured  that  two  or  more  distinct 
affections  of  the  horse  have  the  same  appellation — one  of  which,  it  is  now 
admitted,  is  identical  with  vaccinia  of  the  cow  and  may  communicate  it ;  and 
the  reason  why  so  many  experimenters  have  failed  to  vaccinate  the  cow  from 
the  horse  is  that  they  have  used  the  virus  of  the  wrong  disease,  or  have  taken 
virus  from  horses  which  had  been  affected  with  the  true  disease,  but  from 
ulcers  which  had  lost  their  specific  character. 

Prior  to  the  time  of  Jenner  variolous  inoculation  was  practised  in  most 
civilized  countries,  since  variola  produced  in  this  way  was  found  to  be  milder 
than  when  arising  from  infection.  This  practice  is  now  obsolete,  forbidden 
in  some  places  by  legislative  enactments.  It  is  superseded  by  vaccination. 
Vaccination,  or  the  introduction  of  vaccine  lymph  into  the  system,  is  quickly 
and  conveniently  performed  by  scarifying  w4th  a  lancet  and  rubbing  into  the 
incisions  the  lymph  or  a  little  of  the  scab  pulverized  and  dissolved  in  a  drop 
of  cold  water.  It  may  also  be  performed  by  scraping  off  the  epidermis  with 
the  edge  of  the  instrument  till  the  blood  begins  to  ooze ;  and  also,  though 
with  less  certainty  of  success,  by  puncturing  the  skin  with  the  point  of  the 
lancet  or  by  an  instrument  called  the  vaccinator.  The  scab  should  never  be 
employed  when  it  is  possible  to  obtain  pure  lymph,  since  it  contains  animal 
matter  apart  from  the  virus,  and  may  be  the  medium  through  which  other 
diseases  may  be  communicated.  Besides,  it  is  much  less  active  than  pure 
lymph. 

If  the  child  have  a  vascular  nsevus,  this  may  be  selected  as  the  point  of 
vaccination.  Unless  of  large  size,  it  can  usually  be  cured  by  the  inflamma- 
tion which  vaccinia  produces.  Statistics  collected  by  Simon,  as  well  as 
Marson,  show  that  in  those  who  contract  varioloid  the  larger  the  number 
of  vaccine  cicatrices  the  milder  the  disease  and  the  less  the  proportionate 
number  of  deaths.  In  Simon's  statistics  of  those  who  stated  that  they  had 
been  vaccinated,  but  who  presented  no  cicatrix,  21  f  per  cent,  died ;  of  those 
who  had  one  cicatrix,  7j  per  cent,  died  ;  of  those  who  had  two,  4i  per  cent, 
died  ;  of  those  who  had  three,  If  per  cent,  died  ;  while  of  those  who  had  four 
or  more  cicatrices,  only  f  per  cent.  died.  These  statistics  would  seem  to  indi- 
cate the  propriety  of  vaccinating  in  several  places.  But,  so  far  as  appears, 
when  two  or  more  cicatrices  were  observed  the  patients  may  have  been  vac- 


VACCINIA.  319 

cinated  at  different  times,  at  intervals  of  several  years  ;  and  if  so  the  inference 
would  not  follow  that  more  complete  protection  is  produced  by  vaccinating 
in  several  places  than  in  one.  Moreover,  if  vaccination  be  performed  in  the 
usual  manner  by  several  incisions  on  the  arm,  and  the  virus  be  fresh  and 
active,  usually  two  or  more  distinct  vesicles  arise,  which  unite  in  their  devel- 
opment and  probably  protect  the  system  as  much  as  if  they  were  separated 
by  a  wider  space. 

Appearances  ;  Symptoms. — In  genuine  vaccination  no  effect  is  observed, 
except  the  slight  inflammation  due  to  the  operation,  till  the  close  of  the  third 
day.  Then  the  specific  inflammation  commences.  This  is  indicated  by  a  small 
red  point,  at  flrst  scarcely  visible,  indurated  and  slightly  elevated,  as  deter- 
mined by  the  touch  rather  than  by  the  eye.  This  increases,  and  on  the  fifth 
day  the  cuticle  over  the  inflamed  part  begins  to  be  raised  by  a  transparent  and 
thin  liquid.  The  vesicle  increases  in  diameter,  and  by  the  sixth  day  presents 
an  umbilicated  appearance  and  is  surrounded  by  a  faint  and  narrow  red  zone. 
At  the  close  of  the  eighth  day  the  vesicle  is  fully  developed.  Its  size  varies 
considerably.  It  is  usually  from  a  sixth  to  a  third  of  an  inch  in  diameter,  and 
oval  or  circular.  If  the  vaccination  have  been  performed  by  incisions,  the  size 
of  the  matured  vesicle  may  be  considerably  larger  and  its  shape  irregular,  in 
consequence  of  the  union  of  two  or  more  vesicles.  The  eruption  now  presents 
a  whitish  or  pearl-colored  appearance,  due  to  the  whiteness  of  the  cuticle  and 
the  transparence  of  the  liquid  underneath.  If  the  vaccination  be  performed 
by  incisions,  it  is  not  unusual  to  observe  over  the  centre  of  the  vesicle,  and 
adhering  to  it,  a  small  yellowish  scab,  which  has  resulted  from  the  scarifica- 
tion and  which  contains  none  of  the  virus. 

The  vaccine  vesicle,  like  that  of  variola,  consists  of  compartments,  com- 
monly eight  or  ten,  with  complete  partitions,  so  that  there  is  no  intercom- 
munication. On  the  ninth  day  the  inflamed  areola  becomes  more  distinct 
and  its  diameter  rapidly  increases.  Its  color  is  deep  red,  its  temperature  is 
considerably  elevated,  and  it  is  accompanied  by  more  or  less  induration  of  the 
subcutaneous  tissue,  and  it  is  tender  to  the  touch.  On  the  tenth  day  the  pock 
has  reached  its  full  development.  The  areola  extends  from  one  to  two  inches 
away  from  the  vesicle,  becoming  fainter  at  its  outer  circumference  and  grad- 
ually disappearing  in  the  healthy  skin.  The  shape  of  the  outer  circumference 
of  the  areola  is  irregular,  projecting  farther  at  one  point  than  another,  though 
its  general  form  is  circular. 

On  the  tenth  day,  when  the  inflammation  has  reached  its  maximum,  the 
heat,  itching,  and  tenderness  in  and  around  the  pock  are  such  that  the  child 
is  often  feverish  and  restless.  Occasionally  the  glands  of  the  axilla  become 
swollen  and  tender.  In  other  cases,  in  which  there  is  but  a  moderate  amount 
of  inflammation,  the  constitutional  disturbance  is  slight. 

At  the  close  of  the  tenth  day  or  on  the  eleventh  the  inflammation  begins 
to  decline  ;  the  areola  becomes  narrower  and  then  disappears ;  the  induration 
and  tenderness  abate  ;  and  with  this  change  the  pustule  desiccates,  its  liquid 
is  absorbed,  and  there  results  a  brownish  or  dark  mahogany-colored  scab, 
which  is  detached,  ordinarily,  between  the  fourteenth  and  twenty-first  days. 
The  cicatrix,  at  first  reddish  like  all  recent  cicatrices,  gradually  becomes  paler, 
and  remains  whiter  than  the  surrounding  integument.  It  presents  several 
minute  depressions  or  pits,  which  indicate  the  genuineness  of  the  vaccination. 

The  theory  that  smallpox  becomes  vaccinia  by  passing  through  the  heifer, 
as  we  have  given  it  above,  has  for  many  years  been  undisputed.  But  recently 
the  theory  has  been  promulgated  that  vaccinia  and  variola,  instead  of  being 
forms  of  the  same  disease,  are  essentially  distinct — that  when  the  heifer 
is  inoculated  with  the  virus  of  smallpox,  the  disease  which  is  produced  is 
a  modified  smallpox,  but  not  vaccinia,  which  occurs  as  a  spontaneous  disease 


320  CONSTITUTIOXAL  DISEASES. 

among  cattle.  It  may  be  that  the  old  theory,  which  no  one  doubted  until 
recently,  is  wrong,  but  that  vaccination  prevents  smallpox  just  as  a  mild 
attack  of  scarlet  fever  prevents  a  severe  attack  of  the  same  disease,  shows, 
in  my  opinion,  a  close  relationship  between  vaccinia  and  the  severe  malady 
which  it  prevents.  We  wait  for  more  conclusive  facts  in  support  of  the 
new  theory  before  accepting  it. 

Anomalies,  Complications,  and  Sequelae. — The  vesicle  is  often  broken 
accidentally  or  by  the  nails  of  the  child.  If  the  top  of  the  vesicle  be  destroyed 
or  most  of  the  compartments  be  opened,  the  inflammation  is  commonly  in- 
creased, considerable  suppuration  occurs,  and  there  results  a  large,  irregular, 
yellowish  scab  consisting  of  the  virus  mixed  with  desiccated  pus.  The  scab 
is  entirely  unreliable  and  unfit  for  the  purpose  of  vaccination,  though  the 
protective  power  of  the  disease  is  not  diminished  by  injury  of  the  vesicle 
even  if  it  be  totally  destroyed.  The  cicatrix  which  results  from  extensive 
injury  to  the  vesicle  is  usually  large  and  without  the  indented  points  which 
characterize  the   normal  cicatrix. 

In  rare  cases,  when  the  inflammation  which  surrounds  the  vesicle  is 
intense  and  deep-seated,  suppuration  occurs  in  the  subjacent  connective 
tissue,  giving  rise  to  an  abscess.  This  abscess  is  commonly  of  small  size, 
but  it  increases  the  fretfulness  and  constitutional  disturbance  which  attend 
vaccinia.  This  subcutaneous  suppuration  occurs  most  frequently  in  those 
who  have  a  scrofulous  or  vitiated  state  of  system.  Inflammation  of  the 
lymphatic  glands  of  the  axilla  I  have  spoken  of  as  not  infrequent  in  vaccinia. 
This  sometimes  proceeds  to  suppuration,  producing  an  unpleasant  though  not 
serious  complication. 

It  sometimes  happens  that  vesicles  appear  in  other  parts  besides  the  points 
where  the  virus  was  inserted.  These  supernumerary  vesicles  commonly  occur 
where  the  cuticle  has  been  removed  by  scalds  or  injuries. 

Trousseau  relates  the  case  of  an  infant  whom  he  had  vaccinated.  On  the 
eleventh  day  he  was  astonished  to  find  twenty-seven  vaccine  pustules  on  the 
face,  trunk,  and  limbs.  This  infant  had,  however,  before  the  vaccination  a 
simple  non-specific  eruption  over  the  whole  body,  and  it  was  believed  that  it 
had  produced  these  vaccinations  by  transferring  the  lymph  with  its  nails  to 
the  various  parts  where  the  cuticle  was  denuded. 

It  is  not  unusual,  also,  to  observe  minute  papules  appearing  on  parts  of 
the  surface  simultaneously  with  or  soon  after  the  vesicle,  and  in  a  few  days 
declining.     These  seem  to  be  abortive  vaccine  eruptions. 

One  of  the  most  serious  complications  is  erysipelas.  This  may  occur 
directly  from  the  operation  or  from  the  inflammation  caused  by  the  vesicle 
when  the  virus  possesses  no  deleterious  property ;  and,  again,  it  may  result 
from  some  unknown  element  in  the  virus.  It  may  occur  immediately  after 
the  operation,  when  it  commonly  prevents  the  working  of  the  virus,  or  during 
the  vesicular  or  pustular  stage,  or,  again,  after  desiccation  and  separation  of 
the  scab.     I  have  observed  it  at  all  these  periods. 

Erysipelas,  occurring  as  a  complication  of  vaccinia,  is  invariably  referred 
by  the  friends  to  the  virus  employed,  and  the  physician  who  has  had  the  mis- 
fortune to  vaccinate  is  often  unjustly  blamed.  In  many  of  these  cases  there 
is  a  strong  predisposition  to  erysipelas  at  the  time  of  the  vaccination,  and 
the  operation  or  the  inflammation  which  accompanies  the  normal  develop- 
ment of  the  vesicle  serves  simply  as  an  exciting  cause.  Erysipelas  would 
occur  as  soon  from  a  non-specific  sore ;  indeed,  we  not  infrequently  are  called 
to  cases  of  this  disease  in  young  children  which  commence  from  non-specific 
sores  upon  the  genitals  or  on  one  of  the  limbs.  That  the  fault  is  not  in  the 
virus  employed  is  evident  from  the  fact  that  other  children,  vaccinated  with 
the  same,  have  simple  uncomplicated  vaccinia. 


VACCINIA. 


321 


Septic£emia  is  a  very  serious  complication  of  vaccinia.  On  one  occasion 
since  the  publication  of  the  last  edition.  450  infants  were  vaccinated  in  the 
Foundling  Asylum.  This  institution  being  under  the  charge  of  a  large  sister- 
hood, all  the  inmates  are  clean,  and  all  the  450  did  well  with  one  exception. 
This  infant,  in  its  second  year,  is  believed  by  the  physicians  who  examined  it 
to  have  poisoned  the  vaccine  sore  by  scratching  it  with  dirty  finger  nails.  It 
had  sores  and  a  dusky  red  discoloration  of  parts  of  the  surface,  and  a  deep 
ulcer  over  its  right  leg  denuding  the  tibia  nearly  half  its  length.  We  were 
taught  the  important  lesson  which  surgeons  practise,  of  disinfecting  the  skin 
before  the  operation  and  to  protect  it  subsequently  by  some  dressing. 

Sometimes,  on  the  other  hand,  the  cause  of  erysipelas,  whatever  it  may 
be,  exists  in  the  virus.  (For  further  facts  in  reference  to  this  subject  the 
reader  is  referred  to  our  remarks  on  erysipelas.) 

The  fact  is  established  by  many  observations  that  syphilis  is  communi- 
cable by  vaccination.  The  symptoms  of  it  may  not  appear  till  vaccinia  has 
terminated  or  for  a  little  time  subsequently,  but  it  then  constitutes  a  very 
serious  sequel.  A  physician  of  this  city,  well  known  in  this  community  as 
skilful  in  the  diagnosis  and  treatment  of  skin  diseases,  and  therefore  not 

Fig.  4.5. 


Vaccine  vesicles.    Normal  shape  and  size  on  tenth  day. 


likely  to  be  mistaken  as  regards  the  nature  of  the  diseases,  states  that  he 
communicated   syphilis  to  two  infants  by  vaccinating  with  the  same  scab. 
Both  had  the  characteristic  syphilitic  eruption.     In  January,  1868,  an  infant 
21 


322  CONSTITUTIONAL  DISEASES. 

was  brought  to  Prof.  Alonzo  Clark's  clinic  in  this  city  having  syphilitic  rupia, 
which  in  the  opinion  of  the  physicians  present  was  undoubtedly  the  result 
of  vaccination. 

Trousseau  relates  the  case  of  a  young  woman  eighteen  years  old  who  was 
vaccinated  with  virus  taken  from  an  infant  apparently  in  perfect  health.  The 
vaccination  was  unsuccessful,  but  twenty-three  days  subsequently  his  atten- 
tion was  called  to  an  eruption  which  had  appeared  in  two  places  on  the  woman's 
arm  corresponding  with  the  points  where  the  virus  had  been  inserted.  The 
eruption  was  that  of  ecthyma,  which  by  the  next  examination,  which  was 
five  days  subsequently,  had  been  transformed  into  rupia.  The  axillary  lym- 
phatic glands  were  tumefied  and  indolent ;  finally  roseola  appeared,  which 
removed  all  doubts  as  to  the  syphilitic  character  of  the  disease.  There  was 
syphilitic  infection,  which  first  manifested  itself  in  the  points  where  vaccina- 
tion had  been  performed  (^Article  de  la  Vaccine).  It  is  not  ascertained  in 
Professor  Clark's  case,  nor  is  it  stated  in  Trousseau's,  whether  the  lymph  or 
scab  was  employed  for  vaccination.  There  can  be  little  doubt  that  the  pure 
lymph  never  communicates  anything  but  vaccinia,  and  if  by  vaccination  any 
other  disease  be  imparted,  a  little  blood  has  mingled  with  the  lymph  or  the 
scab  has  been  employed. 

The  vesicle  in  genuine  vaccinia  is  sometimes  very  small,  not  having  a 
diameter  of  more  than  two  lines.  Occasionally  the  development  of  the 
vesicle  is  retarded.  It  does  not  appear  till  two  or  three  days  later  than  the 
usual  time,  or  even  a  longer  period. 

Vaccinia  is  modified  by  certain  diseases.  It  is  arrested  by  measles  and 
scarlet  fever,  pursuing  its  course  after  the  subsidence  of  the  exanthem.  On 
the  other  hand,  it  sometimes  modifies  the  paroxysmal  cough  of  pertussis,  but 
only  during  the  time  when  the  pock  is  maturing.  Eczematous  eruptions 
occasionally  occur  after  vaccinia,  as  they  often  do  after  the  other  eruptive 
fevers,  or  if  already  present  they  may  be  aggravated. 

Subsequent  Vaccinations. 

A  second  vaccination,  performed  prior  to  the  ninth  day  after  the  first 
vaccination,  is  successful.  A  genuine  vaccine  eruption  results,  which  is 
smaller  the  more  advanced  the  primary  disease.  This  second  eruption  over- 
takes the  first.  On  the  ninth  day  the  susceptibility  to  vaccinia  is,  in  most 
eases,  lost,  so  that  vaccination  performed  on  the  tenth  or  subsequent  days 
is  unsiiccessful. 

As  a  rule,  an  acute  contagious  disease  occurs  only  once  in  the  same 
individual.  Vaccinia  is  an  exception.  In  most  people,  after  a  few  years  it 
can  be  produced  a  second  time,  and  cases  of  a  third  or  fourth  successful 
vaccination  at  intervals  of  a  few  years  are  not  uncommon.  Now,  subsequent 
cases  of  vaccinia  differ  from  the  first,  which  has  been  described  above.  The 
period  of  incubation  is  shorter,  and  the  vesicular,  pustular,  and  desiccative 
stages  succeed  each  other  more  rapidly,  so  that  the  whole  period  of  the  disease 
is  less.  The  variation  from  the  appearance  and  course  of  the  first  vesicle  is 
proportionate  to  the  degree  of  protection  which  the  first  vaccination  still  afi"ords 
both  as  regards  smallpox  and  vaccinia.  If  several  years  have  elapsed  since 
the  first  vaccination,  and  the  protective  power  which  it  affords  is  nearly  lost, 
the  second  vaccinia  difi"ers  but  little  from  the  first.  If,  on  the  other  hand, 
the  first  vaccination  still  aifords  nearly  complete  protection,  the  result  of  the 
second  is  slight ;  the  eruption  is  insignificant,  lacking  the  characteristic  appear- 
ance of  the  vaccine  vesicle,  resembling  a  common  sore,  and  disappearing  within 
a  week.  It  is  not  accompanied  by  the  infiamed  areola  or  any  appreciable  con- 
stitutional disturbance. 


VACCINIA.  323 

Vaccination  often  produces  no  result.  This  is  sometimes  due  to  the  fact 
that  the  lymph  or  scab  employed  is  useless.  It  has  spoiled  by  keeping  or 
never  has  been  good.  In  other  cases  it  is  due  to  a  lack  of  susceptibility  in 
the  person.  Some  take  vaccinia  with  difficulty  and  only  after  several  vacci- 
nations ;  just  as  children,  though  fully  exposed,  often  fail  to  take  measles  or 
scarlet  fever,  on  account  of  a  condition  of  the  system  which  prevents  the 
reception  of  the  virus  or  antagonizes  and  controls  its  action.  In  some 
instances  after  vaccination  an  eruption  is  produced  which  may  or  may  not 
be  genuine,  but  it  immediately  becomes  purulent  and  is  soon  broken.  A  large 
yellow,  uneven  scab  results,  having  none  of  the  appearance  and  containing  none 
of  the  vaccine  virus.  This  scab,  as  well  as  the  liquid  matter  which  preceded 
the  formation  of  the  scab,  is  utterly  useless  for  the  purpose  of  vaccination, 
and  if  so  employed  will  probably  cause  a  sore  from  its  irritating  effect,  but 
not  of  a  specific  character.  If,  in  place  of  the  true  vaccine  vesicle,  the  erup- 
tion presents  the  appearance  which  I  have  described — namely,  that  of  a  pus- 
tule, soon  breaking  and  forming  a  large  irregular,  yellowish  scab — the  vaccinia 
(if  it  be  correct  so  to  designate  it)  must  be  considered  spurious.  A  sore  has 
been  produced  by  the  animal  matter  which  was  employed  in  the  vaccination 
along  with  the  virus,  which  has  modified  the  action  of  the  virus,  and  probably 
has  rendered  it  useless  as  a  means  of  protection  ;  or  there  may  have  been  no 
virus  inserted  with  this  animal  matter.  The  physician  should  in  such  cases 
insist  on  a  second  vaccination. 

Cases  like  the  above  are  of  frequent  occurrence,  and  the  parents  of  the 
child  are  often  satisfied  with  the  result.  They  see  an  eruption  following  vac- 
cination, accompanied  by  considerable  inflammation  and  leaving  a  cicatrix. 
Unless  undeceived  by  the  physician,  they  probably  remain  in  the  belief  of 
the  child's  security  until,  perhaps,  it  takes  smallpox.  Such  cases  obviously 
tend  to  diminish  the  confidence  which  the  public  should  have  in  vaccination 
as  a  means  of  protection  from  smallpox,  and  on  account  of  their  frequent 
occurrence  it  is  important  in  every  case  that  the  physician  should  see  the 
result  of  his  vaccination.  It  has  been  proposed,  as  a  means  of  determining 
the  genuineness  of  vaccinia,  to  revaceinate  when  the  eruption  begins,  and 
if  the  first  be  genuine  the  second  will  overtake  it.  This  is  called  Brice's  test, 
but  it  is  not  necessary,  since  the  physician,  familiar  with  the  appearance  of 
the  true  vesicle,  can  determine  at  once  its  genuineness  by  the  sight. 

Protection  from  Vaccination — Revaccination. 

It  was  believed  by  the  early  advocates  of  vaccination  that  the  general 
performance  of  this  operation  would  soon  eradicate  smallpox  from  the  com- 
munity, so  that  it  would  be  interesting  only  to  the  medical  historian  as  a 
scourge  of  past  ages.  This  result,  however,  is  only  partially  achieved.  As 
a  rule,  the  greater  the  benefit  of  any  measure  designed  to  ameliorate  the 
condition  of  mankind,  the  greater  and  more  numerous  are  the  obstacles  which 
diminish  its  effectiveness.  Science  is  full  of  examples  like  this.  Fortunately, 
these  obstacles  as  regards  vaccination  are  not  such  as  to  impair  the  confidence 
of  physicians  in  its  protective  power,  and  it  is  not  too  much  to  expect  that 
this  simple  operation  will  yet  be  the  means  of  rendering  smallpox  a  disease 
almost  unknown,  unless  in  its  modified  form. 

Vaccination  should  be  performed  in  the  first  year  of  life.  In  rural  dis- 
tricts, where  there  is  little  danger  of  exposure  to  smallpox,  it  may  be  deferred 
till  the  age  of  ten  or  twelve  months.  In  the  city,  on  the  other  hand,  where 
there  is  constant  intercourse  of  people  and  where  contagious  diseases  are  often 
contracted  in  ignorance  of  the  time  and  place  of  exposure,  an  earlier  vaccina- 
tion is  advisable.     Some  physicians  recommend  performance  of  the  operation 


324  CONSTITUTIONAL  DISEASES. 

as  early  as  the  age  of  four  or  six  weeks.  The  objection  to  this  is  that  if 
erysipelas  occur  so  young  an  infant  is  likely  to  perish  from  it,  whereas  an 
infant  three  or  four  months  old  ordinarily  recovers.  For  this  reason  I  believe 
that  the  most  suitable  age  is  about  four  months  for  the  city  infant  in  ordinary 
times ;  but  if  smallpox  be  epidemic,  vaccination  should  be  performed  at  an 
earlier  age.  I  have  vaccinated  even  the  new-born  infant  when  smallpox  had 
broken  out  in  adjoining  apartments. 

Vaccinia  usually  extinguishes,  for  a  time,  the  susceptibility  to  smallpox. 
According  to  Mr.  Gintrac,  varioloid  does  not  occur  within  two  years  in  those 
who  have  been  vaccinated.  It  may,  however,  in  exceptional  instances,  occur 
in  a  mild  form  within  a  few  months  after  vaccination.  The  protection  afforded 
by  vaccination  graduall}'  diminishes  by  time,  but  it  does  not  probably,  as  a 
rule,  entirely  cease.  Varioloid,  however,  occurring  thirty  or  forty  years  after 
a  successful  vaccination  is  likely  to  be  severe,  and  it  may  even  be  fatal,  show- 
ing that  it  has  been  but  slightly  modified.  In  other  cases,  even  after  so  long 
an  interval,  the  symptoms  present  a  degree  of  mildness  which  indicates  that 
the  protective  power  of  the  vaccination  is  not  entirely  lost. 

If  a  second  vaccination  be  practised  soon  after  the  scab  from  the  first  vac- 
cination has  fallen,  it  will  usually  produce  no  result,  but  in  other  cases  it  gives 
rise  to  a  little  redness,  swelling,  and  indui'ation,  which  show  that  vaccinia  has 
been  reproduced,  though  in  a  very  mild  and  insignificant  form.  It  is  probable 
that  in  these  cases  varioloid  might  also  occur  by  exposure,  though  with  a 
mildness  corresponding  with  that  of  the  vaccinia.  The  longer  the  period 
after  the  first  vaccination,  the  greater  the  number  of  those  in  whom  a  second 
vaccination  is  effective,  and,  as  has  already  been  stated,  the  greater  also  the 
liability  to  the  variolous  disease  until  the  system  is  protected  by  a  second 
vaccination.  A  second  vaccination  should  be  performed  about  the  sixth  or 
eighth  year,  and  a  third  between  the  fifteenth  and  twentieth  years.  If  small- 
pox be  epidemic,  it  is  proper  to  vaccinate  all  who  have  not  been  vaccinated 
within  three  or  four  years. 

Selection  of  Virus. 

The  lymph  is  preferable  to  the  scab  for  vaccination,  provided  that  it  can 
be  obtained  fresh.  The  scab  is  more  easily  preserved,  and  therefore,  if  the 
lymph  and  the  scab  be  old,  the  latter  is  to  be  preferred.  The  lymph  should 
be  taken  on  the  fifth  day  if  the  vesicle  be  sufl&ciently  developed.  It  may  also 
be  taken  on  the  sixth,  seventh,  or  even  eighth  day,  provided  that  the  areola 
has  not  formed.  The  lymph  of  the  fifth  day  acts  with  greater  energy,  though 
that  of  the  sixth  or  seventh  day  is  not  much  inferior.  Lymph  obtained  after 
the  formation  of  the  areola  is  less  efficient,  though  it  may  communicate  the 
genuine  disease. 

There  is  no  mode  of  vaccination  so  reliable  as  the  use  of  lymph  taken 
directly  from  the  arm  and  immediately  inserted — the  arm-to-arm  vaccination. 
Lymph  can  be  preserved  for  a  few  days  on  a  flattened  surface  of  whalebone 
or  the  segment  of  a  quill,  and  if  employed  within  a  week  it  will  usually  com- 
municate vaccinia.  Lymph  may  be  preserved  a  longer  period  between  two 
surfaces  of  glass,  but  the  best  way  of  preserving  it  is  in  capillary  glass  tubes. 
The  end  of  the  tube  is  placed  within  the  vesicle,  and  the  lymph  ascends  by 
capillary  attraction.  When  a  sufficient  quantity  is  received,  the  ends  are 
sealed  by  holding  them  for  a  moment  in  a  flame.  Care  is  requisite  in  doing 
this  so  as  not  to  heat  the  lymph,  as  it  is  spoiled  by  a  temperature  much  above 
that  of  the  body.  When  the  lymph  is  used,  the  ends  of  the  tube  are  broken, 
and  by  blowing  gently  through  it  a  sufficient  quantity  is  received  on  the  point 
of  a  lancet. 


VACCINIA.  325 

If  the  scab  be  genuine,  it  presents  a  dark-brown  or  mahogany  color,  and 
has  a  circular,  oval,  or  at  least  a  rounded  form  ;  it  is  firm  or  compact,  and  has 
a  lustre.  Soft,  yellowish,  and  irregular  scabs  are  not  genuine,  and  those  of  a 
dull  appearance  or  without  lustre  have  usually  spoiled  in  the  keeping.  The 
scab  is  best  preserved  in  soft  beeswax,  which  excludes  the  air,  and  it  should 
be  kept  in  a  cool  place.  It  is  the  belief  of  many  that  the  vaccine  virus  grad- 
ually becomes  weaker  by  passing  successively  through  the  human  system 
(Condie,  American  Journal  of  the  Medical  Sciences,  April,  1865),  and  that 
therefore  different  specimens  of  virus  work  with  different  energy  according 
to  the  degree  of  removal  from  the  cow.  To  what  extent  this  view  is  correct 
is  not  fully  ascertained,  but  certainly  if  the  virus  employed  continue  to  pro- 
duce a  small  vesicle  attended  only  by  a  little  inflammation,  there  is  reason  to 
believe  that  the  protection  which  it  imparts  is  less  than  that  from  virus  which 
works  with  greater  energy,  and  it  should  be  exchanged  for  such.  In  New 
York  we  are  able  to  obtain  at  any  time  lymph  directly  from  the  heifer.  It 
has  never  passed  through  human  blood,  for  the  original  lymph  came  from 
cattle  in  one  of  the  provinces  of  France,  where  vaccinia  was  prevailing  epi- 
demically. The  popular  objection  to  vaccination  is  obviated  by  the  use  of 
this  lymph,  but  it  works  with  great  energy,  producing  a  large  pock  and  a 
sore  which  is  often  a  month  in  healing.  I  have  found  it  very  reliable,  and 
prefer  to  use  it  in  ordinary  cases. 

In  the  Boston  Medical  and  Surgical  Journal  of  October  12,  1882,  appeared 
a  sketch  of  the  following  remarkable  case.  It  shows  a  new  and  unusual  phase 
of  vaccinia  : 

"  The  case  about  to  be  reported  is  entirely  unique  ;  the  record  of  a  similar 
one  I  have  been  unable  to  find  anywhere.  Mrs.  B.,  a  healthy  woman,  the 
mother  of  two  children,  was  vaccinated  February  13th,  with  bovine  virus, 
by  her  family  physician,  Dr.  Harris  of  Roxbury,  through  whose  kindness  I 

Fig.  46. 


Vaccinia  communicated  by  the  mother's  milk. 


saw  the  case,  and  to  whom  I  am  indebted  for  the  following  notes.  On  the 
fifth  day  after  vaccination  the  patient  complained  of  headache,  was  feverish, 
and  in  fact  had  the  usual  amount  of  discomfort  that  attends  a  successful 
revaccination.     Mrs.  B.  was  at  this  time  nursing  her  infant,  a  child  about 


326  CONSTITUTIONAL  DISEASES. 

six  months  old.  The  child  had  not  been  vaccinated  on  account  of  eczema 
from  which  it  was  suifering  at  that  time.  On  March  9th,  as  nearly  as  the 
mother  can  remember,  an  eruption  appeared  on  the  head,  thorax,  and  the 
legs  of  the  child,  who  had  been  feverish  and  irritable  for  two  or  three  days 
previous.  On  some  portions  of  the  body  the  eruption  was  confluent,  but  on 
the  arms  and  thighs  it  presented  the  characteristic  appearance  of  cow-pox. 
It  was  not  an  instance  of  accidental  inoculation,  for  there  was  no  possible 
way  by  which  the  child  could  have  introduced  the  virus  at  so  many  difi"erent 
points.  The  disease  must  have  been  contracted  from  the  mother  through 
the  medium  of  her  milk." 


CHAPTER    VI. 

VARICELLA. 

Varicella,  chickenpox,  or  swinepox  is  the  shortest  and  mildest  of  the 
eruptive  fevers.  It  is  highly  contagious,  so  that  few  children  escape  who  are 
exposed  to  it.  Its  period  of  incubation  is  from  fifteen  to  seventeen  days. 
Hutchinson  {Brit.  Med.  Journ.,  1881)  and  Le  Gendre  (Z>e  Concours  Med.,  1887) 
state  that  varicella  is  inoculable,  but  some  years  ago  inoculations  which  I 
performed  with  the  lymph  of  the  varicellar  vesicle  were  without  result. 
It  attacks  the  same  individual  but  once,  and  it  occurs  as  an  epidemic.  It 
has  been  thought  by  some  to  prevail  most  immediately  before,  during,  or 
after  epidemics  of  smallpox,  and  it  has  been  conjectured  that  it  is  a  modified 
form  of  variola,  and  hence  its  name,  which  signifies  little  variola.  This  idea 
is,  however,  entertained  by  few,  and  it  is  opposed  by  the  following  facts :  Vari- 
cella may  occur  after  variola  or  variola  after  varicella  without  any  modifica- 
tion, and  the  two  diseases  are  very  dissimilar  as  regards  gravity  of  symptoms 
and  duration.  The  variolous  disease,  whether  smallpox  or  varioloid,  often 
occurs  in  the  adult ;  varicella,  on  the  other  hand,  is  a  disease  of  infancy  and 
childhood.  I  have  seen  one  adult  case,  which  I  recall  to  mind,  and  Professor 
Flint  states  that  he  has  also  observed  varicella  in  the  adult,  but  its  occurrence 
at  this  period  of  life  is  rare.  Senator  relates  a  case  that  occurred  at  the  age 
of  eleven  days.     In  584  cases  observed  by  Baader  the  ages  were  as  follows : 

Cases.  Age. 

382 1-5  years. 

191 6-10     " 

7    11-15     " 

2   16-20     " 

2   21-40     " 

Moreover,  varicella  and  variola  have  been  known  to  occur  simultaneously  in 
the  same  individual.  Such  a  case  was  reported  by  M.  Delpech  in  a  memoir 
published  in  1845. 

Symptoms. — Varicella  usually  commences  with  such  symptoms  as  usher 
in  ordinary  mild  febrile  attacks — namely,  headache,  languor,  chilliness,  and 
sometimes  aching  in  the  back  and  limbs.  Fever  supervenes,  which  is  usually 
moderate,  the  pulse  rising  perhaps  to  100  or  112,  and  the  thermometer  show- 
ing an  increase  of  temperature,  but  less  than  occurs  in  the  other  eruptive 
fevers.  These  symptoms  which  precede  the  eruption  are  sometimes  absent 
or  are  so  mild  as  to  escape  notice.     The  fever  usually  ceases  on  the  second 


VARICELLA.  327 

clay,  but  it  may  return  on  the  following  night.  The  appetite  is  rarely  lost, 
and  most  children  continue  more  or  less  at  their  amusements. 

When  the  above  symptoms  have  continued  about  twenty-four  hours  the 
eruption  appears  first  over  the  trunk,  and  soon  afterward  over  the  face  and 
limbs.  It  consists  of  minute  disseminated  papules  which  become  vesicular 
in  the  course  of  a  few  hours.  The  occurrence  of  the  vesicular  stage  is  nearly 
simultaneous  on  all  parts  of  the  surface,  and  commonly  fresh  vesicles  appear 
during  the  first  three  or  four  days.  The  vesicles  lack  the  hard,  indurated 
base  of  the  variolous  eruption,  though  they  are  sometimes  surrounded  by  a 
faint  zone  of  redness.  They  differ  also  from  the  variolous  eruption  in  the 
absence  of  umbilication  and  in  irregularity  of  shape.  Some  are  small  and 
acuminate,  some  hemispherical  and  of  medium  size,  and  others  oval  or  elon- 
gated and  of  large  size.  The  inflammation  is  quite  superficial,  not  involving 
the  subcutaneous  tissue  and  scarcely  affecting  the  deepest  layer  of  the  skin. 

The  vesicles  vary  in  size  from  the  diameter  of  half  a  line  to  that  of  even 
three  lines.  They  occasionally  give  rise  to  slight  itching.  On  the  second 
day  of  the  eruption  or  third  day  of  the  disease  they  are  still  fully  developed, 
their  liquid  contents  being  nearly  transparent.  At  the  close  of  this  day  the 
liquid  begins  to  be  somewhat  cloudy  and  its  absorption  commences.  On  the 
fourth  day  of  the  disease  desiccation  progresses  rapidly,  and  by  the  fifth  the 
liquid  has  for  the  most  part  disappeared,  and  a  scab  results,  small,  thin,  and 
of  a  yellowish-brown  color.  The  scabs  are  soon  detached,  the  redness  which 
indicated  their  seat  disappears,  the  epiderm  which  had  been  raised  and 
removed  by  the  eruption  is  reproduced  in  its  normal  state,  and  in  a  few  days 
all  evidence  of  varicella  is  effaced.  A  cicatrix  occasionally  results,  but  it  is 
due  not  to  the  simple  varicellar  eruption,  but  to  a  sore  produced  from  the 
eruption  by  the  scratching  of  the  child. 

The  number  of  vesicles  varies  considerably  in  different  cases.  They  are 
never,  so  far  as  I  have  observed,  confluent ;  but  they  are  sometimes  so  abun- 
dant in  young  children  that  if  the  disease  were  variola  it  would  be  called 
severe  discrete.  They  occur  also  on  the  buccal  and  faucial  surfaces,  where 
they  soon  break,  forming  small  ulcers.  The  duration  of  the  disease  from 
the  first  symptoms  until  the  disappearance  of  the  crusts  is  eight  or  ten  days. 

Mr.  J.  Hutchinson  of  London  has  described  a  rare  form  of  varicella  in 
which  the  eruption  becomes  gangrenous.  It  occurs  most  frequently  in  feeble, 
ill-conditioned  children,  but  sometimes  in  those  who  are  well  nourished.  Only 
a  portion  of  the  vesicles  become  gangrenous.  Where  the  gangrene  occurs  a 
deep  and  unhealthy  ulcer  forms  underneath  the  scab,  which  does  not  heal  or 
heals  slowly.  This  rare  form  of  varicella  is  very  fatal,  death  sometimes 
occurring  from  pyasmia  and  secondary  abscesses.  Crocker  states  (London 
Lancet^  ^V-Sij  30,  1885)  that  the  gangrene  sometimes  occurs  upon  a  part  of 
the  surface  which  is  not  the  seat  of  the  eruption. 

Complications;  SEQUELiE.  — Complicating  maladies  which  sometimes 
supervene  in  varicella  do  not,  for  the  most  part,  occur  in  consequence  of  this 
disease,  but  are  independent  of  it.  Erysipelas  has  in  rare  instances  super- 
vened on  the  varicellar  eruption,  but  its  occurrence  is  attributable  to  the 
ordinary  causes  of  this  disease,  rather  than  to  varicella.  Various  sequelae 
of  varicella  have  been  mentioned  by  writers,  among  which  we  may  mention 
anaemia,  pemphigus,  urticaria,  bronchitis  or  bronchi-pneumonia  (Meigs  and 
Pepper),  ulcers  leading  to  glandular  enlargements  and  tuberculosis,  and 
nephritis  (Henoch,  Janssen,  Oppenheim). 

Diagnosis. — Obviously,  the  only  diseases  with  which  varicella  is  liable 
to  be  confounded  are  such  as  present  vesicles  at  some  stage  of  their  course. 
From  the  local  vesicular  eruptions  this  disease  is  diagnosticated  by  the  fact 
that  the  vesicles  appear  on  all  parts  of  the  surface.     It  is  sometimes  mistaken 


328  CONSTITUTIONAL  DISEASES. 

foi"  variola  or  varioloid,  or  vice  versa — a  mistake  very  damaging  to  the  reputa- 
tion of  the  physician.  The  points  of  diiferential  diagnosis  are  the  symptoms 
of  invasion — severe  and  lasting  three  or  four  days  in  the  one,  mild  and  con- 
tinuing only  one  day  in  the  other  ;  an  eruption  passing  slowly  through  its 
stages  from  the  papular  to  the  pustular,  umbilicated.  with  circular,  raised 
and  inflamed  base,  appearing  first  on  the  face  and  neck,  and  not  till  a  day 
later  on  the  legs,  in  the  one  disease ;  while  in  the  other  the  evolution,  shape, 
and  course  of  the  eruption,  as  described  above,  are  materially  different.  By 
proper  attention  to  these  distinctive  features  it  is  rarely  difficult  to  diagnosti- 
cate varicella. 

Prognosis.  —  In  ordinary  uncomplicated  varicella  this  disease  is  always 
favorable.  Gangrenous  varicella,  which  is  very  rarely  seen  in  America,  may 
be  fatal,  and  complications  may  render  a  case  grave. 

Treatment.  —  On  account  of  the  general  mildness  of  varicella,  prophy- 
lactic measures,  as  isolation  of  the  patient,  are  seldom  enforced  in  America, 
and  the  disease,  when  not  complicated  or  gangrenous,  requires  little  treat- 
ment ;  but  the  patient  should  be  quiet  and  indoor  during  its  continuance. 
Large  vesicles  upon  the  face  should  be  punctured  early  and  irritation  by 
rubbing  should  be  avoided.  Complications  and  gangrenous  varicella  require 
appropiate  treatment,  especially  supporting  remedies.  Anaemia  or  glandular 
swellings  remaining  after  varicella  require  tonics,  especially  cod-liver  oil  and 
syrup  of  the  iodide  of  iron. 


CHAPTER    VII. 

DIPHTHEEIA. 

Diphtheria  is  one  of  the  most  dreaded,  one  of  the  most  fatal,  and 
unfortunately  one  of  the  most  common,  maladies  of  childhood.  It  is  pro- 
duced by  a  micro-organism.  It  is  characterized  by  the  occurrence  of  a 
grayish-white  pellicle  upon  the  mucous  surface  or  the  skin  deprived  of  its 
protecting  epithelium.  The  specific  principle  is  ordinarily  received  by  the 
inspiration  of  infected  air,  but  it  is  sometimes  received  by  direct  contact 
of  infected  matter  with  one  of  the  surfaces  not  lying  in  the  respiratory  tract. 

Diphtheria  is  a  disease  of  antiquity.  M.  Sanne  mentions  the  following 
names  by  which  it  has  been  known  in  different  countries  and  at  different 
periods:  Ulcus  Syriacum,  ulcus  ^gyptiacum,  garrotillo,  morbus  suffocans, 
affectus  strangulatorius,  pestilentis  gutturis  affecto,  pedaneho  maligna,  angina 
maligna,  anginosa  passio.  mal  de  gorge  gangreneux,  ulcere  gangreneux,  angina 
polyposa,  angine  maligna,  croup,  diphtheritis,  diphtheria.  These  terms  express 
the  prominent  characteristics  of  diphtheria. 

It  is  impossible  to  state  or  form  a  probable  conjecture  in  regard  to  the 
time  when  diphtheria  originated,  but  its  origin  antedated  the  Christian  era. 
According  to  Aurelianus,  Asclepiades,  who  lived  one  hundred  years  before 
Christ,  scarified  the  tonsils  and  performed  laryngotomy  for  the  relief  of  res- 
piration, and  it  is  supposed  that  he  treated  cases  of  membranous  croup,  and 
probably  diphtheria.  Aretaeus,  a  Greek  physician  of  Cappadocia  at  the  com- 
mencement of  the  Christian  era,  gives  in  writings  still  extant  a  clear  and 
accurate  description  of  mild  and  severe  diphtheria.  After  describing  what  he 
designates  ulcers  upon  the  tonsils,  "  covered  with  a  white,  livid,  or  black  con- 
crete product,"  he  adds :  "  If  the  malady  invades  the  chest  by  the  trachea,  it 


DIPHTHERIA.  329 

causes  suffocation  on  tlie  same  day.  Children  up  to  the  age  of  puberty  are 
most  exposed  to  this  disease."  He  gives  also  a  graphic  and  truthful  descrip- 
tion of  the  suffering  of  the  child  when  the  disease  extends  to  the  larynx,  and 
croup  results.  Gralen,  in  the  second  century  of  the  Christian  era,  apparently 
alludes  to  diphtheria  when  he  describes  a  fatal  disease  prevalent  in  his  time 
in  which  fragments  of  '"  membranous  tunic  "  are  expelled.  He  states  that  he 
is  able  to  determine  by  the  manner  in  which  the  fragments  are  expelled,  by 
coughing  or  spitting  (hawking),  whether  they  are  detached  from  the  larynx 
or  the  pharynx.  Coelius  Aurelianus,  a  Latin  physician  who  is  supposed  by 
some  to  have  lived  in  the  second  century,  and  by  others  as  late  as  the  fifth 
century,  describes  a  grave  angina  in  which  the  symptoms  which  sometimes 
arise  correspond  with  those  in  diphtheritic  croup  and  diphtheritic  paralysis  as 
observed  at  the  present  time.  In  the  fifth  century  Aetius  of  Amida  described 
a  disease  accompanied  by  "  crusty  and  pestilential  ulcers,''  sometimes  having 
a  whitish  and  in  other  instances  an  ashy  or  rusty  color,  and  not  preceded  by 
a  discharge.  Aetius  alludes  to  the  hoarseness  which  he  says  sometimes  super- 
venes and  is  a  source  of  danger  up  to  the  seventh  day. 

From  the  close  of  the  fifth  century  until  the  sixteenth  the  record  of 
■diphtheria  is  broken.  It  is  probable  that  during  the  long  period  embraced 
in  the  Dark  Ages  every  decade  witnessed  epidemics  of  this  fatal  malady, 
but  if  they  were  observed  and  recorded  the  records  were  lost,  the  literature 
of  diphtheria  sharing  the  fate  of  general  literature  during  this  time  of  intel- 
lectual darkness.  On  the  revival  of  learning  many  epidemics  of  diphtheria 
were  recorded  in  the  medical  literature  of  Europe,  and  this  disease  has  since 
been  a  common  topic  of  discussion  in  the  civilized  portions  of  the  Eastern 
hemisphere. 

Those  who  have  made  special  study  of  diphtheria  believe  that  its  first 
occurrence  in  Xorth  x\merica  was  in  New  England.  It  is  stated  that  Samuel 
Danforth  of  Roxbury,  a  graduate  of  Harvard,  lost  three  of  his  children  in 
1659,  within  two  weeks,  from  a  disease  which  was  designated  "  malady  of 
bladders  in  the  windpipe."  Again,  John  Josselyn  made  two  voyages  to  New 
England  in  1638  and  1663,  and  in  his  memoranda  he  states  that  the  English 
in  New  England  "  are  troubled  with  a  disease  in  the  mouth  and  throat,  which 
hath  proved  mortal  to  some  in  a  very  short  time.  This  disease  is  designated 
quinsies  and  imposthumations  of  the  almonds  with  great  distempers  of  colds." 
Whether  these  early  New  Englanders  had  diphtheria  or  not  I  am  unable 
to  say,  but  nearly  a  century  had  elapsed  from  the  time  of  Danforth  and 
Josselyn  when  the  much  wider  and  more  fatal  epidemic,  more  clearly  one  of 
diphtheria,  occurred. 

On  March  20,  1635,  at  Kingston,  a  town  fifty  miles  northeast  of  Boston, 
occurred  the  first  case  of  the  disease,  which  was  destined  to  overrun  the  British 
possessions  in  North  America.  The  first  forty  attacked  by  it  died ;  the  first 
patient  survived  three  days ;  the  three  next  attacked  lived  four  miles  from 
the  first  patient.  When  the  epidemic  reached  Boston,  Dr.  William  Douglass 
made  a  full  and  accurate  clinical  examination  of  it,  and  wrote  a  monograph 
containing  the  result  of  his  observations.  Douglass,  not  knowing  that  Bos- 
ton was  soon  to  be  the  "  Athens  of  America,"  states  in  his  exordium  that  in 
plantation  life  neither  honor  nor  credit  are  to  be  acquired  by  writing.  His 
sole  object  in  publishing  his  monograph  was  to  induce  others  to  investigate 
the  disease  more  fully.  Death,  he  states,  usually  occurred  from  the  fauces 
or  neck,  which  was  greatly  swollen.  J.  Dickinson,  A.  M.,  of  Cambridge,  a 
clergyman,  published  what  he  designated  "  Observations  on  that  terrible 
Disease  vulgarly  called  '  Throat  Distemper.'  "  He  writes :  "  Some  expecto- 
rated incredible  quantities  of  a  tough  whitish  slough  from  their  lungs 

I  have  seen  several  pieces  of  this  crust  several  inches  long,  and  near  an  inch 


330  CONSTITUTIONAL  DISEASES. 

broad,  torn  from  tlie  lungs  by  the  vehemence  of  the  cough."  Dickinson  also 
remarks  that  one  attack  of  the  epidemic  disease  does  not  protect  from  a  sec- 
ond. One  patient  had  at  intervals  four  distinct  attacks,  the  last  being  fatal. 
The  fact  of  the  recurrence  of  the  throat  affection  is  sufficient  proof  of  its 
diphtheritic  rather  than  scarlatinous  nature,  as  is  also  the  fact  that  the  cha- 
racteristic pellicular  inflammation  sometimes  occurred  upon  abraded  or 
wounded  surfaces  at  a  distance  from  the  fauces,  while  the  latter  was  but 
slightly  or  not  at  all  affected.  This  widespread  and  gradually  extending 
epidemic  of  diphtheria  was  the  first  occurring  within  historic  times  in  North 
America  and  probably  in  the  Western  hemisphere. 

The  Hon.  Cadwallader  Golden,  Esq.,  His  Majesty's  Lieutenant-Governor 
of  the  State  of  New  York,  wrote  a  letter  to  Dr.  Fothergill  in  1753,  printed 
in  the  London  Medical  Observations  and  Inquiries,  vol.  i.  He  wx'ites  that 
this  new  throat  disease  extended  gradually  westward  from  Kingston,  tra- 
versing New  England,  but  it  did  not  reach  the  Hudson  river  until  two  years- 
had  elapsed.  Golden  said  that  it  remained  for  some  time  on  the  east  side 
of  the  Hudson,  but  finally  crossed  to  the  west  side,  and  he  believed  that  it 
spread  over  all  the  British  colonies  in  America.  As  might  be  expected,  in 
due  time  it  reached  New  York,  and  it  was  described  by  Dr.  Samuel  Bard  in 
a  paper  published  in  1771  and  having  the  following  title :  "  An  Inquiry  into 
the  Nature,  Gause,  and  Cure  of  the  Angina  Sufi"ocativa,  or  Sore-throat  Dis- 
temper." Bard  wrote  as  follows :  "  Upon  the  whole,  therefore,  I  am  led  to 
conclu.de  that  the  disease  called  by  the  Italians  morbus  strangulatorius ;  the 
croup  of  Dr.  Home ;  the  sore  throat  of  Huxham  and  Fothergill ;  this  disease,, 
and  that  described  by  Dr.  Douglass  of  Boston,  however  they  may  differ  in 
the  symptoms  of  putrescence  and  malignancy,  do  all  bear  an  essential  affin- 
ity and  relationship  to  each  other,  and  in  fact  arise  from  the  same  leaven." 
Dr.  Jacob  Ogden  of  Jamaica,  Long  Island,  described  this  widespread  throat 
distemper  as  he  observed  it  in  the  townships  of  Long  Island.  His  last  paper 
on  this  malady  was  published  in  1774,  thirty-nine  years  after  the  first  case  in 
Kingston,  and  just  before  the  breaking  out  of  the  Revolutionary  war.  I  am 
not  aware  that  any  outbreak  of  diphtheria  occurred  in  this  country  during 
the  eighteenth  century  after  the  commencement  of  the  war.  The  fact  that 
families  deserted  their  homes  and  fled  to  a  distance  for  safety,  especially 
from  the  cities  along  the  Atlantic  coast,  may  aid  in  explaining  the  disappear- 
ance of  this  disease.  After  the  disappearance  of  this  widespread  epidemic 
we  hear  little  or  nothing  of  the  occurrence  of  diphtheria  upon  this  continent 
until  nearly  a  century  had  elapsed,  except  that  occasional  isolated  cases  of 
pseudo-membranous  laryngitis,  popularly  designated  membranous  croup, 
occurred  now  and  then  with  little  evidence  of  contagiousness.  It  may 
have  been  produced  by  the  streptococcus  and  have  been  a  croup  of  the 
pseudo-diphtheritic  nature. 

In  the  first  half  of  the  present  century  diphtheria  was  regarded  as  a  very 
important  disease  in  Europe,  and  was  made  the  subject  of  investigation  by 
the  most  renowned  clinical  teachers,  among  whom  we  may  mention  Jurine 
(1807),  Bretonneau  (1821),  Bourgeoise  (1823),  Gendron  (1825),  Billard 
(1826),  Deslandes  (1827),  Blanquin  (1828),  Broussais  (1829),  Trousseau 
(1830),  Gheyne  (1833),  Fricout  and  Burley  (1836),  Boudet  (1842),  Guersant 
and  Blache  (1844),  Moland  (1845),  Damot  (1846),  and  Heine  (1849).  During 
this  half  century,  ending  with  1850,  which  witnessed  such  an  augmentation 
of  the  literature  of  diphtheria  in  Europe,  this  disease  attracted  but  little 
attention  in  America.  It  appears  to  have  been  much  less  prevalent  on  this 
continent  than  in  the  Old  World.  It  may  have  occurred  in  small  epidemics 
in  various  localities  from  the  time  of  Dr.  Bard  until  1850,  but  they  attracted 
so  little  notice  from  American  physicians  that  no  monograph  or  communica- 


DIPHTHERIA.  331 

tion  to  medical  journals  relating  to  diphtlieria,  whicli  was  wortliy  of  preserva- 
tion, appeared  during  this  long  period. 

Etiology. — Diphtheria  is  caused  by  a  bacillus,  which  alights  upon  the 
faucial  or  other  mucous  surface,  or  the  skin  denuded  of  its  epidermis,  and 
obtains  there  a  nidus  favorable  for  its  development  and  propagation.  It  is 
designated  the  Klebs-Loeffler  bacillus,  having  been  discovered  by  Klebs  in 
1883,  and  subsequently  more  fully  investigated  by  Loeffler.  It  is  a  small 
linear  microbe,  having  nearly  the  length  of  the  tubercle  bacillus,  but  ordi- 
narily more  than  double  its  thickness.  It  often  exhibits  a  granular  appear- 
ance, and  is  stained  in  two  minutes  by  the  violet  of  methyl.  It  presents 
aspects  which  under  the  microscope  are  characteristic.  It  often  exhibits  a 
more  intense  coloration  of  its  extremities  than  of  its  central  parts.  Both  its 
extremities  are  sometimes  swollen,  so  that  its  shape  approximates  that  of  the 
dumb-bell,  or  only  one  is  swollen,  so  that  its  shape  resembles  that  of  the  pear 
or  gourd. 

According  to  all  bacteriologists  this  bacillus  does  not  enter  the  internal 
organs  except  in  rare  instances.  It  does  not  ordinarily  extend  more  deeply 
than  the  mucosa,  the  parts  below  being  protected  by  a  layer  of  fibrinous 
lymph. 

Since  the  specific  bacillus  ordinarily  acts  only  on  superficial  parts,  it  does 
not  in  itself  produce  systemic  or  blood  poisoning,  but  it  generates  a  toxine 
which  is  readily  taken  up  by  the  lymphatics  or  blood-vessels  and  is  conveyed 
to  every  part  of  the  system,  causing  the  systemic  infection  from  which  so 
many  of  the  victims  of  diphtheria  perish. 

L.  Brieger  and  Karl  Fraenkel  say  of  this  toxine  that  it  is  destroyed  by  a 
heat  above  110°  F.  (60  C),  and  may  be  evaporated  at  122°  F.  (50  C).  It 
is  soluble  in  water,  but  insoluble  in  alcohol.  It  is  not  precipitated  by  ebul- 
lition, nor  by  the  following  medicinal  agents :  sulphate  of  sodium,  nitric  acid, 
and  acetate  of  lead,  but  is  precipitated  by  concentrated  carbolic  acid,  the 
ferrocyanide  of  potassium,  acetic  acid,  carbolic  acid,  ^nd  nitrate  of  silver. 
It  has  the  following  composition : 

Carbon   ...  45.35 

Hydrogen 7.13 

Azote 16.33 

Sulphur 1.39 

Oxygen 29.80 

The  investigations  of  Eoux,  Yersin,  and  others  have  shown  that  the 
diphtheria  bacillus  separated  by  passing  through  the  Pasteur-Chamberland 
porcelain  filter,  and  becoming  separated  from  its  toxine,  loses  its  virulent 
property,  while  the  clear  filtered  fluid,  free  from  microbes,  contains  the 
toxine  without  diminution  of  its  poisonous  character.  Grandmaison  says 
that  although  the  Klebs-Loefiler  bacillus  appears  only  on  superficial  inflamed 
parts,  the  poison  generated  by  it  entering  the  system  causes  paralysis,  gan- 
glionic engorgement,  albuminuria,  patches  of  sphacelus,  and  visceral  lesions, 
which,  although  they  may  be  latent  during  life,  are  discovered  by  micro- 
scopic examination  of  the  diseased  viscera  in  the  cadaver. 

Although  the  Klebs-Loefiler  bacillus  is  the  recognized  cause  of  true 
diphtheria,  certain  accessory  germs,  mainly  cocci,  occur  during  the  course 
of  the  attack,  in  the  pseudo-membrane,  upon  and  in  the  inflamed  surface, 
and  also  in  internal  organs,  if  the  disease  be  severe,  having  obtained  a  nidus 
favorable  for  their  development  in  and  upon  the  diseased  parts.  It  appears, 
from  examinations  made,  that  these  accessory  germs  are,  in  some  cases,  taken 
up  by  the  lymphatics  and  blood-vessels,  and  conveyed  to  the  lymph-nodes 
and  the  connective  tissue  of  the  neck,  causing  inflammatory  tumefaction,  and 


332  CONSTITUTIONAL  DISEASES. 

to  internal  organs  -whicli  are  not  readied  by  the  Loeffler  bacillus.  These  acces- 
sory germs  increase  the  severity  and  mortality  of  true  diphtheria.  Their 
presence  as  a  complication  is  an  interesting  fact,  because,  as  we  will  see,  the 
streptococcus  and,  in  a  less  degree,  other  forms  of  cocci,  unaided  by  the 
diphtheria  bacillus,  sometimes  cause  so  severe  an  inflammation  of  the  mucous 
surface  that  fibrin  exudes,  producing  a  pseudo-membrane. 

Klehs-Loejfler  Bacillus  in  Healthy  Individuals. — Roux  and  Yersin  have 
found  in  the  mouths  of  healthy  children  and  adults  a  bacillus  which,  in  a 
morphological  point  of  view,  is  identical  with  the  Klebs-Loeffler  bacillus. 
They  found  it  not  only  in  Paris,  but  also  at  a  distant  village  situated  near- 
the  sea  where  diphtheria  had  not  occurred  within  the  memory  of  man.  In 
this  village  Eoux  and  Yersin  examined  50  children  and  found  this  benign 
bacillus  in  26.  It  does  not  differ  from  the  Klebs-Loeffler  either  in  its  indi- 
vidual form  or  in  the  form  of  a  colony,  but  only  in  the  number  of  its 
colonies.  Instead  of  producing  a  considerable  culture  in  the  bouillon,  it 
only  produces  a  slight  culture.  Hence  Roux  and  Yersin  believe  that  this 
harmless  bacillus  is  none  other  than  the  Klebs-Loeffler,  deprived  of  its  viru- 
lence. They  have  been  unable  to  produce  its  transformation  into  the  genuine 
diphtheritic  bacillus  or  the  reverse,  but  do  not  doubt  that  this  transformation 
is  possible.  This  innocuous  bacillus  has  been  found  most  frequently  in  benign 
diphtheria  and  in  persons  recently  cured  of  diphtheria. 

Dr.  W.  H.  Park  writes  as  follows  upon  this  subject :  "  In  1888  Hofmann 
states  that  besides  finding  the  diphtheria  bacilli  in  cases  of  true  diphtheria, 
he  had  found  them  in  twenty-six  out  of  forty-five  throats  in  which  no  diph- 
thei'ia  had  existed.  Some  of  these  bacilli  were  shorter,  thicker,  and  more 
regular  in  form  than  the  Loeffler  bacilli,  and  grew  more  readily  on  agar,  the 
growth  being  more  luxuriant  and  whiter.  Others,  however,  were  in  all 
respects  identical  with  the  Loeffler  bacillus,  except  that  those  from  healthy 
throats  were  not  virulent.  He  did  not  feel  able  to  state  whether  or  not  these 
two  forms  were  identical  with  the  virulent  diphtheria  bacilli  of  Loeffler  or  a 
diiferent  form  of  bacteria.  Loeffler  himself  and  most  German  writers  have 
considered  them  to  be  altogether  a  different  form  of  diphtheria,  while  Roux 
and  Yersin,  most  French,  and  some  German  bacteriologists,  look  upon  them 
as  identical.  Roux  and  Yersin,  in  their  studies  on  diphtheria,  gave  careful 
attention  to  the  relationship  of  the  so-called  pseudo-diphtheria  bacillus  to  the 
true  one.  The  majority  of  the  bacilli  they  experimented  with  were  identical 
with  the  Loeffler  bacilli  in  growth,  size,  and  form,  and  differed  simply  in  not 
possessing  virulence." 

It  is  well  known  that  the  bacillus  having  its  full  vitality  and  virulence 
may  remain  a  long  time  in  the  throats  of  convalescent  patients.  Escherich 
expresses  (Berlin,  Min.  Woclien.,  1893,  Nos.  21—23)  the  belief  that  the  growth 
of  the  virulent  bacillus  sometimes  continues  for  a  time  in  the  throats  of  con- 
valescent patients,  who  no  longer  exhibit  symptoms  of  the  disease,  and  is  the 
source  of  infection  to  others.  Thus  the  nurse  in  a  hospital  had  the  bacilli  in 
her  throat,  and  without  being  diseased  herself,  gave  diphtheria  to  the  children 
intrusted  to  her  care.  I  have  seen  recently  a  malignant  case  of  diphtheria, 
which  was  apparently  contracted  by  embracing  a  schoolmate  in  the  street, 
who  had  to  all  appearance  entirely  recovered  from  a  diphtheritic  attack,  and 
had  gone  into  the  street  for  the  first  time. 

As  in  that  other  microbic  disease,  erysipelas,  one  attack  does  not  afford 
protection  against  a  second  seizure.  The  belief  has  even  been  expressed  by 
certain  clinical  observers  that  patients  during  convalescence  are  sometimes 
reinfected,  by  receiving  the  bacillus  from  the  bedding,  curtains  or  furniture, 
which  they  themselves  have  infected.     (Plate  I.) 

For  the  excellent  representations  of  cultures  of  the  bacillus  of  diphtheria 


PLATE   I. 


Col    111.--  Ml'  lii}.liiliri-ia    liarilli  X  ll'4  (liaiii. 


■'■i''<f»A 


B.  J)i2)lith.  Col.  Luxuriaut  Growth. 


Colouies  B.  D.  x  240  diarn. 


^ 


\y 


•;*£=. 


PmikIo  (hiihth    (    A    \  i_4  di  lui 


Di])lulieria  Bacilli  x  KXMj  diam. 

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ChaiaLti  U'-tK   Diplithcria  Bacilli  x  luiiO. 


../<    ^i: 


% 


Chaiacteustic  Diphtheria  Bacilli  x  1000. 


PLATE   II. 


Even— 

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Pseudo-dii^litheria  Bacilli  x  1000. 


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Pseudo-diph.  Bacilli.     Agar  Culture  x  1000. 


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ii-om  Throat  Exudate  x  luOO. 


•aiue  from  Serum  Culture  x  lUUO. 


DIPHTHERIA.  333 

(Plates  I  and  II)  I  am  indebted  to  the  kindness  of  the  New  York  Board  of 
Health. 

Vitality  of  the  Klebs-Loeffler  bacillus. — D'Espine  and  E.  de  Mariqual  state 
that  cultures  kept  sixteen  months  have  retained  their  primary  virulence.  M. 
Sevestre  quotes  instances  in  which  the  contagion  of  diphtheria,  after  being 
latent  for  long  periods,  communicated  the  disease.  Thus  a  girl  in  a  locality 
where  there  was  no  diphtheria,  examined  the  clothes  worn  by  her  mother, 
who  had  died  of  this  disease  two  years  previously,  the  clothes  having  been 
in  a  chest  during  this  time.  After  about  the  usual  time  she  was  attacked 
by  diphtheria.  A  brush  used  for  swabbing  the  throat  of  a  child  having 
diphtheria  was  wrapped  in  paper  and  laid  aside.  Four  years  subsequently,  a 
man  having  simple  sore  throat  made  an  application  to  it  with  the  brush,  and 
his  fauces  soon  after  became  the  seat  of  a  diphtheritic  exudate.  A  severe 
and  fatal  epidemic  of  diphtheria  occurred  in  a  Norman  village.  Twenty- 
three  years  had  elapsed  and  no  recent  case  of  diphtheria  had  occurred  at  or 
near  the  place,  when  excavations  were  made  in  the  graveyard,  and  the  bodies 
of  those  who  died  of  diphtheria,  nearly  a  quarter  of  a  century  previously 
were  disturbed.  The  son  of  the  grave-digger,  who  had  collected  the  bones 
of  the  victims  of  diphtheria  and  had  piled  them  together,  was  immediately 
afterward  attacked  with  this  disease.  He  was  the  first  patient  in  the  epi- 
demic which  followed.  Sevestre  relates  other  cases  showing  the  remarkable 
vitality  of  the  Klebs-Loeffler  bacillus,  which  it  is  probable  from  authentic 
observations,  remains  latent,  not  only  for  months  but  years,  and  subsequently 
becomes  active  under  favorable  circumstances. 

Pseudo-diphtheria  or  Diphtheroid^  a  pseudo-membranous  inflamraation 
caused  by  the  streptococcus  and  to  a  less  extent  by  other  forms  of  cocci. 

In  a  paper  read  before  the  Berlin  Medical  Society  by  Baginsky.  and  dis- 
cussed by  Virchow,  Henoch,  Guttmann,  Fraenkel,  Bitter  and  others,  Bagin- 
sky stated  that  he  had  made  tube-cultures  from  the  false  membrane  of  all 
the  cases  of  sick  children  admitted  into  the  hospital  during  the  preceding 
year  with  the  diagnosis  of  diphtheria.  He  obtained  cultures  of  the  Klebs- 
Loeffler  bacillus  in  118  out  of  154  cases.  In  most  of  these  cultures  the 
microbes  associated  with  the  bacillus  disappeared  during  the  cultivation, 
while  the  bacillus  multiplied,  was  typical,  and  was  easily  recognized.  In  the 
remaining  36  cases  cultivation  yielded  no  bacillus,  but  only  cocci ;  and  32  of 
these  recovered  in  a  few  days  without  any  complication.  Of  the  four  who 
died  two  had  empyema,  one  pneumonia  complicating  measles,  and  the  remain- 
ing one  had  severe  paralysis  at  the  time  of  admission. 

True  Pseudo-diphtheria 

Diphtheria.  (due  to  cocci). 

Baginsky 118  cases.  36  cases. 

T.  M.  Pruden 0     "  24     " 

M.  Martin 128     "  72     " 

Wm.  H.  Park 127     "  114     " 

CarlJanson 63     "  37     " 

The  distinguished  bacteriologists  and  clinical  observers  present  at  the 
Berlin  3Iedical  Society  as  stated  above,  and  who  expressed  their  views, 
agreed  in  the  main  that  it  is  proper  to  recognize  a  true  diphtheria  produced 
only  by  the  Klebs-Loeffler  bacillus,  and  another  form  of  pseudo-membranous 
inflammation,  presenting  similar  gross  anatomical  characters  to  those  in  true 
diphtheria,  but  caused  by  cocci  (mainly  the  streptococcus  and  staphylococcus). 
The  latter  is  designated  pseudo-diphtheria,  in  order  to  distinguish  it  from 
true  diphtheria  or  that  caused  by  the  Klebs-Loeffler  bacillus,  and  this  nomen- 
clature or  distinction  is  commonly  accepted  by  bacteriologists  in  both  hemi- 


334  CONSTITUTIONAL  DISEASES. 

speres.  Psendo-diplitheria  like  true  diphtheria  is  accompanied  by  fever, 
tumefaction  of  the  lymphatic  glands,  and  is  much  less  fatal  than  genuine 
diphtheria.  The  preceding  table  shows  the  relative  frequency  of  true  and 
pseudo-diphtheria,  as  ascertained  in  different  laboratories  by  the  examinations 
of  specimens. 

Mixed  Infection. — Although  the  term  true  diphtheria  is  applied  to  that 
form  of  pseudo-membranous  inflammation  which  is  caused  by  the  Klebs- 
Loeffler  bacillus,  and  pseudo-diphtheria  to  that  which  is  caused  by  other 
microbes,  the  two  having  different  toxines  must  be  entirely  distinct  from 
each  other  in  their  essential  nature  however  close  their  resemblance.  Never- 
theless, an  accurate  diagnosis  is  often  rendered  more  diflBcult  by  the  fact, 
which  is  more  and  more  recognized,  that  in  a  large  proportion  of  cases  there 
is  a  mixed  infection,  that  is  the  coexistence  of  the  Klebs-Loeffler  bacillus  and 
forms  of  cocci  which  are  pathogenic.  Of  course  a  patient  who  is  sick  from 
the  combined  action  of  the  diphtheria  bacillus  and  of  cocci  which  penetrate 
the  system  is  less  amenable  to  treatment  than  one  in  whom  only  one  form 
of  microbe  is  present. 

Dr.  I.  L.  Morse  has  published  the  following  statistics  relating  to  the 
etiology  and  pathology  of  diphtheria  and  pseudo-diphtheria : 

Percentage  of 
Mortality. 

Klebs-Loeffler  alone  in  46  cases  of  which  20  died 43  per  cent. 

"  "       with  streptococci  in  21  cases  of  which  6  died   .28  "  " 

"  "        with  staphylococci  in  93  cases  of  which  43  died,  46  "  " 

"  "        with  streptococci  and  staphylococci  in  77  cases 

of  which  29  died    .    .    .  ' 38  "  " 

"  "        with  others  in  3  of  wliich  1  died 33  "  " 

Streptococci  alone  in  18  of  which  1  died 5  "  " 

Staphylococci  alone  in  27  of  which  15  died 40  "  " 

Staphylococci  and  streptococci  99  of  which  19  died 19  "  " 

Others  in  5  of  which  2  died 40  "  " 

Although  the  toxine  generated  by  the  Klebs-Loeffler  bacillus  is  more 
fatal  than  any  of  the  cocci  or  than  any  toxine  generated  by  cocci,  the  com- 
bined action  of  the  two  evidently  produces  the  highest  mortality,  and  the 
least  amenable  form  of  diphtheritic  disease.  The  internal  inflammations,  as 
broncho-pneumonia,  which  are  so  liable  to  occur  in  cases  of  mixed  infection, 
ar.e  believed  to  be  mostly  due  to  cocci,  since  these  organisms  penetrate  the 
system.  The  opinions  of  distinguished  bacteriologists  confirmatory  of  this 
statement  might  be  mentioned.     (Plate  II.) 

Age. — Most  of  the  published  statistics  relating  to  the  ages  of  diphtheritic 
patients  evidently  embrace  all  cases  of  pseudo-membranous  inflammation, 
whether  the  cause  be  the  Klebs-Loeffler  bacillus  or  streptococcus  and  staph- 
ylococcus— in  other  words,  whether  the  disease  be  diphtheria  or  pseudo-diph- 
theria. Trousseau  has  said  that  diphtheria  does  not  spare  any  age,  but  is 
most  common  between  the  ages  of  two  and  five  or  six  years.  Gruersant 
believes  that  the  age  of  greatest  frequency  is  between  the  second  and  seventh 
years,  and  Barthez  and  Rilliet  agree  with  him.  Buillon-Lagrange  in  73  cases 
occurring  in  one  epidemic  treated — 

Under  2  years 14  cases. 

P^oin    2  to    6  vears 18  " 

"       6tol2  '  " .  10  " 

"     12  to  18     "      9  " 

"     18  to  20     " 15  " 

"     20  to  40     "       4  " 

"     40  to  50     "      1  " 

Above  50     "      2  " 


2  to 

3     ' 

3  to 

4     ' 

4  to 

5     ' 

5  to 

6     ' 

6  to 

7     ' 

7  to 

8     ' 

8  to 

9     ' 

9  to  15      ' 

L5  to  17     ' 

DIPHTHERIA.  335 

According  to  M.  Barthez,  in  Sainte-Eugenie  Hospital  during  twenty  years 
the  ages  of  tlie  diphtheritic  patients  were  as  follows,  adults  being  excluded 
from  this  institution : 

Under  1  year .    81  cases. 

From    1  to    2  years 314  " 

319  " 

292  " 

200  " 

103  " 

59  " 

36  " 

.24  " 

82  " 

2  " 

Louis  has  observed  that  diphtheria  may  occur  at  an  advanced  age,  but 
that  it  is  infrequent  after  the  age  of  forty  years,  and  rare  after  sixty  years. 

As  in  scarlet  fever,  so  in  diphtheria,  cases  are  infrequent  under  the  age 
of  six  months.  Oertel  says :  "  In  the  first  half  year  the  infant  organism 
seems  to  be  not  at  all  susceptible  to  the  disease."  Nevertheless,  cases  are  on 
record  showing  that  pseudo-membranous  inflammation  due  to  microbes  does 
occur  even  in  the  newly-born.  Dr.  Abraham  Jacobi  says  :  "  I  have  met  with 
three  cases  of  diphtheria  of  the  pharynx  and  larynx  myself.  One  of  these 
became  sick  on  the  ninth  day  after  birth,  and  died  on  the  thirteenth  day ; 
the  other  died  on  the  sixteenth  day  after  birth ;  the  third  was  taken  when 
seven  days  old,  and  died  on  the  ninth  day"  (^Treatise  on  Diphtheria^  1880). 
The  following  cases  of  diphtheria  in  the  newly-born  have  also  been  reported : 

Number.  Age.  Author. 

1 14  days Ligri. 

1 15     " Bi'etonneau. 

1 17     " Bednar. 

1 8     " Bouchut. 

1 7     " Weikeit. 

Several  cases Parrot. 

18 Eiredey. 

A  disease  of  the  newly-born  has  occasionally  been  observed  in  maternity 
wards  which  seems  to  be  of  diphtheritic  origin,  but  which  presents  unusual 
features.  Thus,  Dr.  W.  S.  Bigelow  reports  in  the  Boston  Medical  and  Surgical 
Journal^  for  March  11,  1875,  ten  cases  occurring  in  the  latter  part  of  1873  in 
the  Boston  Lying-in  Asylum,  all  fatal  but  two.  The  prominent  symptoms 
and  anatomical  characters  were  a  dark  hue  of  the  skin,  hfematuria,  pseudo- 
membranous exudation  upon  certain  mucous  surfaces,  dark-green  stools, 
enlarged  and  dark  spleen,  engorged  kidneys ;  in  some  of  the  cases  effusion 
of  blood  into  the  pelves  of  the  kidneys  and  along  the  urinary  tract. 

A  case  similar  to  those  observed  by  Dr.  Bigelow  came  under  my  notice. 
Malignant  diphtheria  occurred  in  a  family  in  West  Fifty-third  Street  in  1880. 
The  patient,  a  boy  of  ten  years,  died,  and  the  remaining  two  children,  as  soon 
as  the  nature  of  the  malady  was  apparent,  were  sent  from  the  house.  Never- 
theless, one  of  them,  seven  days  after  the  removal,  was  attacked  with  diph- 
theria of  the  hemorrhagic  form,  and  died  in  less  than  one  week.  Blood 
escaped  from  the  nostrils,  from  the  fauces,  from  the  vessels  under  the  skin 
in  numerous  places,  causing  hemorrhagic  spots,  and  from  the  kidneys  or 
urinary  tract,  causing  hfematuria.  The  mother  suffered  great  mental  depres- 
sion, although  her  general  health  seemed  good.  Her  infant,  born  three 
months  subsequently  to  the  occurrence  of  diphtheria  in  her  family,  was  well 


336  CONSTITUTIONAL  DISEASES. 

developed,  but  it  presented  also  a  similar  hemorrhagic  cachexia.  Blood 
escaped  from  the  vessels  under  the  skin,  causing  blotches  and  prominences, 
and  from  the  mucous  surfaces.  The  bleeding  was  persistent  and  copious 
from  the  umbilicus,  so  that  death  occurred  in  less  than  a  week.  The  poison 
elaborated  by  microbes  is  subtle  and  penetrating,  causing  the  specific  inflam- 
mation in  the  uterine  walls  of  the  parturient  woman,  even  when  her  fauces 
are  not  affected ;  but  the  exact  causal  relation  of  diphtheria  or  pseudo-diph- 
theria to  cases  like  the  above  must  be  determined  by  future  observations. 

It  is  certain  that  pseudo-membranous  inflammations  of  a  microbic  cha- 
racter sometimes  appear  in  newly-born  infants.  An  epidemic  of  this  occurred 
in  the  New  York  Infant  Asylum  in  1887.  Five  infants  under  the  age  of 
thirty-seven  days  had  the  pseudo-membranous  exudate  upon  the  surfaces 
which  are  usually  affected,  but  this  was  before  the  distinction  was  made 
between  true  diphtheria  and  pseudo-diphtheria  based  upon  different  microbic 
causes.  Prof.  Prudden,  who  conducted  one  of  the  post-mortem  examinations, 
made  the  following  record  :  ••  The  anatomical  diagnosis,  then,  is  diphtheria 
of  pharynx,  larynx,  and  trachea,  with  double  broncho-pneumonia,  localized 
septic  inflammation  of  the  umbilical  vein  and  hypogastric  arteries  and  the 
abdominal  wall  surrounding  them."  This  epidemic  in  the  infant  asylum,  so 
far  as  could  be  determined  by  laboratory  cultures  and  investigations,  was 
produced,  not  by  the  agency  of  the  Klebs-Loeffler  bacillus,  but  by  the  strep- 
tococcus. Probably,  therefore,  the  epidemic  was  one  of  pseudo-diphtheria, 
and  not  of  diphtheria. 

Incubative  Period. — In  inoculated  animals  this  is  from  twelve  hours  to 
three  days.  In  Trendelenberg's  experiments  the  incubative  period  was 
mostly  from  one  to  three  days ;  in  Lagrave's  about  twenty  hours.  In 
Duchamp's  inoculations  the  animals  died  after  forty-eight  hours,  with  the 
larynx  and  trachea,  upon  which  the  infectious  material  was  applied,  covered 
with  pseudo-membrane.  Oertel  says  that  the  rabbits  upon  which  he  experi- 
mented by  inoculation  of  the  muscles  perished  in  from  thirty  to  thirty-six 
hours,  rarely  after  forty-two  hours,  the  disease-process  extending  rapidly  to 
neighboring  tissues.  When  diphtheria  is  contracted  by  a  child  upon  a  wounded 
surface  the  incubative  period,  although  short,  may  extend  four  days.  The 
history  of  such  a  case  was  contributed  by  Mr.  Phillips  to  the  British  Medical 
Journal.  Instruments  which  had  been  employed  in  performing  tracheotomy 
in  a  case  of  diphtheritic  croup  were  in  a  few  hours  used  for  circumcision. 
Four  days  later  the  wounded  prepuce  was  covered  with  a  pseudo-membrane 
which  extended  over  the  glans,  causing  much  oedema  of  the  prepuce  and 
retention  of  urine. 

When  diphtheria  is  contracted  in  the  usual  manner — that  is,  by  the  inspi- 
ration of  air  containing  the  specific  principle — the  period  of  incubation  appears 
to  be  somewhat  longer  than  when  it  is  communicated  by  direct  contact.  My 
observations  lead  me  to  believe  that  when  the  incubative  period  is  short  the 
disease  is  likely  to  be  severe,  and  when  the  incubative  period  is  long  the 
attack  is  mild.  I  was  enabled  to  ascertain  very  nearly  the  incubative  period 
in  the  following  cases :  A  boy  of  nine  years  was  in  the  same  room  about  one 
hour  on  Saturday  with  a  child  who  had  fatal  diphtheria.  On  the  following 
Tuesday,  without  any  other  exposure,  he  sickened  with  a  fatal  form  of  the 
malady.  Mrs.  E.  assisted  in  nursing  a  severe  case  of  diphtheria  from  Novem- 
ber 11  to  13,  187-1.  after  which  she  returned  home,  several  blocks  away.  On 
the  evening  of  the  15th  she  complained  of  sore-throat,  and  on  the  following 
day  the  diphtheritic  exudate  was  observed  upon  her  tonsils.  On  the  19th, 
the  pellicular  formation  had  disappeared  and  she  was  convalescent.  On  the 
20th.  her  sister,  who  resided  with  her,  and  who  had  not  been  elsewhere 
exposed,  was  also   attacked.     In  three   other  cases  which  came  under  my 


DIPHTHERIA.  337 

observation  the  incubative  period  seemed  to  be  accurately  fixed  at  six  to 
seven  days.  Sarnii  says  that  the  incubation,  so  far  as  could  be  determined, 
was  as  follows : 

From    1  to    2  davs 7  cases. 

"       2  to    8    ""  48     " 

"       8  to  13    "  23     " 

"     13  to  15    " 6     " 

"     15  to  20    "  14     " 

Modes  of  Propagation. — Xo  fact  is  better  established  than  that  diphtheria 
does  not  originate  de  novo  whatever  may  be  the  insanitary  conditions.  It 
is  produced  by  the  reception  in  or  upon  some  parts  of  the  system  of  the  pre- 
existing specific  germ.  Its  extreme  contagiousness  from  person  to  person  is 
well  known.  A  moment's  exposure  to  the  breath  of  a  patient,  or  in  the 
infected  room  where  he  is  under  treatment  or  has  been  perhaps  weeks  or 
months  previously,  has  in  numberless  instances  communicated  the  disease. 
The  virus  adheres  tenaciously  to  objects  on  which  it  happens  to  alight.  The 
clothing  of  a  patient,  even  when  the  disease  has  been  in  its  mildest  form,  his 
bedding,  the  furniture  of  his  room,  and  the  objects  which  he  handles,  may 
for  weeks  afterward  communicate  the  disease  even  when  transported  to  a 
distance.  A  child  was  for  a  brief  period  in  a  room  where  diphtheria  had 
occurred  two  months  previously,  and,  after  the  usual  incubative  period, 
sickened  with  the  disease.  The  diphtheritic  poison  may  remain  in  an  active 
state  for  months  between  the  leaves  of  a  book  handled  by  a  patient  having  a 
mild  attack  or  during  convalescence. 

Most  of  the  contagious  diseases  of  children  are  quickly  detected  by  cha- 
racteristic symptoms  or  appearances  with  which  the  most  ignorant  families  are 
to  a  certain  extent  familiar  ;  but  mild  diphtheria  possesses  so  few  subjective 
symptoms  that  it  is  often  not  suspected  or  detected  even  in  intelligent  families 
who  are  watchful  of  their  children.  Children  with  mild  diphtheria  sit  among 
other  children  in  the  schools,  the  city  conveyances,  in  the  churches  and  dis- 
pensaries, and  frequently  communicate  to  those  who  are  near  them  a  malig- 
nant form  of  the  disease  from  which  the  unfortunate  victims  quickly  perish. 
The  diphtheritic  microbes  are  so  subtle,  and  their  vitality  and  power  of  propa- 
gation so  great  that  it  is  difl&cult  to  prevent  the  extension  of  diphtheria  in 
the  schools  and  places  of  public  resort. 

Many  instances  are  related  in  which  diphtheria  is  communicated  by  direct 
contact  with  some  infected  solid  substance,  as  a  particle  of  the  diphtheritic 
exudate,  muco-purulent  secretion  from  an  infected  surface  or  the  blood  of  a 
patient.  In  a  considerable  number  of  instances  recorded  in  the  literature 
over-anxious  and  self-sacrificing  young  surgeons  have  sucked  the  obstruction 
from  the  tracheotomy-tube  in  cases  of  diphtheritic  croup  with  perhaps  relief 
to  the  patients,  but  with  the  occurrence  of  fatal  diphtheria  in  themselves 
from  the  exposure.  A  diphtheritic  conjunctivitis,  severe  and  dangerous  to 
the  eye,  has  sometimes  occurred  in  the  attending  physician  or  nurse  after 
examination  of  the  fauces  of  the  diphtheritic  patient,  produced  probably  by 
a  particle  of  pseudo-membrane  or  muco-pus  thrown  into  the  eye  by  the 
expulsive  cough.  In  these  instances  of  communication  by  direct  contact  the 
poison  is  received  either  upon  one  of  the  mucous  surfaces  or  upon  the  skin 
denuded  of  its  protecting  epidermis.  It  is  well  known  that  filthy  accumula- 
tions of  all  kinds  afford  a  nidus  which  is  favorable  for  the  development  of  the 
Loefiler  bacillus.  Hence  the  theory  seemed  plausible  that  poisonous  gases 
escaping  into  the  nurseries  through  broken  waste-pipes  or  from  decaying  refuse 
matter  in  and  around  domiciles  conveyed  the  Loefiler  bacillus  and  was  the 
source  of  diphtheria.  City  physicians  who  were  called  to  treat  diphtheria  in  the 
22 


338  CONSTITUTIONAL  DISEASES. 

small,  damp,  dark,  and  dirty  apartments  of  the  tenement-liouses  and  inhaled 
the  foul  gases  were  led  to  the  irresistible  conviction  that  these  gases  were  the 
vehicle  of  the  fatal  bacillus.  But  investigations  relating  to  the  nature  of 
sewer-gas  have  shown  that  this  belief  that  sewer-gas  is  the  carrier  of  the 
Loeffler  bacillus  is  probably  untenable.  Mr.  L.  Parry  Laws  presented  to  the 
Main  Drainage  Committee  of  London  the  results  of  his  investigations  relating 
to  the  composition  of  sewer-gas,  undertaken  at  their  request.  His  examina- 
tions, as  well  as  those  previously  made  by  Connolly  and  Haldane,  showed  that 
the  air  of  sewers  contained  about  twice  the  quantity  of  carbonic  acid  and  about 
three  times  the  quantity  of  organic  matter  above  that  found  in  the  external  air 
at  the  same  time.  Moreover,  the  sewer-air  contained  a  smaller  number  of  micro- 
organisms than  the  air  which  they  examined  in  domiciles.  Mr.  Laws  found 
that  the  micro-organisms  of  the  sewer-gas  were  related  to  those  of  the  air 
outside,  and  the  forms  present  were  almost  wholly  moulds  and  micrococci. 

Investigations  like  those  related  above  have  led  to  the  belief  on  the  part 
of  many  bacteriologists  that  sewer-gas  does  not  convey  the  Loeffler  bacillus 
into  domiciles  through  untrapped  or  defective  waste-pipes,  as  was  formerly 
believed ;  but  the  causal  relation  of  this  gas  to  diphtheria  is  like  other  foul 
exhalations  which  cause  deterioration  of  the  system,  weaken  the  powers  of 
resistance,  and  render  the  action  of  the  diphtheritic  bacillus  which  happens 
to  be  present  more  virulent  and  fatal.  Probably  the  sewer  and  other  fetid 
gases  increase  the  virulence  of  the  Loeffler  bacillus,  and  perhaps,  under  cer- 
tain circumstances,  it  renders  the  benign  bacilli  virulent,  but  this,  however 
plausible,  has  not  been  proven. 

Diphtheria  contracted  from  Animals.  —  Observations  are  accumulating 
which  show  that  diphtheria  occurs  in  certain  domestic  animals  and  is  some- 
times communicated  from  them  to  man.  That  certain  animals  are  liable  to 
it  has  been  shown  by  inoculations  in  many  laboratories,  made  for  experimental 
purposes.  The  feathered  tribe  especially  appear  to  be  susceptible  to  this 
disease.  On  the  island  of  Skiathos.  off  the  north-eastern  coast  of  Greece,  no 
diphtheria  had  occurred  during  at  least  thirty  years  previously  to  1884, 
according  to  Dr.  Bild,  the  physician  of  the  island.  In  that  year  a  dozen 
turkeys  were  introduced  from  Salonica.  Two  of  them  were  sick  at  the  time 
and  died  soon  afterward  ;  the  others  became  aifected  subsequently,  and  of  the 
whole  number  seven  died,  three  recovered,  and  two  were  sick  at  the  time  of 
the  inquiry.  These  two  had  laryngeal  obstruction  with  difficult  breathing  and 
swelling  of  the  glands  of  the  neck.  As  further  evidence  that  the  disease  was 
true  diphtheria,  one  of  the  turkeys  that  survived  had  paralysis  of  the  feet. 
The  turkeys  were  in  a  garden  on  the  north  side  of  the  town,  and  the  pre- 
vailing winds  from  the  island  are  from  the  north.  When  this  sickness  was 
occurring  among  the  turkeys  an  epidemic  of  diphtheria  commenced  in  the 
houses  nearest  to  the  garden  and  spread  through  the  town.  It  lasted  five 
months,  and,  of  one  hundred  and  twenty-five  cases  in  a  population  of  four 
thousand,  thirty-six  died.  Diphtheria  was  from  this  time  established  on  the 
island,  and  frequent  epidemics  of  it  have  occurred  since. ^  M.  Menzies^  states 
that  diphtheria  is  common  among  the  poultry  in  Italy,  in  which  country  the 
flat  roofs  of  the  houses  afford  a  resting-place  for  turkeys,  fowls,  pigeons,  and 
rabbits,  and  their  evacuations  are  carried  by  the  rain  into  the  cisterns  and 
wells.  A  physician  at  Posilippo,  near  Naples,  had  directed  his  servant  not 
to  obtain  drinking-water  from  the  well  next  to  his  house,  but  from  a  well  at 
a  distance.  So  long  as  he  obeyed  the  instruction  his  family  was  well,  but, 
yielding  to  his  indolence,  he  finally  disobeyed  the  command  and  obtained 
water  from  the  infected  well.  Four  of  the  children  who  drank  this  water 
took  diphtheria  and  died,  while  the  fifth  child,  who  did  not  drink  it,  escaped. 
1  Bulletin  Medicale,  Jan.  22,  1888.  ^  Thesis,  Paris,  1881. 


DIPHTHERIA.  339 

Dr.  F.  F.  Wheeler^  states  that  while  in  a  nesting  of  wild  pigeons  he  found 
many  sick  with  a  pseudo-membranous  sore  throat.  He  dissected  many  with 
his  pocket-knife,  which  he  was  obliged  to  throw  away  on  account  of  its  oiFen- 
sive  odor.  There  were  millions  of  pigeons  in  the  nesting,  and  they  were 
hunted  and  eaten  by  the  inhabitants.  In  the  same  year  diphtheria  broke 
out  in  a  most  malignant  form  among  the  people,  causing  many  deaths. 
Several  years  previously  pigeons  nested  in  the  same  locality  or  near  by,  and 
fully  half  of  the  children  in  the  vicinity  had  diphtheria. 

Dr.  Geo.  Turner  -  states  that  a  pigeon  was  brought  to  him  for  dissection. 
The  whole  of  its  windpipe  was  covered  by  a  pseudo-membrane,  as  in  the 
croup  of  a  child.  Pigeons  were  inoculated  in  the  fauces  with  this  mem- 
brane, and  a  similar  disease  was  produced,  which  extended  to  their  eyes 
through  the  nostrils.  Dr.  Turner  also  related  several  other  epidemics  of 
diphtheria  in  different  localities,  accompanied  by  a  fatal  pseudo-membranous 
inflammation  in  the  feathered  tribe,  the  poultry,  turkeys,  pigeons,  and  in  one 
locality  the  pheasants.  At  Tougham  a  man  bought  a  chicken  at  a  low  price, 
as  it  was  affected  with  the  prevailing  disease,  and  cared  for  i-t  at  his  home. 
Soon  after  diphtheria  broke  out  in  his  family  and  this  case  was  the  first  in 
the  village.  Bilhaut  *  states  that  a  pigeon-fancier  had  lost  several  birds  by 
disease.  He  endeavored  to  save  one  of  them  that  was  sick  by  allowing  it  to 
pick  food  from  his  tongue.  The  pigeon  died  and  an  examination  showed 
that  it  died  of  diphtheria.  Before  its  death  the  man  sickened  with  diph- 
theria and  pseudo-membranes  formed  underneath  his  tongue  on  either  side 
of  the  frfenum,  where  the  bird  had  picked  its  food,  and  also  upon  his  tonsils. 
Recently  also  M.  Cagny  has  related  cases  showing  the  propagation  of  diph- 
theria from  the  feathered  tribe  to  man.*  Did  time  permit  other  similar  cases 
might  be  related  published  in  American  medical  journals. 

Bacteriologists  in  their  experiments  have  demonstrated  the  fact  that 
certain  quadrupeds  used  for  experimental  purposes  contract  diphtheria. 
Trendelenberg  inoculated  sixty-eight  rabbits  introducing  diphtheritic  pseudo- 
membrane  through  an  artificial  opening.  Eleven  of  the  rabbits  died  with  the 
symptoms  and  appearance  of  diphtheria.  In  control  experiments  he  intro- 
duced various  foreign  bodies  into  the  larynx  of  rabbits,  and  was  unable  to 
produce  results  or  lesions  resembling  those  in  diphtheria.  Oertel  performed 
twelve  similar  experiments,  and  five  of  the  rabbits  died  after  the  production 
of  pseudo-membranes.  Zahn,  Grerhardt,  Labadie-Lagrave,  Francotte,  Bates- 
Klein,  and  Yulpian  may  be  mentioned  among  those  who  have  obtained  similar 
results  from  their  inoculations.  Bruce  Low,  in  his  report  to  the  Local  Grov- 
ernment  Board,^  states  that  a  little  boy  at  Enfield  had  fatal  diphtheria,  and 
vomited  on  the  first  day  of  his  illness.  A  cat  licked  the  vomited  matter 
from  the  floor,  and  soon  after  the  boy's  death  it  was  noticed  to  be  ill,  and 
its  suffering  and  symptoms  so  closely  resembled  those  of  the  dead  boy's  that 
it  was  destroyed  by  the  owner.  During  the  first  part  of  its  sickness  the  ani- 
mal was  allowed  to  go  out  in  the  back  yard,  and  a  few  days  subsequently 
the  cat  of  a  near  neighbor  became  ill.  This  cat  had  frequented  the  back 
yard.  It  was  nursed  during  its  sickness  by  three  little  girls,  all  of  whom 
took  diphtheria.  Lawrence^  reports  two  cases  in  which  diphtheria  seems  to 
have  been  communicated  by  cats.  In  the  first  case,  that  of  a  little  girl,  a 
careful  inquiry  showed  that  the  child  had  not  been  exposed  to  any  case, 
although  diphtheria  was  prevailing  within  a  mile  of  the  patient's  residence, 
but  she  had  fondled  a  sick  cat  a  few  days  before.     The  cat  died  some  time 

'  American  Practitioner  and  News.  ^  Journal  of  Laryngology  and  Rhinology. 

^  Journal  de  Medicine  cle  Paris,  July  13,  1890. 

*  Journ.  de  Medicine,  July,  1890.     '  =  British  Med.  Journ.,  May  10,  1890. 

^  Med.  Press  and  Circular,  London,  June  4,  1890. 


340  CONSTITUTIONAL  DISEASES. 

afterward,  and  a  second  cat  became  sick  and  was  killed.  Inquiry  disclosed 
the  fact,  that  a  neighboring  farmer  had  lost  seventeen  cats  and  another 
fifteen  cats,  from  a  throat  distemper,  and  one  of  the  farmers  stated  that  he 
had  examined  the  throats  of  some  of  the  cats  and  found  them  covered  with 
a  white  membrane.  S.  C.  Coleman^  of  Colorado,  Texas,  states  that  after  a 
residence  of  five  years  in  Colorado  he  saw  the  first  case  of  diphtheria.  A 
child  of  five  years,  living  thirty  miles  distant  in  the  country,  with  no  neigh- 
bor within  six  miles,  had  diphtheria  followed  by  paralysis.  Being  far  from 
any  source  of  human  contagion,  this  child  had  rarely  seen  other  children. 
The  father  stated  that  two  kittens  had  recently  died  of  what  seemed  to  be 
the  same  disease  as  that  of  the  child,  who  had  nursed  them  and  frequently 
kissed  them.  The  risk  of  fondling  diseased  cats,  which  are  pets  of  the  nursery, 
cannot  be  too  strongly  stated. 

Many  observations  have  shown  during  the  last  few  years  that  milk  affords 
a  favorable  nidus  for  the  propagation  of  the  Klebs-Loeffler  bacillus,  and  that 
occasionally  epidemics  are  produced  by  an  infected  milk-supply.  In  1879, 
Mr.  Wm.  H.  Power,  health  inspector,  investigated  an  outbreak  of  diphtheria, 
and  believed  that  he  traced  it  to  the  milk.  The  cows  that  furnished  the  milk 
that  apparently  caused  the  diphtheria,  had  what  the  veterinary  surgeons 
designated  "  garget  "  or  "  infectious  mammites."  Gooch  has  described  an  out- 
break of  diphtheritic  tonsilitis  in  Eton  College  which  he  traced  to  the  milk 
supplied.  The  cows  furnishing  milk  drank  water  which  contained  sewage 
from  a  neighboring  farm.  The  investigation  showed  that  the  milk  when 
boiled  was  harmless,  since  the  boiling  destroyed  the  germs,  but  when  used 
unboiled  the  disease  was  communicated.  The  cows  were  removed  to  another 
pasturage,  where  the  water  used  by  them  was  different,  and  the  epidemic 
ceased.  The  disease  was  in  all  instances  propagated  by  the  milk  supply. 
Observations  therefore  show  that  milk,  which  is  the  culture  medium  of  vari- 
ous pathogenic  microbes,  is  sometimes  the  medium  of  the  communication  of 
diphtheria,  as  it  is  known  to  be  of  scarlet  fever. 

Diagnosis. — No  more  important  duty  devolves  upon  the  physician  than 
that  of  making  an  early  and  correct  diagnosis  of  diphtheria  and  of  those  mal- 
adies of  the  throat  which  resemble  diphtheria  in  appearance,  but  are  in  their 
nature  distinct  from  it.  If  the  case  be  one  of  diphtheria,  its  nature  should 
be  recognized  at  the  beginning,  so  that  proper  remedial  measures  be  employed 
as  well  as  measures  designed  to  prevent  propagation.  If  the  disease  be  not 
diphtheria,  a  correct  diagnosis  is  required  so  that  needless  treatment  and 
alarm  be  prevented.  In  many  cases  the  diagnosis  is  easy  or  highly  prob- 
able after  diphtheria  has  continued  twenty-four  hours,  since  in  addition  to 
the  fever  and  pain  in  swallowing,  the  characteristic  whitish-gray  pellicle  has 
begun  to  form  on  one  or  both  tonsils.  If  the  exudate  be  not  limited  to  the 
tonsils,  but  extend  to  the  fauces,  and  cover  more  or  less  the  pillars  and  arch 
of  the  palate  and  the  uvula,  the  disease  is  probably  diphtheria.  Still  cer- 
tainty in  regard  to  the  nature  of  the  disease  in  many  instances  requires  a 
microscopic  examination.  Prof.  H.  M.  Biggs  '  of  the  New  York  Health  Board 
states  that  within  a  certain  time  of  the  large  number  of  suspected  cases  of 
diphtheria  removed  from  the  tenement  houses  and  slums  of  New  York  to  the 
Willard  Parker  Hospital,  30  to  50  per  cent,  of  them  did  not  have  true  diph- 
theria, but  pseudo-diphtheria  or  pellicular  inflammation,  caused  by  forms  of 
cocci,  especially  by  the  streptococcus.  The  result  of  treatment  corresponded 
with  that  observed  elsewhere,  for  of  those  shown  by  the  microscope  to  have 
true  diphtheria,  20  to  nearly  50  per  cent,  perished ;  while  of  those  that  had 
pseudo-diphtheria,  the  mortality  was  from  1  to  nearly  5  per  cent. 

Like  other  well-known  bacteriologists,  those  doing  the  bacteriological 
^  New  York  Medical  Record,  Nov.,  1890.         ^  Journ.  of  Laryngology,  Sept.,  1894. 


DIPHTHERIA.  341 

work  of  the  New  York  Health  Board  have  been  able  to  produce  cultures  and 
make  returns,  indicating  the  nature  of  the  disease  in  from  twelve  to  twenty- 
four  hours.  The  following  is  extracted  from  the  report  of  Dr.  Biggs : 
"  During  the  past  three  months  four  hundred  and  five  cases  of  true  diphtheria 
have  been  subjected  to  repeated  bacteriological  examinations,  performed  at 
short  intervals  during  the  course  of  the  disease,  and  during  convalescence. 
In  all  of  these  cases  cultures  were  made  at  the  beginning  of  the  disease,  again 
after  the  lapse  of  three  or  four  days,  and  finally  at  short  periods  after  the 
complete  disappearance  of  the  false  membrane,  until  the  throat  was  found  to 
be  free  from  the  diphtheria  bacillus.  In  two  hundred  and  forty-five  of  these 
four  hundred  and  five  cases  the  diphtheria  bacilli  disappeared  within  three 
days  after  the  complete  separation  of  the  false  membrane ;  in  one  hundred 
and  sixty  cases  the  diphtheria  bacilli  persisted  for  a  longer  time — namely,  in 
one  hundred  and  three  cases  for  seven  days  ;  in  thirty-four  cases  for  twelve 
days  ;  in  sixteen  cases  for  fifteen  days  ;  in  four  for  three  weeks,  and  in  three 
for  five  weeks  after  the  time  when  the  exudation  had  completely  disappeared 
from  the  upper  air-passages. 

"  In  many  of  these  cases  the  patients  were  apparently  well  many  days 
before  the  infectious  agent  had  disappeared  from  the  throat.  These  results 
show  that  in  a  considerable  proportion  of  cases  persons,  who  have  had 
diphtheria,  continue  to  carry  the  germs  of  the  disease  in  their  throats  for 
many  days  after  all  signs  and  symptoms  of  the  disease  have  disappeared. 
No  doubt  the  disease  is  largely  disseminated  by  these  persons,  who  are  appar- 
ently well,  and  who  mingle  with  others  while  their  throat  secretions  still  con- 
tain the  diphtheria  bacilli. 

''  These  experiments  have  led  the  Health  Department  to  adopt  the  rule 
that  no  person  who  has  suffered  from  diphtheria  shall  be  considered  free  from 
contagion  until  it  has  been  shown  by  bacteriological  examination,  made  after 
the  disappearance  of  the  membrane  from  the  throat,  that  the  throat  secre- 
tions no  longer  contain  the  diphtheria  bacilli,  and  that  until  such  examina- 
tions have  shown  such  absence  all  cases  in  boarding  houses,  hotels,  and  tene- 
ment houses  must  remain  isolated  and  under  observation.  Disinfection  of 
the  premises,  therefore,  will  not  be  performed  by  the  department  until  exam- 
ination has  shown  the  absence  of  the  organisms." 

Let  us  more  closely  compare  the  diagnostic  characters  of  diphtheria  with 
those  of  other  and  distinct  diseases  from  which  it  is  very  important  that 
diphtheria  should  be  difi"erentiated  in  practice. 

Pseudo-dipliiheria  or  Diphtheroid. — Perhaps,  I  have  already  sufiiciently 
stated  the  diagnostic  characters  of  this  disease.  Pseudo-diphtheria  is  pro- 
duced by  the  streptococcus,  sometimes  associated  with  other  forms  of  cocci. 
The  streptococcus  does  not  generate  so  deadly  a  poison  as  that  of  the  Klebs- 
Loeffler  bacillus.  Consequently,  the  systemic  infection  in  true  diphtheria  is 
much  more  fatal  than  in  pseudo-diphtheria.  While  the  Klebs-Loeffler  bacil- 
lus does  not  enter  the  system,  or  rarely  does  so,  the  forms  of  cocci  do,  and  there 
is  frequently  a  mixed  infection,  the  Loefiler  bacillus  being  present  with  the 
streptococcus  and  staphylococcus.  But  diphtheria  and  pseudo-diphtheria, 
although  their  differential  diagnosis  is,  in  many  instances,  difficult  or  impos- 
sible without  bacteriological  examination,  require  essentially  the  same  treat- 
ment. 

Follicidar  Pharyngitis  or  Tonsillitis.  —  This  is  a  common  disease,  most 
likely  of  microbic  origin.  It  frequently  extends  through  families,  all  or  most 
of  the  children  being  affected  by  it.  It  is  attended  by  fever,  dysphagia,  and 
an  inflammatory  hypersemia,  not  only  of  the  tonsils,  but  of  the  pharyngeal 
surface  generally.  It  commences  suddenly  like  diphtheria,  with  headaches, 
chilliness,  heat  of  surface,  the  temperature  often  rising  to  103°  Fah.,  languor 


342  CONSTITUTIONAL  DISEASES. 

and  frequently  pain  in  the  back  and  extremities.  The  dysphagia  attracts 
attention  to  the  fauces,  the  surface  of  which  is  seen  to  be  hypergemic,  espe- 
cially its  tonsilar  portion.  In  a  few  hours  a  whitish  material  exudes  from 
the  crypts  of  the  tonsils,  forming  rounded  masses  of  the  size  of  a  small  pin's 
head.  This  secretion,  occurring  as  small  rounded  salient  masses,  distinct  from 
one  another  is  distinguished  by  its  appearance  from  the  diphtheritic  pseudo- 
membrane,  which,  at  first,  is  a  thin  pellucid  exudate,  becoming  thicker  subse- 
quently. Consisting  simply  of  epithelial  cells,  held  together  by  the  secretion, 
these  small  rounded  masses  are  quickly  detached  by  the  swab  or  brush,  when 
they  are  found  to  be  friable,  readily  crushed  between  the  thumb  and  fingers, 
and  having  a  fetid  odor.  If  two  or  more  of  them  happen  to  unite,  forming 
an  appearance  like  that  of  the  diphtheritic  membrane,  they  still  present  the 
same  physical  characters,  and  are  readily  detached  from  the  tonsilar  surface 
without  hemorrhage.  This  peculiar  secretion  of  follicular  tonsilitis  is  usually 
limited  to  the  tonsilar  portion  of  the  pharynx,  and  is  of  short  duration,  no 
new  secretion  occurring  after  two  or  three  days. 

Pultaceous  Pharyngitis ;  Confluent  Muguet.  —  This  form  of  pharyngitis 
occurs  in  low  or  debilitated  states  of  the  system.  It  occurs  in  protracted  and 
exhausting  diseases,  attended  by  malnutrition  and  faulty  digestion.  As  the 
term  "pultaceous"  indicates,  the  inflammatory  product  is  soft  and  friable, 
coming  away  in  fragments  when  touched  by  the  brush  or  sponge  without 
bleeding  or  injury  to  the  mucous  membrane.  Under  the  microscope  it  is 
found  to  consist  of  epithelial  cells,  often  in  fragments,  but  no  fibrin.  In  cer- 
tain cases  to  which  the  term  cryptogamic  is  properly  applied,  a  cryptogam,  the 
oidium  albicans,  is  also  present.  When  the  substance  forming  this  soft  and 
pultaceous  pellicle  is  removed,  the  mucous  membrane  underneath  is  entire, 
hypergemic,  and  sometimes  covered  with  a  newly-formed  epithelial  layer. 
The  appearance  of  the  pultaceous  product  to  the  naked  eye  may  closely  re- 
semble that  in  diphtheria,  but  its  friable  character,  its  epithelial  nature  and 
the  absence  of  fibrin,  which  the  microscope  reveals,  renders  the  diagnosis 
certain. 

Scarlatinous  Pharyngitis ;  often  icith  more  or  less  Gangrene  and  Con- 
tiguous Inflammations  as  Adenitis  and  Celhilltls  of  the  NecJc. — As  a  rule,  the 
microbe,  which  causes  the  destructive  inflammation  in  the  fauces  and  adja- 
cent parts  in  scarlet  fever  is  the  coccus  in  its  various  forms,  especially  the 
streptococcus  (Booker  and  others).  Gangrene  of  the  fauces  may  supervene 
at  any  time,  and  it  bears  a  close  resemblance  to  the  destructive  action  caused 
by  the  Loefiler  bacillus.  This  bacillus  may  occur,  constituting  a  true  diph- 
theritic complication,  but  its  advent  is  usually  after  the  scarlet  fever  has  con- 
tinued a  few  days,  when  it  is  announced  by  an  aggravation  of  symptoms. 
An  exact  diagnosis  must  be  made  by  the  microscope. 

Ilerjjetic  Pharyngitis. — Small  vesicular  eruptions  of  short  duration  some- 
times attend  the  initial  stage,  after  which  small  white  or  grayish-white  ulcers 
remain.  Their  small  size  and  history  serve  for  diagnosis.  After  ablation 
of  the  tonsils  or  injury  of  the  fauces  by  highly-irritating  applications  as 
ammonia  the  appearance,  in  some  cases,  closely  resembles  diphtheria,  but  it 
is  difi'erentiated  by  the  history. 

Anatomical  Characters.  —  Within  a  day,  and  usually  within  a  few 
hours,  from  the  commencement  of  the  inflammation  a  small,  slightly-raised, 
whitish  or  grayish  spot  or  patch  is  observed,  usually  upon  the  tonsilar  por- 
tion of  the  inflamed  surface — very  significant  as  a  diagnostic  sign  and  as  a 
forerunner  of  what  is  to  happen.  This  patch,  termed  the  pseudo-membrane, 
gradually  becomes  firmer,  and  at  the  same  time  thicker  and  broader  from 
fresh  exudations  underneath.  It  retains  for  a  time  its  grayish-white  color, 
but  it  becomes  brownish-white  from  age.     In  mild  cases  the  pseudo-membrane 


DIPHTHERIA.  343 

is  usually  limited  to  the  tonsilar  surface,  but  in  severe  cases  it  covers  the 
uvula,  portions  of  the  velum,  the  isthmus,  and  the  walls  of  the  pharynx, 
both  lateral  and  posterior.  It  does  not  ordinarily  attain  a  greater  thickness 
than  one-eighth  to  one-sixth  of  an  inch.  I  have  seen  it,  however,  not  far 
from  one-third  of  an  inch  thick. 

The  inflamed  mucous  membrane  is  not  only  hyperaemic  and  infiltrated 
with  serum,  but  it  also  contains  numerous  round  white  corpuscles  (leu- 
cocytes), which  may  result  in  part  from  proliferation  of  connective-tissue 
corpuscles,  but  are  believed  by  most  pathologists,  since  Cohnheim's  well- 
known  discovery,  to  be  in  great  part  wandering  white  corpuscles  of  the  blood 
which  have  escaped  throtigh  the  walls  of  the  blood-vessels  along  with  the 
fibrin.  In  the  commencement  of  the  diphtheritic  inflammation,  before  the 
pseudo-membrane  forms,  we  often  observe  a  grayish  tinge  of  the  mucous 
surface,  which  is  due  to  the  crowding  of  the  cellular  elements  in  and  under- 
neath the  mucous  membrane ;  for  these  newly-formed  cells  not  only  infiltrate 
the  mucous  membrane,  but  can  also  be  traced  into  the  submucous  con- 
nective tissue.  Even  where  the  inflammation  remains  catarrhal,  as  it  does 
over  certain  areas  in  all  cases  of  diphtheria,  this  infiltration  of  the  mucous 
and  submucous  tissues  with  cells  is  common. 

During  the  active  period  of  diphtheria  it  is  often  astonishing  to  see  with 
what  rapidity  the  pseudo-membrane  returns  when  removed  by  force.  A  few 
hours  suffice  to  restore  it  as  firm  and  extensive  as  before  the  interference.  In 
the  most  favorable  cases  the  membrane  is  detached  in  a  few  days,  and  is  not 
reproduced.  Its  separation  is  promoted  by  the  secretions  underneath,  espe- 
cially by  pus,  which  is  secreted  in  abundance  between  it  and  the  tissues 
underneath,  which  have  preserved  their  integrity.  In  most  instances  it  does 
not  separate  in  mass,  but  disappears  by  progressive  licj[uefaction.  Occasion- 
ally, even  in  cases  which  do  not  present  a  severe  type,  the  diphtheritic  patch 
does  not  disappear  until  the  lapse  of  four  or  five  or  even  six  weeks,  or  if  it 
softens  and  is  detached  another  appears  in  its  place.  .  In  these  instances  of  an 
unusual  prolongation  diphtheria  has  been  designated  chronic. 

Such  are  the  appearances,  character,  and  history  of  the  pseudo-membrane 
in  this  malady.  Although  its  common  seat  is  upon  the  fauces,  and  in  mild 
cases  it  is  limited  to  them,  nevertheless  all  the  mucous  surfaces  are  liable  to 
be  attacked  by  the  inflammation  in  consequence  of  the  infection  of  the  blood, 
and  therefore  in  severe  cases,  and  even  in  cases  of  moderate  severity,  we  often 
find  the  product  elsewhere  as  well  as  upon  the  fauces,  and  in  localities  where 
from  its  mechanical  eff'ect  it  greatly  increases  the  danger  and  even  compro- 
mises life.  The  mucous  membi'ane  of  the  nostrils,  mouth,  larnyx,  trachea, 
bronchial  tubes.  Eustachian  tubes,  conjunctiva,  cesophagus,  stomach,  intestines, 
vagina,  prepuce,  and  even  the  delicate  lining  membi'ane  of  the  middle  ear,  are 
at  times  the  seat  of  diphtheritic  inflammation  with  the  characteristic  product. 
In  a  case  which  occurred  in  the  Nursery  and  Child's  Hospital  of  New  York 
the  surface  of  the  stomach  was  almost  completely  lined  by  the  diphtheritic 
formation,  so  as  apparently  to  abolish  the  function  of  this  important  organ. 
The  occurrence  of  the  pseudo-membrane  in  the  nares  is  common,  and  is 
attended  by  the  discharge  from  the  nose  of  thin  mucus  and  pus.  Nasal 
diphtheria  involves  great  danger  from  the  fact  that  it  is  likely  to  give  rise 
to  systemic  infection  of  a  grave  type.  In  the  nursing  infant  it  is  also  dan- 
gerous, since  by  its  mechanical  eff'ect  it  interferes  with  lactation.  The  thin, 
irritating  discharge  produces  excoriations  around  the  nostrils  and  upon  the 
upper  lip.  I  have  met  only  one  case  of  diphtheritic  inflammation  of  the 
intestines  in  which  the  diagnosis  was  certain.  A  physician  in  whose  family 
diphtheria  was  occurring  became  seriously  sick  with  symptoms  which  closely 
resembled  those  of  typhoid  fever.     After  a  long   sickness  he  expelled  per 


344  CONSTITUTIONAL  DISEASES. 

rectum  about  one  foot  of  pseudo-membrane  of  a  cylindrical  form,  evidently 
derived  from  the  surface  of  the  intestines.  In  the  subsequent  months  the 
patient  suffered  from  constipation  and  severe  abdominal  pains,  apparently  due 
to  contraction  in  healing  of  the  large  intestinal  ulcer.  Death  finally  occurred 
from  this  state  of  the  intestines.  The  formation  of  the  diphtheritic  pellicle 
upon  the  vulva  and  vaginal  walls  is  not  infrequent,  and  in  parturient  women 
exposed  to  diphtheria  it  sometimes  occurs  upon  the  uterine  walls,  usually 
with  a  fatal  result.  A  considerable  number  of  cases  are  on  record  in  which 
diphtheritic  inflammation  occurred  upon  the  prepuce  after  circumcision,  pro- 
ducing the  usual  pseudo-membrane,  and  in  one  instance  in  my  practice, 
referred  to  above,  it  attacked  the  prepuce  the  day  after  I  had  dilated  it 
with  an  instrument  clean  and  free  from  infection. 

The  Blood. — The  blood  in  cases  of  a  severe  type  is  usually  darker  than  in  health 
and  the  clots  soft.  After  death  from  diphtheritic  croup  it  is  also  dark  from  the 
excess  of  carbonic  acid  in  it.  The  chemical  changes  which  the  blood  undergoes  in 
diphtheria  are  partially  known.  MM.  Andral  and  Gavarret  found  a  notable  diminu- 
tion of  fibrin  in  grave  infectious  diseases,  as  typhoid  fever,  puei-peral  fever,  etc.,  and 
it  is  not  improbable  that  the  same  is  true  of  diphtheritic  blood,  although  the  exuda- 
tion of  fibrin  is  so  abundant.  M.  Bouchut  and  others  have  noticed  an  excess  of  the 
white  corpuscles  in  the  blood  in  diphtheritic  patients,  so  that,  instead  of  three  or 
four  in  the  field  of  the  microscope,  as  many  as  sixty  have  been  counted.  M.  Sanne 
writes  of  diphtheria:  "It  is  necessary  to  recognize  in  the  dark-brown  blood  an 
abnormal  accumulation  of  the  debris  of  the  red  corpuscles,  debris  of  little  abun- 
dance in  the  normal  state,  augmented  considerably  under  the  noxious  influence 
of  the  diphtheritic  poison,  which  has  rapidly  produced  destruction  of  a  great 
number  of  globules."  '  Small  extravasations  of  blood  in  the  various  organs  are 
among  the  most  constant  lesions.  They  have  been  most  frequently  observed  in  the 
brain  and  its  meninges,  the  lungs,  spleen,  and  kidneys.  In  one  case  which  I 
examined  after  death  in  the  New  York  Foundling  Asylum  the  extravasations  in 
and  under  the  gastric  mucous  membrane  produced  mottling  as  great  as  that  of  the 
skin  in  measles. 

The  most  minute  examinations  of  the  organs  in  diphtheria  yet  published  are 
those  recently  made  by  Oertel,  and  we  will  present  a  summary  of  them  in  the 
following  pages. 

Brain  and  Spinal  Cord. — The  anatomical  changes  occurring  in  these  organs 
are  in  a  measure  described  in  our  remarks  on  diphtheritic  paralysis.  Oertel  dis- 
covered, as  the  earliest  anatomical  change  in  the  brain  and  spinal  cord  as  well  as 
in  the  membranes,  a  venous  hyperaemia,  with  small  extravasations  of  blood,  "  not 
larger  than  a  pea,"'  in  the  white  medullary  matter  of  the  brain,  while  in  the  corti- 
cal layer  and  in  the  central  parts  no  extravasation  was  found.  In  the  most  severe 
forms  of  the  disease  small  hemorrhages  not  larger  than  a  pea  were  found  not  only 
in  the  cerebral  meninges,  but  also  in  various  parts  of  the  brain.  These  produced 
some  softening  in  their  immediate  neighborhood.  These  small  hemorrhages  have 
been  found  also  in  or  upon  the  medulla  oblongata  and  spinal  cord,  but  with  less 
softening.  Buhl,  in  addition  to  the  extravasations  in  and  upon  the  brain  and 
spinal  cord,  discovered  in  one  case  great  enlargement  of  the  anterior  and  posterior 
roots  and  the  ganglionary  swellings  of  the  spinal  nerves.  The  swelling  was  found 
to  be  due  to  the  accumulation  of  cells  and  nuclei  in  the  sheaths  of  the  nerves  and 
to  extravasations  of  blood.  These  anatomical  changes  were  most  marked  at  the 
roots  of  the  lumbar  nerves.  (For  further  particulars  relating  to  the  pathology 
of  the  nervous  system  in  diphtheria  the  reader  is  referred  to  our  remarks  on 
Paralysis.) 

Tonsils.  —  Covering  these  organs  is  the  pseudo-membrane,  consisting  of  the 
usual  fibrillar  meshwork,  enclosing  leucocytes,  changed  epithelial  cells,  and  amor- 
phous matter :  the  older  the  exudation  the  coarser  is  the  network.  The  adenoid 
tissue  and  the  septa  have  undergone  hyperplasia.  The  follicles  ai'e  crowded  with 
cells  which  have  undergone  necrobiosis.  As  a  result  of  the  necrobiosis  masses  are 
formed  of  various  shapes  and  sizes,  staining  deeply.  In  consequence  of  the  necro- 
biosis and  degenerative  changes  the  follicles  become  a  hyaline  network  infiltrated 

^  Traiie  de  la  Diphtherie,  p.  107,  Paris,  1877. 


DIPHTHERIA.  345 

with  leucocytes  and  granules.  In  advanced  cases  the  adenoid  and  connective  tissues 
undergo  a  similar  necrobiotic  change,  and  are  so  blended  with  the  pseudo-membrane 
that  it  is  difficult  to  determine  where  the  latter  ends  and  the  tonsilar  tissue  begins. 
The  vessels  of  the  tonsils  undergo  a  hyaline  thickening  of  their  walls,  and  if  this 
occur  chiefly  in  the  intima  total  occlusion  may  result.  In  the  tissues  immediately 
surrounding  the  tonsils  hyaline  degeneration  of  the  muscular  fibres  occurs  (Zenker's 
degeneration),  and  the  connective  tissue  between  the  muscular  fibres  is  infiltrated 
with  leucocytes. 

Faucial  Surface  and  Uvula. — These  parts  are  often  also  covered  with  pseudo- 
membrane,  and  are  more  or  less  changed  by  the  application  of  remedies.  The  line 
of  separation  of  the  exudate  and  underlying  tissues  cannot  be  readily  distinguished. 
The  upper  portion  of  the  diphtheritic  pellicle  is  filled  with  bacteria  and  with  leu- 
cocytes and  other  cells  which  have  undergone  necrobiosis.  In  the  mucosa  next  to 
the  pseudo-membrane  hyaline  degeneration  of  the  connective  tissue  occurs,  and  the 
mucosa  is  infiltrated  with  cells  which  have  undergone  marked  changes.  The  nuclei 
of  the  connective-tissue  cells  exhibit  various  stages  of  degeneration  and  decay, 
though  the  cells  may  retain  their  form.  The  deeper  layers  of  the  mucosa,  like  the 
upper,  are  infiltrated  with  leucocytes. 

The  uvula  in  severe  cases  is  usually  swollen  and  cedematous,  and  sometimes 
entirely  covered  by  the  diphtheritic  pellicle.  When  the  uvula  is  involved  in  the 
general  faucial  inflammation,  necrobiosis  of  the  cells  and  nuclei  occurs  in  every 
part  of  it.  The  cells  in  the  arterial  adventitia  and  in  the  perivascular  tissue  exhibit 
necrobiotic  change,  their  nuclei  being  disintegrated.  In  the  uvula,  also,  hyaline 
degeneration  occurs  in  the  Avails  of  the  vessels. 

Epiglottis. — The  epithelial  cells  covering  the  epiglottis  undergo  marked  prolif- 
eration early  in  the  disease,  and  are  infiltrated  with  leucocytes.  They  soon  begin 
to  undergo  degeneration,  forming  granular  masses.  Areas  of  necrobiosis  occur, 
and  finally  hyaline  degeneration  of  the  network  takes  place.  The  leucocytes  ex- 
tend deeply  into  the  mucous  membrane,  followed  by  degenerative  and  necrobiotic 
changes.  In  places  the  epithelium  is  thrown  off,  and  a  pseudo-membrane  forms  of 
exuded  fibrin  and  necrobiotic  leucocytes  and  epithelium.  Bacteria,  along  with  leu- 
cocytes and  degenerated  epithelial  cells,  occupy  the  meshes  of  the  pseudo-mem- 
brane. 

Lungs. — The  anatomical  characters  of  the  air-passages  are  fully  treated  of  in 
the  article  on  Diphtheritic  Croup.  Catarrhal  bronchitis  is  common  in  diphtheria. 
It  is  not  often  absent  in  croup,  and  one  of  the  chief  sources  of  danger  in  this  dis- 
ease is  the  extension  of  pseudo-membrane  from  the  laryngo-tracheal  surface  to  the 
bronchial,  and  the  transformation  of  the  catarrhal  into  a  croupous  inflammation. 
When  bronchitis  occurs  the  inflammation  creeps  downward  gradually  from  the 
laryngo-tracheal  surface,  and  its  severity  is  proportionate  to  the  degree  of  extension. 
When  there  is  a  general  bronchitis  and  it  is  very  liable  to  become  croupous,  the 
muco-purulent  exudation  is  abundant.  When  pseudo-membranous  bronchitis 
occurs,  there  are  usually  portions  of  the  bronchial  tree  in  which  the  inflammation 
remains  catarrhal.  One  of  the  chief  sources  of  danger  in  diphtheritic  croup  is  the 
extension  of  the  inflammation  to  the  bronchial  tubes  and  the  abundant  secretion  of 
muco-pus,  which  clogs  the  tubes  and  prevents  proper  decarbonization  of  the  blood. 
When  the  bronchitis  becomes  croupous,  a  thin,  easily-detached  film  appears  upon 
the  intensely-red,  hypergemic,  and  swollen  bronchial  surface.  It  increases  in  thick- 
ness and  firmness,  and  is  of  a  brownish-gray  color.  Whatever  the  stage  of  the  inflam- 
mation, the  pseudo-membrane  can  always  be  readily  detached  from  the  bronchial 
surface,  since  its  relation  to  it  is  one  of  apposition,  and  not  of  integral  connection, 
as  upon  the  pharyngeal  surface.  In  the  large  tubes  and  those  of  medium  size 
hollow  cylinders,  more  or  less  complete,  form  ;  but  in  the  smaller  tubes,  if  the 
pseudo-membrane  extend  to  them,  solid  cylinders  are  produced.  Frequently,  in  the 
bronchial  croup  of  diphtheria,  while  the  entire  bronchial  surface  is  intensely  red 
and  swollen,  the  pseudo-membrane  is  absent  in  certain  parts ;  in  other  parts  it 
forms  cylinders,  in  other  parts  still  longitudinal  bands  of  a  ribbon  shape  are  pro- 
duced, and  in  more  or  fewer  of  the  minuter  tubes,  plugs  which  entirely  fill  the  lumina 
and  prevent  the  entrance  of  air  exist.  The  alveoli  beyond  these  plugs  gradually  col- 
lapse, and  more  or  fewer  of  them  return  to  the  unexpanded  foetal  state.  From  the 
tubes  which  are  still  pervious  the  muco-pus  is  with  difficulty  expectorated  on 
account  of  its  viscidity,  and  this  thick  secretion  contains  floating  particles  of 
pseudo-membrane.     Pseudo-membranous  bronchitis  in  diphtheria  is  in  nearly  all 


346  CONSTITUTIONAL  DISEASES. 

instances  an  extension  of  a  laryngo-tracheal  croup.  It  occurs,  according  to  Sanne, 
most  frequently  between  the  second  and  sixth  days. 

Various  forms  of  pulmonary  disease  occur  in  diphtheria,  usually  as  a  complica- 
tion and  often  as  a  final  result  of  the  downward  extension  of  inflammation  from 
the  larynx,  trachea,  and  bronchial  tubes.  Splenization,  atelectasis,  and  broncho- 
pneumonia are  common  complications  of  diphtheritic  croup.  Broncho-pneumonia, 
like  pseudo-membranous  laryngo-tracheitis  and  pseudo-membranous  bronchitis, 
upon  which  it  largely  depends,  occurs  usually  in  the  first  week  of  diphtheria.  In 
121  cases  of  broncho-pneumonia  complicating  diphtheria,  observed  by  Sann6,  the 
pneumonia  commenced  in  2  on  the  first  day  of  diphtheria  and  in  71  between  the 
second  and  sixth  days  inclusive. 

Pulmonary  congestion,  occupying  by  preference  the  depending  portions  of  the 
lungs,  especially  the  posterior  and  inferior  portions  of  the  lower  lobes,  is  also  not 
infrequent.  It  occurs  when  respiration  is  obstructed  in  croup  and  when  the  circu- 
lation is  feeble  in  consequence  of  heart-failure.  In  the  dyspnoea  which  accom- 
panies paralysis  of  the  pneumogastrics,  venous  congestion  of  the  lungs  commonly 
occurs. 

Peter  found  the  lesions  of  pleurisy  9  times  in  121  autopsies  in  diphtheria,  and 
Sanne  observed  them  in  20  cases.  The  latter  writer  says  :  "  All  forms  of  diph- 
theria, but  particularly  croup  and  pseudo-membranous  bronchitis,  are  to  be  found 
with  pleurisy.     Pleurisy  always  accompanies  some  other  phlegmasia." 

Vesicular  emijhysenia  commonly  occurs  during  the  progress  of  croup.  When- 
ever, in  consequence  of  occlusion  of  the  tubes,  a  considerable  part  of  a  lung  fails 
to  receive  air,  its  alveoli  begin  to  retract  and  collapse,  and  the  alveoli  which  receive 
air,  which  are  principally  those  in  the  superior  and  anterior  portions  of  the  lung, 
are  over-distended,  since  their  function  is  compensatory.  Vesicular  emphysema 
consequently  results,  and  in  exceptional  instances  the  vesicles  rupture  and  the 
escaped  air  passes  into  the  connective  tissue,  producing  interstitial  emphysema. 

Pulmonary  apoplexy  occasionally  occurs,  the  extravasations  usually  being  of 
small  size  and  disseminated  thi'ough  the  lungs.  It  is  most  frequent  in  malignant 
cases — in  cases  attended  by  profound  blood-poisoning.  It  has  been  attributed  in 
some  instances  to  pulmonary  emboli  resulting  from  cardiac  thrombosis,  or  microbic 
masses  intercepted  in  the  capillaries.  Puhnonary  (edema  also  occasionally  occurs, 
especially  in  cases  of  bronchial  croup,  pulmonary  congestion,  and  broncho-pneu- 
monia. Oertel  in  his  recent  microscoj^ic  examinations  of  the  lungs  noted  sub- 
pleural  hemoi'rhages  and  hemorrhages  extending  to  the  alveoli,  which  were  com- 
pressed. "  Leucocytes  infiltrated  the  alveolar  septa,  and  in  later  stages  invaded  the 
alveoli,  the  epithelium  of  which  became  detached,  and  the  characters  of  catarrhal 
pneumonia  were  thus  produced.  Some  alveoli  contained  fibrinous  exudation,  and 
in  one  severe  case  the  alveolar  contents  consisted  of  nuclei  which  exhibited  disin- 
tegrating changes  somewhat  like  those  in  necrobiosis." 

Lymphatic  Glands. — Enlargement  of  the  cervical  and  submaxillary  glands  is  of 
common  occurrence  in  diphtheria,  and  it  is  a  diagnostic  symptom  of  some  value. 
Hyperplasia  of  the  cells  of  these  glands  occurs,  with  numerous  hemorrhagic  points 
in  their  capsules  and  in  the  periglandular  tissue.  Points  of  necrobiosis,  staining 
faintly,  occur  in  the  glands,  more  in  the  cortical  than  in  the  central  portions.  The 
cells  exhibit  evidences  of  disintegration,  and  when  this  process  is  advanced  granular 
masses  form  in  the  affected  foci.  Hyaline  degeneration  is  also  observed  in  portions 
of  the  glandular  tissue,  a  degeneration  common  in  other  organs  in  diphtheria. 
Where  disintegration  is  not  too  far  advanced  cells  with  polymorphous  nuclei  are 
observed — evidence  of  an  active  hyperplasia.  Hyperplasia  with  points  of  hemor- 
rhagic extravasation  takes  place  also  in  the  bronchial  glands,  but  fewer  points  of 
necrobiosis  occur  than  in  the  cervical  and  submaxillary  glands,  and  these  chiefly  in 
the  follicles.  The  lymph-ducts  may  contain  no  normal  cells,  and  only  those  which 
have  disintegrated  nuclei  along  with  other  products  of  disintegration. 

Heart. — The  state  of  the  heart  will  be  in  part  described  in  our  remarks  relating 
to  cardiac  paralysis.  Small  extravasations  of  blood  under  the  pericardial,  and  less 
frequently  the  endocardial,  surface  have  been  observed.  Oertel  attributes  these 
hemorrhages  to  changes  in  the  walls  of  the  vessels  caused  by  the  diphtheritic  virus, 
and  Buhl,  to  nuclear  proliferation  in  the  walls  and  mechanical  obstruction.  Leu- 
cocytes in  masses  often  occur  under  the  pericardium  and  endocardium  and  between 
the  muscular  fibres.  Sometimes  the  muscle-nuclei  have  undergone  segmentation 
and  degenerative  changes.     These  nuclear  changes  occur  mostly  in  fibres  under 


DIPHTHERIA.  347 

the  endocardium  and  around  the  coronary  arteries.  The  nuclei  in  the  muscular 
coat  of  the  arteries  are  increased  in  size,  and  slight  proliferation  and  desquamation 
of  the  endothelia  and  infiltration  of  the  adventitia  also  take  place. 

Mouth,  Stomach,  Intestines. — The  diphtheritic  pellicle  sometimes  forms  in  the 
cavity  of  the  mouth,  generally  in  small  patches  ;  but  the  buccal  surface  is  usually 
only  superficially  involved,  except  upon  the  tongue,  where  the  pellicle  extends  more 
deeply.  I  have  elsewhere  stated  that  the  diphtheritic  exudate  sometimes  occurs 
upon  the  surface  of  the  stomach  and  portions  of  the  intestines,  producing  more  or 
less  destruction  of  the  mucous  membrane.  IS'ecrobiotic  foci  have  been  observed  by 
Bizzozero  and  Oertel  in  the  intestinal  follicles  and  agminate  glands,  but  to  a  less 
extent  than  upon  the  respiratory  surfaces.  Active  cell-proliferation  and  disinte- 
gration and  cleavage  of  nuclei  occur,  but  these  altered  cells  are  mixed  with  others 
which  are  normal.  The  epithelium  is  for  the  most  part  retained  and  normal,  and 
hyaline  changes  have  not  been  observed  in  the  gastro-intestinal  vessels.  The  mes- 
enteric glands  sometimes  undergo  enlargement  from  hyperplasia,  especially  when 
the  intestines  are  affected  and  points  of  necrobiosis  occur  in  them.  For  the  most 
part,  however,  the  gastro-intestinal  surface  is  less  frequently  affected  than  other 
mucous  surfaces. 

Spleen. — -The  diphtheritic  virus  reaches  this  organ  through  the  blood-current. 
The  spleen  is  swollen,  so  as  to  render  its  capsule  tense.  The  pulp  is  soft,  rising  up 
through  the  cut  surface  of  the  capsule  :  the  follicles  are  large  and  prominent ;  in 
the  pulp  are  extravasations  of  blood  and  hgematoidin  masses,  and  the  vessels  are 
distended.  Hyperplasia  of  the  splenic  corpuscles  occurs,  which  is  most  marked 
around  the  bifurcations  of  the  arteries,  so  that  the  reticulum  is  less  prominent. 
The  follicles  are  surrounded  by  a  wide  zone  of  the  reticulated  cells,  among  which 
we  find  lymphatic  corpuscles,  leucocytes,  and  large  round  cells.  The  nuclei  in  the 
cells  undergo  two  changes :  first,  direct  segmentation  as  in  ordinary  cell-division, 
and  fragmentation,  in  which  the  chromatin  is  broken  up  in  small,  irregularly-dis- 
posed masses  and  the  nuclear  juice  is  susceptible  of  staining.  In  the  Malpighian 
follicles  either  numerous  epithelioid  cells  form,  as  mentioned  by  Stilling,^  or  large 
cells  occur.  The  latter  stain  better  by  coloring  reagents  than  the  epithelioid  cells, 
but  less  than  the  leucocytes.  The  epithelioid  cells  occur  mostly  in  young  patients. 
A  wide  zone  of  leucocytes  surrounds  and  invades  the  follicles.  The  necrobiotic 
process  also  occurs  as  in  other  organs,  beginning  with  nuclear  disintegration,  and 
when  at  its  maximum  the  follicles  are  surrounded  and  loaded  with  the  altered 
nuclei  furnished  by  the  round  or  epithelioid  cells.  Hemorrhages  also  occur  in  the 
follicles.  In  some  protracted  cases  the  vessels  of  the  pulp  exhibit  the  hyaline 
degeneration. 

Liver. — Capillary  hemorrhages  take  place  within  the  capsule,  and  occasionally 
within  the  parenchyma.  Leucocytes  occur  at  certain  points  within  the  liver,  infil- 
trating the  tissue  of  the  organ.  They  occupy  the  interlobular  spaces  and  do  not 
exhibit  nuclear  changes.     The  hepatic  cells  are  unchanged  or  they  become  fatty. 

Kidneys. — Albuminuria  occurs  from  different  causes,  as  we  have  stated  else- 
where. Feeble  heart-action,  obstructed  respiration,  fever,  and  the  direct  irritating 
action  of  the  diphtheritic  virus  upon  the  blood  and  kidneys,  are  sufiicient  causes. 
The  kidneys  may  be  normal  in  cases  of  albuminuria,  or  exhibit  different  degrees  of 
parenchymatous  inflammation.  Hemorrhages,  glomerulitis,  and  disseminated  neph- 
ritis are  common  lesions  observed  in  the  kidneys  in  those  who  have  died  having 
diphtheritic  albuminuria.  Hemorrhagic  points  occur  not  only  under  the  capsule,  but 
also  in  the  glomeruli  and  in  and  between  the  tubules.  Cell-infiltration  takes  place 
around  the  vessels  and  the  cells  exhibit  nuclear  disintegration.  On  examining  the 
glomeruli,  thickening  of  Bowman's  capsule  is  sometimes  observed,  with  some  albu- 
minous exudation  underneath  it,  and  epithelial  proliferation  and  desquamation.  The 
nuclei  and  endothelia  of  the  glomerular  capillaries  are  increased,  and  the  chromatin 
and  nuclear  juice  have  undergone  disintegrating  and  degenerative  changes — results 
of  inflammation.  The  capillaries  are  therefore  in  a  degree  diseased  through  the 
action  of  the  blood-poison.  The  epithelium  of  the  convoluted  and  straight  tubes  is 
also  diseased.  The  epithelial  cells,  undergoing  cloudy  swelling,  become  detached 
from  the  basement  membrane,  fill  the  lumina  with  the  necrosed  product,  and  some 
of  them  escape,  forming  casts  in  the  urine.  Occasionally  only  the  outer  portion  of 
the  cell  is  necrosed  and  detached,  the  part  adjacent  to  the  basement  membrane  con- 

^  Virchow'  s  Arehiv,  Bd.  ciii. 


348  CONSTITUTIONAL  DISEASES. 

taining  the  nucleus  remaining  in  situ.  Oertel  says  that  when  the  entire  cells  are 
thrown  off  granular  casts  are  formed,  but  if  only  the  outer  portions  are  lost  hyaline 
casts  are  produced.  The  collecting  tubes,  filled  with  granular  masses  containing 
broken  nuclei,  cells,  and  epithelia,  may  be  dilated. 

Symptoms. — Diphtheria,  like  scarlet  fever,  varies  greatly  in  severity, 
from  a  form  so  mild  that  medical  advice  is  not  sought  and  the  child  is  not 
even  confined  to  his  home,  to  a  form  so  severe  that  the  system  is  at  once 
overpowered  and  the  patient  is  in  a  critical  state  from  the  first.  In  general 
in  the  commencement  of  an  epidemic  the  symptoms  are  more  severe  than 
when  the  epidemic  influence  is  abating.  During  the  continuance  of  the 
attack  the  prominent  symptoms,  such  as  arrest  attention,  are  often  dispro- 
portionate to  the  gravity  of  the  case.  Striking  instances  illustrative  of  this 
fact  have  occurred  in  my  practice,  the  friends  not  supposing  that  there  was 
any  serious  ailment,  and  not  seeking  medical  advice  until  the  fatal  termina- 
tion was  near. 

In  benign  diphtheria  the  initial  symptoms  are  often  slight,  such  as 
languor  or  lassitude,  slight  chilliness  succeeded  by  fever  of  a  light  form, 
mild  headache,  pain  or  aching  in  the  body  or  limbs,  thirst,  and  impaired 
appetite.  Usually  some  soreness  of  the  throat  is  noticed  in  swallowing  soon 
after  the  attack  begins,  and  this  continues.  But  the  patient  with  mild  diph- 
theria often  continues  to  walk  about,  in  the  belief  that  he  is  affected  with  a 
slight  and  temporary  ailment.  Children  with  mild  diphtheria  in  the  poorer 
families  are  usually  allowed  to  go  abroad,  and  do  great  harm  by  propagating 
the  disease.  The  symptoms  in  these  mild  cases  so  closely  resemble  those 
from  a  severe  cold  that  the  disease  is  liable  to  be  mistaken  for  it.  The 
slight  tenderness  or  sensation  of  fulness  in  the  fauces  usually  experienced  by 
those  old  enough  to  express  their  sensations  should  always  lead  to  an  exam- 
ination of  the  fauces,  when  the  character  of  the  attack  will  frequently  be 
apparent.  A  distinguished  clergyman  of  the  Pacific  coast  who  fell  a  victim 
to  this  disease  dreamed  a  few  nights  before  he  complained  of  his  illness  that 
his  throat  was  cut.  Doubtless  the  diphtheritic  inflammation  had  already 
commenced,  so  that  what  seemed  a  forewarning  had  a  natural  explanation. 
So  insidious  was  the  commencement  in  this  case  that  the  disease  had 
advanced  beyond  all  hope  of  relief  when  medical  advice  was  fii'st  sought. 

Soon  after  the  attack  commences  inspection  of  the  fauces  reveals  redness 
of  the  tonsilar  surface,  and  this  extends  until  the  entire  fauces  present  an 
injected  appearance.  After  the  lapse  of  twelve  to  thirty-six  hours,  or  even 
as  late  as  forty-eight  hours,  from  the  commencement  of  the  disease,  the 
diphtheritic  exudate  begins  to  form  over  the  tonsils,  producing  the  character- 
istic pellicle.  Before  it  forms  we  often  observe  a  grayish  color  of  the  prom- 
inent part  of  the  tonsils,  produced  by  the  infiltration  of  the  mucous  m.em- 
brane,  and  even  of  the  surface  of  the  tonsils,  with  newly-formed  cells.  The 
exudate  may  appear  as  points,  which  coalesce,  forming  a  patch,  or  as  a  pelli- 
cle, which  soon  becomes  thicker  and  at  the  same  time  firm.  Its  anatomical 
characters  are  described  elsewhere. 

But  in  most  cases,  in  all  except  of  the  mildest  type,  the  initial  symptoms 
are  more  severe  than  we  have  delineated  above.  The  attack  in  the  ordinary 
as  well  as  severe  form  of  diphtheria  commences  abruptly,  like  scarlet  fever, 
without  a  premonitory  stage  and  with  pronounced  symptoms  from  the  first. 
The  temperature  rises  to  102°,  103°,  or  even  104°  F.,  with  corresponding 
heat  of  surface,  thirst,  languor,  loss  or  impairment  of  appetite,  tenderness  of 
throat,  etc.  Delirium  as  well  as  eclampsia  may  occur  ;  but  both  are  rare. 
The  temperature  ordinarily  begins  to  fall  after  the  second  or  third  day  in 
favorable  cases,  and  often  in  those  of  a  grave  and  fatal  type.  Subsequently 
to  the  third  or  fourth  day  the  temperature  is  frequently  but  little  elevated. 


DIPHTHERIA.  349 

The  diphtheritic  poison,  when  the  system  is  fully  under  its  influence,  does 
not  exhibit  any  marked  tendency,  like  that  of  scarlet  fever,  to  increase  the 
animal  heat.  Even  in  profound  and  fatal  diphtheritic  blood-poisoning  rap- 
idly approaching  an  unfavorable  termination  the  thermometer  often  indicates 
nearly  the  normal  temperature,  so  that  the  inexperienced  practitioner  may  be 
deceived  by  this  fact  in  his  prognosis.  A  continued  elevation  of  temperature 
considerably  above  the  normal  should  lead  the  physician  to  examine  for  some 
complication,  perhaps  nephritis. 

The  tongue  is  moist  and  slightly  furred.  Many  patients  vomit  in  the 
commencement;  and,  if  this  symptom  cease  or  be  not  repeated,  it  is  not  of 
grave  import ;  but  vomiting  occurring  often,  so  that  a  considerable  part  of 
the  food  is  rejected,  is  common  in  grave  cases  and  is  an  unfavorable  prog- 
nostic symptom.  It  frequently  is  due  to  uraemia.  The  appetite  in  severe 
cases  is  usually  poor.  Repugnance  to  food  from  loss  of  appetite  and  pain  in 
swallowing  characterize  severe  forms  of  the  disease.  There  are  no  notable 
symptoms  referable  to  the  state  of  the  intestines.  The  stools  appear  normal, 
except  as  they  are  changed  by  the  medicines  prescribed.  In  all  cases  except 
the  mildest  a  rapid  destruction  of  red  corpuscles  occurs  and  a  relative  in- 
crease of  white  corpuscles.  Hence  the  anaemia,  which  is  soon  manifested  by 
pallor  of  the  surface,  and  which  rapidly  increases  as  the  disease  advances.  The 
early  loss  of  the  tendon  reflex  has  recently  been  brought  to  the  notice  of  the 
profession.  It  often  occurs  as  early  as  the  first,  second,  or  third  day.  It  is 
fully  treated  of  in  our  remarks  relating  to  diphtheritic  paralysis  in  subse- 
quent pages.  It  is  a  symptom  of  diagnostic  value.  Diphtheritic  inflamma- 
tions have  a  marked  tendency  to  produce  hyperplasia,  and  consequent  notable 
enlargement  of  the  lymphatic  glands  in  their  immediate  neighborhood.  The 
poisonous  and  irritating  products  of  the  inflammation  upon  the  surface  taken 
up  by  the  lymphatics  and  deposited  in  the  adjacent  glands  produce  in  them 
tenderness,  swelling,  an  increased  afilus  of  arterial  blood,  and  a  rapid  increase 
of  the  cellular  elements.  An  inflammation  both  of  the  lymphatic  ducts  and 
glands  arises,  with  more  or  less  oedema  and  sometimes  inflammation  of  the 
adjacent  connective  tissue.  Suppuration  of  the  glands  and  connective  tissue, 
though  it  may  occur,  is  much  less  frequent  than  in  scarlet  fever. 

Teviperature. — There  is  probably  no  other  disease  in  which  the  thermometer 
furnishes  so  little  aid  to  an  understanding  of  the  case  as  in  this,  since  the  degree  of 
fever  does  not  sustain  any  fixed  relation  to  the  amount  of  blood-poisoning.  Malig- 
nant diphtheria  with  profound  blood-poisoning  and  approaching  a  fatal  termination 
may  be  almost  apyretic,  while  a  benign  form  of  the  disease  with  but  little  blood- 
poisoning  may  commence  with  considerable  fever  (102°,  103°,  or  104°  F.).  Fever 
in  diphtheria  is  rather  a  symptom  of  the  inflammation  than  of  the  blood-poisoning. 
Considerable  elevation  of  temperature  in  diphtheria  usually  indicates  an  active 
pharyngitis,  tonsilitis,  laryngo-tracheitis,  bronchitis,  pneumonia,  or  nephritis. 
Therefore,  although  the  thermometer  does  not  aid  in  determining  the  amount  of 
blood-poisoning,  it  enables  us  to  form  an  opinion  in  regard  to  the  extent  and  sever- 
ity of  the  inflammation  which  may  be  present.  The  thermometer  is  also  useful 
when  diphtheria  occurs  as  a  complication  of  another  constitutional  disease,  as 
scai'let  fever,  measles,  typhoid  fever,  since  it  indicates  the  severity  of  this  disease. 

Such  is  the  clinical  history  of  diphtheria  as  it  usually  occurs,  its  local  manifes- 
tation being  primarily  upon  the  tonsilar  portion  of  the  fauces,  and  extending  from 
the  tonsils,  when  the  case  is  severe,  to  the  posterior  surface  of  the  fauces,  over  the 
anterior  and  posterior  pillars,  and  to  the  uvula.  The  uvula,  when  it  is  involved,  be- 
comes so  greatly  swollen,  even  two  or  three  times  its  normal  size,  as  to  lie  upon  the 
tongue,  and,  especially  if  it  be  covered  by  a  pseudo-membrane,  to  fill  up  the  space 
between  the  swollen  tonsils  and  intercept  the  view  of  the  posterior  fauces.  When 
the  inflammation  is  intense  and  the  pseudo-membrane  has  not  yet  formed  or  has 
been  removed  by  solvent  applications,  the  tonsilar  portion  of  the  fauces  often  pre- 
sents a  grayish  appearance  from  infiltration  of  leucocytes.     This  infiltration,  if  so 


350  CONSTITUTIONAL  DISEASES. 

ffreat  as  to  obstruct  the  circulation,  leads  to  necrosis ;  but,  as  we  have  stated  else- 
where, the  necrosis  of  the  mucous  membrane  is  more  likely  to  occur  when  it  is  still 
covered  by  the  pseudo-membrane,  the  pseudo-membrane  and  mucous  surface  being 
incorporated  with  each  other  and  being  detached  together.  The  color  of  the 
pseudo-membrane,  at  lirst  whitish  or  a  grayish  white,  becomes  in  a  few  days,  in 
severe  cases,  a  yellowish  broM'n  by  the  action  of  the  atmosphere  and  sometimes  by 
extravasation  of  blood.  If  the  membrane  be  abundant,  it  is  likely  to  have  in  a  few 
days  a  musty  and  offensive  odor,  due  to  commencing  decomposition.  The  constant 
inhalation  of  the  highly  poisonous  gases  which  result  is  detrimental  to  the  patient, 
and  they  inci'ease  the  danger  of  infection  in  others.  However,  with  the  use  of  dis- 
infectants, now  so  commonly  employed,  the  poisonous  gaseous  products  of  decom- 
position are  not  so  common  as  in  former  times.  Since  the  pseudo-membrane  is  in- 
corporated with  the  mucous  membrane  and  capillaries  penetrate  its  under  surface, 
forcible  detachment  of  the  pellicle  is  likely  to  give  rise  to  hemorrhage.  Hemor- 
rhage is  always  a  bad  prognostic  sign.  The  duration  of  the  pseudo-membrane  is 
very  variable.  On  the  average  in  favorable  cases  it  is  from  one  to  two  weeks.  There 
are  cases,  however,  in  which  the  ulcerated  surface  is  long  in  healing,  and  the  ulcers 
are  covered  many  days  with  the  grayish-white  diphtheritic  exudate.  In  exceptional 
cases,  at  the  close  of  the  third  or  even  fourth  week,  we  occasionally  observe  on  the 
faucial  surface  diphtheritic  patches  two  or  three  lines  in  diameter,  without  surround- 
ing inflammation,  in  those  who  consider  themselves  nearly  well  and  who  would 
appear  in  the  streets  if  they  were  allowed  to  do  so.  We  will  consider  elsewhere 
how  long  enforced  seclusion  of  the  patient  should  be  enjoined  in  order  to  prevent 
the  propagation  of  the  disease  to  others. 

Nares. — Usually  inflammation  of  the  nostrils  occurring  in  diphtheria  is  second- 
ary to  that  of  the  pharynx.  The  pharyngitis  has  continued  one  or  more  days  when 
a  discharge  of  a  thin  serous  appearance  occurs  from  the  nostrils.  This  is  attended 
by  swelling  of  the  Schneiderian  membrane ;  and  in  proportion  to  the  amount  of 
swelling  the  respiration  through  the  nostrils  is  embarrassed.  As  the  inflammation 
continues  the  swelling  increases  and  respiration  is  accompanied  by  a  nasal  snuffle, 
or  the  occlusion  of  the  nostrils  is  so  great  that  it  is  performed  entirely  through  the 
mouth.  The  impediment  to  respiration  in  infants  at  the  breast,  so  as  to  necessitate 
spoon-feeding,  has  been  alluded  to.  The  discharge  is  very  acrid  and  irritating, 
causing  excoriation  around  the  entrance  of  the  nostrils  and  even  upon  the  cheeks. 
It  soon  becomes  more  viscid  or  less  fluid  than  at  first,  and  it  presents  a  creamy 
appearance  from  the  large  proportion  of  pus-corpuscles.  When  the  inflammation 
of  the  nares  is  severe,  the  glands  around  the  articulation  of  the  lower  jaw  usually 
undergo  hyperplasia,  becoming  nodular  and  prominent,  so  as  to  be  apparent  not 
only  to  the  touch,  but  also  to  the  sight. 

Although,  commonly,  diphtheritic  inflammation  of  the  nasal  surface  is  second- 
ary to  that  of  the  fauces,  it  is  sometimes  the  primary  inflammation.  It  may  exist 
for  some  days  before  the  fauces  become  affected,  and  under  such  circumstances  the 
diagnosis  is  frequently  not  made  until  the  disease  is  in  an  advanced  stage  and  pro- 
found blood-poisoning  has  occurred.  In  nasal  diphtheria  the  pseudo-membrane 
probably  occurs  as  early  as  in  other  forms  of  diphtheritic  inflammation,  but  being 
usually  out  of  sight  it  is  not  observed  in  the  first  days  or  until  it  has  extended  so 
that  its  anterior  edge  can  be  seen  on  inspecting  the  nasal  fossa.  From  its  concealed 
position  it  is  easy  to  perceive  why  the  disease  is  so  frequently  overlooked,  and  a 
simple  nasal  catarrh  is  supposed  to  be  present  when  there  is  no  inflammation  of  the 
fauces  to  aid  the  diagnosis  or  it  is  late  in  appearing. 

Nasal  diphtheria  always  involves  great  danger,  since  it  is  very  liable  to  give 
rise  to  systemic  infection  from  the  large  number  of  lymphatics  lodged  in  the  con- 
nective tissue  of  the  nares.  In  certain  severe  cases  accompanied  by  swelling  of  the 
face  there  is  reason  to  think  that  the  inflammation  has  entered  the  antrum  of  High- 
more — a  very  serious  extension.  It  sometimes  extends  up  the  tear-duct,  producing 
its  occlusion,  and  also  along  the  Eustachian  tube.  Hemorrhage  sometimes  occurs 
in  nasal  diphtheria.  In  those  who  recover  the  Schneiderian  membrane  returns 
slowly  to  its  normal  state. 

The  Eye. — We  have  stated  above  that  the  inflammation  sometimes  passes  along 
the  tear-duct  to  the  conjunctiva,  but  in  other  instances  the  inflammation  occurs 
independently  of  this  mode  of  propagation.  Thus,  if  a  child  with  simple  conjunc- 
tivitis contract  diphtheria,  the  pre-existing  inflammation  is  very  liable  to  assume  a 
diphtheritic  character,  in  accordance  with  the  law  already  stated,  that  diphtheria. 


DIPHTHERIA.  351 

attacks  by  preference  surfaces  that  are  already  inflamed.  I  have  elsewhere  stated 
that  diphtheria  at  one  time  entered  the  ophthalmic  wards  of  the  New  York  Found- 
ling Asylum,  and  three  children,  under  treatment  for  granular  lids,  who  contracted 
the  disease,  had  diphtheritic  inflammation  of  the  lids,  with  the  usual  pseudo-mem- 
branous exudate.  The  result  of  diphtheritic  conjunctivitis,  even  with  pi-ompt  and 
appropriate  treatment,  is  likely  to  be  disastrous  as  regards  the  eye.  The  eyelids 
become  red  and  greatly  swollen  from  oedema,  and  their  under  surface  is  soon  lined 
bv  a  thick  and  firm  pseudo-membrane.  The  eye  itself  is  the  seat  of  chemosis.  The 
pseudo-membrane  upon  the  ocular  conjunctiva  is  less  firm,  not  so  thick,  and  more 
in  flakes  than  that  upon  the  palpebral  conjunctiva.  The  eye  affected  by  this  disease 
should  be  closely  watched  and  promptly  and  efficiently  treated ;  but,  unfortunately, 
under  the  most  judicious  treatment  the  cornea  is  likely  to  become  hazy  and  slough- 
ing or  ulceration  follow,  with  total  destruction  of  sight  and  perhaps  prolapse  of 
the  iris. 

The  Ear. — The  ear  may  become  inflamed  by  extension  of  the  inflammation  along 
the  Eustachian  tube  from  the  fauces.  The  opening  of  this  tube  upon  the  faucial 
surface  is  small  and  slit-like  in  the  child,  and  moderate  inflammation  and  exudation 
are  sufBcient  to  close  it.  When  this  occurs  the  patient  complains  of  pain  in  the 
site  of  the  tube  and  in  the  ear.  The  formation  of  a  membrane  plugging  the  tube 
and  the  extension  of  the  inflammation  to  the  ear,  producing  an  otitis  media,  add 
very  much  to  the  gravity  of  the  case.  Perforation  of  the  drum,  caries  of  the  bones 
of  the  ear,  and  that  grave  disease  otitis  interna  may  occur,  increasing  very  much 
the  gravity  of  the  case.  Fortunately,  this  extension  of  the  inflammation  is  not  fre- 
quent. It  does  not  often  occur  excejjt  in  those  malignant  cases  which  are  likely  ta 
be  fatal  from  other  causes.  Sometimes,  also,  a  diphtheritic  otitis  externa  occurs. 
It  is  usually  preceded  by  a  catarrhal  inflammation  which  has  arisen  from  other 
causes  and  was  present  when  the  diphtheria  commenced.  Bezold  described  three 
cases  of  otitis  externa  with  a  diphtheritic  pellicle  upon  the  drum.^  Moos  and  Callait 
have  also  narrated  cases. 

Albuminuria. 

It  is  perhaps  remarkable  that  numerous  epidemics  of  diphtheria  had  been 
observed  before  it  became  known  that  albuminuria  is  a  common  accompani- 
ment of  it.  The  fact  that  the  kidneys  are  affected  so  as  to  give  rise  to  albu- 
minous urine  was  discovered  by  Mr.  Wade  of  Birmingham,  England,  in  1857. 
The  interesting  paper  communicating  his  discovery  was  published  in  the 
Midland  Quarterly  Journal  of  Medicine,  1857.  Immediately  after  its 
appearance  the  subject  to  which  he  drew  attention  was  fully  investigated  in 
different  countries,  and  in  the  same  year  Mr.  -lames  published  his  observa- 
tions in  the  Medical  Times  and  Gazette.  In  the  following  year  (1858)  twa 
noteworthy  papers  appeared  on  the  same  subject,  one  by  MM.  Bouchut  and 
Empis,  read  before  the  Parisian  Academy  of  Sciences  and  published  in  the 
Gazette  des  Hopitaux,  and  another  by  Germain  See,  and  read  before  the  So- 
ciete  des  H6pitaux.  Since  1858  monographs  and  reports  of  cases  too  nume- 
rous to  mention  have  been  published,  so  that  the  literature  of  diphtheritic 
albuminuria  is   quite  full. 

As  to  the  frequency  of  albuminuria  in  diphtheria,  Bouchut  and  Empis 
found  it  in  two-thirds  of  their  cases,  Germain  See  in  one-half  of  his,  and 
Sanne  in  224  cases  out  of  410.  In  New  York  City,  where  diphtheria  has 
been  many  years  naturalized  or  endemic,  I  made  in  the  years  1875  and  1876 
daily  examinations  of  the  urine  in  62  consecutive  cases,  and  found  it  present 
in  24,  while  38  were  recorded  exempt.  But  the  proportion  of  cases  as  stated 
in  my  statistics  is  probably  below  the  truth,  for  the  albuminuria  is  sometimes 
transient,  and  it  often  occurs  as  a  mere  trace  and  is  liable  to  be  overlooked. 
Its  duration  is  frequently  not  more  than  from  one  to  three  days,  and  in  the 
majority  of  instances  it  does  not  continue  longer  than  ten  days ;  but  we  are 

^  Virchoiifs  Archiv,  Ixx.  329. 


352  CONSTITUTIONAL  DISEASES. 

all  familiar  with  cases  in  whicli  it  continues  fifteen  or  twenty  days,  or  even 
for  months. 

The  date  of  the  commencement  of  albuminuria  varies  greatly  in  different 
cases.  Perhaps  the  largest  number  of  observations  bearing  on  this  point  are 
those  of  Sanne.  In  224  cases  albuminuria  was  detected  on  the  first  day  of 
diphtheria  in  3,  on  the  second  day  in  10,  on  the  third  day  in  30,  on  the  fourth 
day  in  30,  on  the  fifth  day  in  22.  From  the  sixth  day  to  the  eleventh  the 
number  on  each  day  in  whom  albuminuria  was  present  for  the  first  time 
varied  from  10  to  33.  After  the  eleventh  day  there  were  only  9  new  cases, 
and  after  the  fifteenth  day  only  1  new  case.  Hence  from  these  statistics  we 
infer  that  there  is  little  danger  that  albuminuria  will  occur  after  the  second 
week  if  the  patient  have  exhibited  no  symptoms  of  it  previously. 

The  amount  of  albumen  in  the  urine  varies  greatly  in  different  patients, 
from  a  slight  cloudiness,  scarcely  visible  after  boiling,  to  so  large  a  quantity 
that  it  becomes  semi-solid  by  the  application  of  heat  or  nitric  acid.  When 
the  proportion  of  albumen  is  very  large,  there  is  also  usually  a  notable  dimi- 
nution in  the  quantity  of  urine  passed.  In  ordinary  cases  the  percentage 
of  albumen  varies  at  different  times.  It  sometimes  disappears  during  one 
or  two  days,  and  we  are  led  to  think  that  the  j^atient  is  rapidly  recovering, 
but  its  reappearance  in  full  quantity  shows  that  the  apparent  improvement 
was  due  to  some  transient  cause.  "  Nothing,"  says  Sanne,  "  is  more  irregu- 
lar than  the  course  of  diphtheritic  albuminuria.  At  one  time  the  precipitate 
is  sudden,  abundant,  and  flocculent ;  at  another  it  commences  with  an  opaque 
cloud,  and  continues  with  this  characteristic  till  the  time  at  which  it  disap- 
pears." Diphtheritic  albuminuria  differs  in  many  respects  from  that  in  scar- 
let fever.  The  urine  at  first,  when  the  renal  disease  is  active,  sometimes 
presents  a  pinkish  tinge,  and  the  microscope  reveals  the  presence  of  red  blood- 
corpuscles,  but  afterward,  and  in  mild  cases  from  the  first,  the  urine  exhibits 
nearly  the  normal  appearance,  even  when  very  albuminous,  in  contradistinc- 
tion to  its  cloudy  appearance  in  scarlet  fever.  The  specific  gravity  is  low, 
falling  to  1010  or  less,  and  casts,  both  granular  and  hyaline,  are  present. 
When  the  kidneys  are  seriously  implicated  the  quantity  of  urine  is  usually 
notably  diminished.  Great  diminution  is  a  serious  symptom,  and  it  often 
precedes  the  fatal  issue. 

In  favorable  cases  the  albuminuria  does  not  in  the  average  continue  as 
long  as  in  scarlet  fever.  The  albumen  may  disappear  from  the  urine  in  two 
or  three  days  if  its  quantity  has  been  small,  and  in  a  large  proportion  of 
cases  it  disappears  within  ten  days ;  but  cases  occur  in  which  albuminuria 
continues  many  months,  with  its  final  disappearance  and  the  complete  restora- 
tion of  the  health.  Thus,  a  boy  of  six  years  treated  by  me  had  nephritis 
following  a  very  mild  attack  of  diphtheria.  His  urine  in  the  first  weeks  was 
deeply  tinged  by  the  presence  of  red  blood-corpuscles,  but  its  quantity  was 
normal,  as  determined  by  daily  examinations,  and  it  contained  nearly  or  quite 
the  normal  amount  of  urea.  Its  specific  gravity  was  at  or  under  1010. 
After  a  time  the  blood-corpuscles  disappeared,  the  urine  when  heated  had 
its  normal  appearance,  its  specific  gravity  became  normal,  and  the  granular 
casts  at  first  present  disappeared.  The  patient  was  uniformly  cheerful,  was 
free  from  fever,  his  appetite  was  good,  and  no  subjective  symptoms  occurred 
to  indicate  renal  disease.  Nevertheless,  after  the  lapse  of  ten  months  a  little 
albu.men  was  still  present  in  the  urine. 

But  the  presence  of  albumen  in  the  urine,  if  considerable,  is  an  unfavor- 
able prognostic  sign.  Sanne  states  that  in  233  cases  of  diphtheria  accompanied 
by  albuminuria  142  died  and  91  recovered.  In  160  cases  in  which  albumi- 
nuria was  absent,  63  died  and  97  recovered.  The  statistics  of  others  corre- 
spond with  those  of  Sanne,  so  that  the  fact  may  be   considered  established 


DIPHTHERIA.  353 

that  a  larger  proportion  of  cases  of  diphtheria  with  albuminuria  perish  than 
of  those  without  albuminuria.  It  does  not  follow  necessarily  from  this  that 
the  affection  of  the  kidneys  which  produces  the  albuminuria  contributes  to 
the  fatal  result,  for  albuminuria  is  more  frequent  in  grave  cases  than  in  those 
of  a  mild  type.  The  termination  in  death  may  be  due,  and  often  is  largely 
due,  to  other  causes  than  the  renal  disease. 

Although  sevei'e  and  so-called  malignant  forms  of  diphtheria  are  more 
likely  to  be  complicated  by  albuminuria  than  are  mild  forms  of  the  disease, 
yet,  as  in  scarlet  fever,  severe  and  fatal  renal  disease  giving  rise  to  albumi- 
nuria sometimes  occurs  in  very  mild  cases  of  diphtheria.  Several  years  ago 
I  attended  a  child  of  six  years  with  the  following  history :  He  had  mild 
pharyngitis,  with  scarcely  appreciable  exudation  and  almost  no  constitutional 
disturbance.  On  the  second  day  the  jiatient  seemed  so  nearly  well  that  both 
the  doctor  and  the  intelligent  grandmother  who  had  charge  of  him  did  not 
think  further  medical  attendance  necessary.  One  week  subsequently  I  was 
summoned  to  the  child  in  haste  on  account  of  neai'ly  complete  suppression 
of  urine.  About  one  drachm  was  passed  each  time  and  at  long  intervals. 
This  when  heated  became  semi-solid.  The  late  Prof.  Austin  Flint,  who  saw 
the  case  in  consultation,  and  myself  notified  the  family  of  the  extreme  grav- 
ity of  the  case  and  its  approaching  fatal  termination — a  prediction  which  was 
verified  in  forty-eight  hours.  In  such  rare  eases,  while  the  diphtheritic 
poison  acts  with  great  power  upon  the  kidneys,  producing  a  fatal  nephritis,  its 
influence  is  feebly  felt  in  those  tissues  which  are  the  usual  seat  of  diphthe- 
ritic inflammation.  Diphtheritic  albuminuria  is  rarely  attended  by  anasarca 
or  by  symptoms  of  urasmic  poisoning.  In  224  cases  of  diphtheritic  albumi- 
nuria embraced  in  Sanne's  statistics,  dropsy  occurred  in  only  7.  Trousseau 
did  not  meet  it  oftener  than  in  1  case  in  20.  Its  infrequency  has  been 
attributed  to  the  fact  that  only  one  kidney  or  only  portions  of  the  kidneys 
have  been  affected,  the  sound  portions  performing  suificiently  the  excretory 
function. 

Oertel  says  :  "  The  albuminuria  of  diphtheria  is  referable  to  many  causes, 
of  which  the  virus  circulating  in  the  blood  is  only  one.  Cardiac  failure, 
respiratory  difiiculty,  the  febrile  process,  are  adequate  for  the  production  of 
this  symptom.  The  kidneys  in  eases  where  albuminuria  has  been  present 
may  be  quite  normal,  or,  on  the  other  hand,  they  may  exhibit  varying 
degrees  of  parenchymatous  inflammation."  ^  The  two  common  causes  appear 
to  be  passive  congestion  of  the  kidneys,  as  of  other  organs,  occurring  during 
the  dyspncea  of  croup  or  from  heart-failure,  the  albumen  escaping  from  the 
over-distended  renal  veins,  and  parenchymatous  nephritis,  in  which  the  tubules 
contain  detached  and  disintegrating  epithelial  cells.  In  parenchymatous 
nephritis  granular  casts  are  commonly  present. 

As  regards  prognosis,  writers  agree  that  diphtheritic  albuminuria  in  itself 
does  not  tend  to  a  fatal  result  in  most  cases,  the  unaffected  portions  of  the 
kidneys,  as  stated  above,  being  sufficient  for  the  excretion  of  the  deleterious 
products,  especially  the  urea,  whose  retention  in  the  system  would  involve 
danger.  Therefore  Sanne  says  "  that  diphtheritic  albuminuria  is  an  epi- 
phenomenon  which  in  the  vast  majority  of  cases  remains  without  influence 
upon  the  course  of  the  disease."  But  cases  do  occur,  as  we  have  seen  by 
the  history  related  above,  in  which  fatal  albuminuria,  or  fatal  nephritis  pro- 
ducing albuminuria,  does  take  place  as  a  complication  or  sequel  of  diphtheria. 

Unruh  in  1881  -  expressed  the  opinion  that  the  albuminuria  of  diphtheria 
results  from  a  simple  transudation.  But  more  exact  microscopic  examina- 
tions show  that  it  is  only  in  cases  of  croupal  asphyxia  or  heart-failure  that 
that  degree  of  passive  renal  congestion  occurs  which  leads  to  a  transudation 

^  SjTiopsis  of  Oertel' s  monograph,  London  Lancet.  ^  Jahrb.  fur  Kinderheilk. 

23 


354  CONSTITUTIONAL  DISEASES. 

of  serum.  When  there  is  no  obstructed  respiration,  and  no  marked  weakness 
of  the  pulse,  the  albuminuria  is  a  result  and  symptom  of  infectious  nephritis. 
Prof.  Bouchard^  states  that  infectious  nephritis,  wherever  the  cause  or  source 
of  the  infection,  is  a  parenchymatous  nephritis.  Says  he  :  "  The  kidneys  are 
sometimes  augmented  in  volume  and  weight.  Their  capsule  has  the  ordinary 
appearance  and  adherence.  The  cortical  substance  appears  sometimes  gray- 
ish, sometimes  congested  and  sprinkled  with  whitish  tracts.  The  medullary 
substance  preserves  its  normal  aspect.  In  kidneys  thus  changed  microscopic 
pathological  anatomy  reveals  integrity  of  the  tubes  of  Henle,  catarrhal  change 
of  the  straight  tubes,  and  to  a  considerable  extent  of  the  convoluted  tubes. 
In  the  convoluted  tubes  the  epithelial  cells  remaining  in  place  are  swollen 

and  sodden  together.     The  cellular  mass  is  entirely  granular Not  only 

are  the  convoluted  tubes  obstructed  by  granular  cells,  but  they  are  filled  in 
some  points  by  colloid  matter  or  by  blood.  The  glomeruli  appear  healthy,  but 
we  have  seen  the  glomerular  capsule  distended  with  blood.  In  another  case 
Renaut  has  seen  it  distended  by  colloid  matter."  Brault'^  has  observed  in 
diphtheritic  albuminuria  intense  congestion  of  the  capillaries  of  the  tubules 
and  glomeruli,  altered  epithelial  cells,  and  transuded  blood-elements  indicative 
of  parenchymatous  inflammation. 

Paralysis. 

Another  very  important  symptom  and  sequel  of  diphtheria  is  paralysis. 
It  has  diagnostic  and  prognostic  value.  Writers  in  medicine  prior  to  the  six- 
teenth century  were  either  ignorant  of  diphtheritic  paralysis,  or  they  vaguely 
alluded  to  it  when  they  described  the  extreme  debility  which  sometimes 
accompanies  or  follows  diphtheria.  No  clear  and  certain  allusion  to  it  has 
been  discovered  in  medical  literature  until  near  the  close  of  the  sixteenth 
century.  According  to  Sanne,  Nicholas  Lepois  referred  to  it  in  1580,  and 
Miguel  Heredia  in  1690.  Ghisi,  in  a  letter  describing  the  epidemic  which 
occurred  in  Cremona  on  the  north  bank  of  the  river  Po  in  1747-48,  writes  of 
his  own  son,  who  had  paralysis  in  a  severe  form  following  diphtheria,  "  I  left 
to  nature  the  cure  of  the  strange  consequences which  had  been  re- 
marked in  many  who  had  already  recovered,  and  which  had  continued  for 
about  a  month  after  recovery  from  the  sore  throat  and  abscess.  During  this 
period  this  child  spoke  through  the  nose,  and  food,  particularly  that  which  was 
least  solid,  returned  through  the  nares  in  place  of  passing  down  the  gullet." 
In  France  also  diphtheritic  paralysis  began  to  attract  attention  at  or  about 
the  time  when  Ghisi  in  Italy  wrote  the  above.  Chomel  in  1748  described 
two  eases,  following  what  he  designated  gangrenous  sore  throat.  The  first 
patient,  he  says,  had  not  quite  commenced  convalescence  at  the  forty-fifth  day 
of  the  disease,  having  still  difiiculty  in  articulating,  speaking  through  the 
nose,  and  having  the  uvula  pendulous.  In  the  second  case  the  patient 
became  squint-eyed  and  deformed,  but  day  by  day  as  his  strength  returned 
he  regained  his  natural  appearance. 

In  America,  in  1771,  Dr.  Samuel  Bard,  of  New  York,  also  related  a  case 
of  this  form  of  paralysis  :  A  girl  of  two  and  a  half  years  had  recovered  from 
a  diphtheritic  sore  throat,  and  a  diphtheritic  pseudo-membrane  upon  the  skin 
following  the  application  of  a  blister  had  disappeared,  when  her  convalescence 
was  retarded  by  paralytic  symptoms.  ''  Whenever,"  says  Bard,  "  she  attempted 
to  drink  she  was  seized  with  a  fit  of  coughing,  yet  she  was  able  to  swallow 
solid  food  without  any  difiiculty.  She  improved,  but  in  the  second  month  she 
could  scarcely  walk  or  raise  her  voice  above  a  whisper." 

From   the  time  of  Chomel.   Ghisi,  and  Bard   more  than  half  a  century 

^ Bevue  de  Medecine,  1881.  '^Jour.  d'Anat.  et  de  Phys.,  Nov.,  1880. 


DIPHTHERIA.  355 

elapsed  during  which  diphtheritic  paralysis  attracted  little  attention,  though 
Jurine  and  Albers  alluded  to  it  in  1809.  It  cannot  be  doubted  that  cases 
occurred  in  this  long  period  wherever  diphtheria  prevailed,  but  it  might  have 
been  of  such  a  type  that  the  paralysis  was  infrequent,  for  Bretonneau,  al- 
though he  was  familiar  with  Ghisi's  and  Bard's  writings,  did  not  recollect 
that  he  had  seen  a  case  of  diphtheritic  paralysis  prior  to  1843.  Although  a 
close  observer  of  diphtheria,  the  paralysis  had  not  been  observed  by  him,  or 
at  least  had  not  attracted  his  attention,  until  it  occurred  in  the  person  of  his 
townsman,  Dr.  Turpin,  in  1843.  Twelve  years  subsequently,  in  1855,  Bre- 
tonneau had  made  a  sufficient  number  of  observations  to  convince  him  that 
diphtheria  frequently  gave  rise  to  a  peculiar  form  of  paralysis,  and  in  his 
writings  of  this  year  he  called  the  attention  of  physicians  to  this  fact.  But 
the  opinions  expressed  by  the  eminent  physician  of  Tours  did  not  gain  gen- 
eral acceptance  until  his  friend  and  admirer.  Trousseau,  at  first  distrustful  of 
the  existence  of  such  a  paralysis  had  made  a  series  of  observations  which 
fully  established  in  his  mind  the  theory  of  Bretonneau.  His  remarks  on  this 
subject,  published  in  his  Treatise  on  Clinical  Medicine,  are  interesting,  as 
showing  how  gradually  important  truths  are  revealed  in  medicine.  He  had 
seen  as  far  back  as  1833  a  marked  case  in  the  service  of  Recamier  in  the 
Hotel-Dieu,  and  another  equally  severe  and  typical  case  in  1846,  but  it  was 
a  long  time  before  he  recognized  this  ailment  as  one  of  the  eifects  of  the 
diphtheritic  poison.  Says  he,  speaking  of  the  cases  seen  in  1833  and  1846 : 
"  They  were  a  dead  letter  to  me,  yet  I  was  acquainted  with  the  case  described 
by  Dr.  Turpin  of  Tours.  Bretonneau  related  it  to  me,  and  said  that  it  was 
a  case  of  diphtheritic  paralysis.     The  statement  seemed  to  me  incredible.     I 

refused  to  see  anything  more  in  the  case  than  a  coincidence It  was 

not  till  about  the  year  1852  that,  enlightened  by  new  cases  better  studied 
and  better  interpreted,  I  understood  diphtheritic  paralysis  as  Bretonneau 
understood  it.  From  this  time,  whenever  an  opportunity  occurred,  I,  in  my 
turn,  called  the  attention  of  my  colleagues  to  this  important  subject."  The 
•clinical  teachings  and  observations  of  Bretonneau  and  Trousseau  were  widely 
read,  and  the  profession  throughout  the  world  soon  recognized  the  fact  that 
diphtheria  often  gives  rise  to  a  form  of  paralysis  which,  if  not  peculiar  to  it, 
is  yet  rare  in  other  infectious  diseases.  Since  these  observations  of  Trous- 
seau were  published,  many  others  have  been  made  and  many  mono- 
graphs on  diphtheritic  paralysis  have  been  written  by  such  men  as  Roger, 
Oerniain  See,  Herman  Weber,  Charcot  and  Vulpian,  Gubler,  Landouzy.  Suss, 
H.  von  Ziemssen,  A.  Jacobi,  and  W.  H.  Thomson.  But  the  nature  of  the 
paralysis  and  the  manner  in  which  it  occurs  are  still  undetermined.  The  fact 
that  there  is  such  a  paralysis  was  slow  in  gaining  acceptance  in  the  minds  of 
physicians,  and  so  the  cause  and  pathology  of  the  paralysis  are  still  not  fully 
ascertained. 

Clinical  History. — The  statistics  of  different  writers  vary  in  regard  to 
the  frequency  of  diphtheritic  paralysis.  Probably  it  is  different  in  different 
epidemics,  and  some  observers  may  overlook  the  milder  cases,  which  soon  re- 
cover, and  which  are  indicated  by  a  slight  impediment  in  swallowing  and  a 
slight  nasal  intonation  of  the  voice.  We  may  accept,  as  approximating  the 
truth  as  regards  its  frequency,  the  following  statistics  of  well-known  and 
painstaking  clinical  instructors,  who  would  be  likely  to  detect  the  mildest 
forms  of  paralysis.  In  937  diphtheritic  cases  observed  by  Cadet  de  Gassi- 
court,  paralysis  occurred  in  128;  16.6  per  cent,  of  Roger's  cases  of  diph- 
theria had  paralysis,  and  11  per  cent,  of  Sanne's  cases. 

But  it  must  be  borne  in  mind  that,  since  paralysis  is  in  most  instances 
post-diphtheritic,  those  severe  cases  which  are  speedily  fatal  from  blood- 
poisoning  or  croup  do  not  live  long  enough  to  suffer  from  it,  and  such  cases 


356  COySTITUTIONAL  DISEASES. 

would  be  more  likely  to  have  the  paralysis,  if  they  lived,  than  the  milder 
cases  which  recover.  Hence  it  has  been  estimated  that,  if  all  diphtheritic 
patients  lived  sufficiently  long,  one  in  every  four,  or  even  one  in  every  three, 
would  exhibit  paralytic  symptoms. 

Time  op  Commencement.  —  In  most  instances  the  paralysis  does  not 
begin  until  the  period  of  apparent  convalescence  from  diphtheria  and  the 
pseudo-membrane  has  nearly  or  quite  disappeared.  Sanne  says  it  most  fre- 
quently appears  from  eight  to  fifteen  days  after  recovery,  the  limit  perhaps 
extending  to  thirty  days,  but  he  adds  that  it  may  appear  from  the  fifth  to 
the  eleventh,  and  even  as  early  as  the  second  or  third  day  of  diphtheria. 
Cadet  de  Gassicourt  states  that  in  twenty  of  his  cases  the  paralysis  began 
before  the  disappearance  of  the  pseudo-membrane,  most  frequently  about  the 
seventh  or  eighth  day  of  diphtheria.  In  two  it  commenced  on  the  third  day, 
and  once  in  a  prolonged  diphtheria  it  began  as  late  as  the  thirty-fifth  day,  the 
pseudo-membrane  still  being  present.  Usually,  according  to  my  observations, 
when  paralysis  follows  diphtheria  the  nasal  voice  and  some  impediment  in 
swallowing  are  observed  early  in  the  stage  of  convalescence,  and  at  a  later 
period  muscles  remote  from  the  fauces  may  or  may  not  be  afiected.  Dr.  L.  E. 
Holt  exhibited  to  the  New  York  Clinical  Society  in  December,  1887,'  a  child 
of  two  years  who  had  diphtheria  in  August  and  a  second  attack  in  the  middle 
of  October.  She  convalesced  slowly,  and  in  her  convalescence  had  no  paralytic 
symptoms,  except  a  nasal  voice,  until  December  1,  when  multiple  paralysis 
suddenly  developed.  A  brother  of  this  patient  also  had  diphtheria  in  October, 
moderately  severe,  and  early  in  convalescence  paralysis  of  the  muscles  of  the 
palate  began,  followed  by  that  of  other  muscles,  but  it  was  not  until  the 
middle  of  December  that  the  lower  extremities  were  paralyzed.  These  cases 
are  examples  of  the  usual  mode  of  commencement  and  extension  of  the 
paralysis. 

Diphtheritic  paralysis  is,  therefore,  with  few  exceptions,  a  late  symptom 
of  diphtheria  or  a  sequel ;  but  Dr.  Boissarie^  has  related  cases  in  which  the 
paralysis  was  not  preceded  by  the  ordinary  synjptoms  of  diphtheria,  and 
which,  so  far  as  I  am  aware,  are  unique.  An  ofiicer  in  the  police  had  been 
ailing  two  or  three  days  ;  he  had  a  nasal  voice  and  drinks  returned  through 
the  nose.  On  inspection  the  velum  palati  was  found  insensible  and  motion- 
less, but  the  fauces  were  otherwise  in  their  normal  state.  In  the  hospital 
alongside  the  barracks  in  which  the  above  case  occurred  a  young  man  without 
fever,  redness,  or  swelling  of  the  fauces  had  also  a  nasal  voice  and  return  of 
liquid  food  through  the  nose.  The  porter  of  the  hospital  was  similarly  aifected, 
and  the  doctor  stated  that  certain  other  patients  in  like  manner  presented 
symptoms  of  paralysis  without  the  history  of  an  antecedent  diphtheria.  Dr. 
Reynaud,  called  in  consultation,  expressed  the  opinion  that  the  paralysis  had 
a  diphtheritic  origin ;  and  this  opinion  was  strengthened  by  the  occurrence 
immediately  afterward  of  an  epidemic  of  diphtheria  in  the  place  where  these 
cases  occurred.  Since  paralysis  is  liable  to  occur  after  cases  of  diphtheria 
that  have  been  very  mild,  as  well  as  after  those  of  a  severe  type,  it  is  prob- 
able that  these  patients  have  had  diphtheria  of  so  mild  a  type  that  it  was 
overlooked. 

The  paralysis,  as  a  rule,  affects  both  motor  and  sensory  nerves.  Thus  in 
paralysis  of  the  velum  and  pharnyx  anassthesia  more  or  less  marked  occurs 
of  the  velum,  the  isthmus  of  the  fauces,  and  the  walls  of  the  pharynx,  in 
addition  to  the  motor  paralysis.  In  the  more  severe  cases  anaesthesia  with 
absence  of  reflex  action  occurs  not  only  over  the  entire  pharynx,  but  also 
over  the  epiglottis.     The  combination  of  motor  and  sensory  paralysis  should 

'  New  York  Medical  Journal,  Dec,  1887.  ^  Gazette  hebdomadaire,  1881. 


DIPHTHERIA.  357 

be  borne  in  mind  in  studying  the  cause  and  nature  of  the  ailment.  The 
muscles  affected  by  diphtheritic  paralysis  atrophy  as  in  other  forms  of 
paralysis.  Dr.  H.  von  Ziemssen^  says  that  such  marked  atrophy  does  not 
occur  in  any  other  disease,  except  in  acute  poliomyelitis  and  saturnine 
paralysis. 

The  symptoms  and  course  of  diphtheritic  paralysis  vary  according  to  its 
location  and  the  muscles  affected.  Therefore  we  will  sketch  the  clinical  his- 
tory of  its  various  forms  separately,  beginning  with  that  which  is  first  in  time, 
most  frequent,  and  least  dangerous  : 

1.  Loss  of  the  Tendon  Reflexes. — In  1882,  Dr.  Buzzard  made  the  obser- 
vation that  the  knee-jerk  is  absent  in  cases  of  diphtheritic  paralysis.  Bernhardt 
stated  that  loss  of  knee-jerk  may  precede  other  nervous  symptoms,  or  may  occur 
without  other  symptoms  indicating  impairment  of  the  nervous  system.  He  also 
stated  a  fact,  now  generally  admitted,  that  the  loss  of  knee-jerk  may  have  diag- 
nostic value  in  indicating  the  diphtheritic  nature  of  a  pre-existing  obscure  disease. 
But  the  profession  in  this  country  had  little  knowledge  of  the  loss  of  the  tendon 
reflexes  in  diphtheria  until  Prof.  R.  L.  McDonnell  of  the  Montreal  General  Hos- 
pital read  a  paper  on  this  subject  before  the  Canada  Medical  Association,  August 
31,  1887,  and  published  it  in  the  Medical  News  of  Philadelphia  in  the  following 
October.  Dr.  McDonnell's  observations  relate  to  18  cases  of  diphtheria  admitted 
into  the  General  Hospital.  Of  these  18  patients,  10  had  loss  of  knee-jerk  at  the 
time  of  admission,  while  in  the  remaining  8  it  was  present.  The  cases  observed 
by  the  doctor  were  sufficient,  he  believed,  to  enable  him  to  make  the  following 
statement :  Knee-jerk  in  many  cases  of  diphthe^'ia  is  absent  from  the  very  first 
day  of  the  illness.  It  is  a  noteworthy  fact  that  in  most  of  the  cases  detailed  by 
McDonnell  in  which  there  was  loss  of  the  tendon  reflex  other  forms  of  paralysis 
subsequently  appeared. 

Since  the  publication  of  Dr.  McDonnell's  paper  many  observations  have  been 
made  confirmatory  of  his  statement.  At  a  meeting  of  the  New  York  Clinical  Soci- 
ety, held  December  23,  1887,  Dr.  L.  E.  Holt  exhibited  a  brother  and  sister  of  five 
and  two  years  with  multiple  paralysis  who  had  lost  the  knee-jerk,  and  the  exami- 
nation of  one  of  them  showed  complete  loss  of  the  plantar  reflex.  Since  the  atten- 
tion of  the  profession  has  been  directed  to  the  loss  of  the  tendon  reflexes,  all  observers 
admit  that  it  is  not  only  the  earliest,  but  also  the  most  frequent,  of  the  paralytic 
symptoms,  probably  occurring  in  one-third  to  one-half  of  all  cases  under  treatment. 
Dr.  Angel  Money,  in  a  discussion  before  the  London  Clinical  Society,  September, 
1887,  stated  that  he  had  observed  an  initial  increase  of  the  knee-jerk  preceding  its 
abolition.  Dr.  H.  von  Ziemssen  remarks  that,  while  the  tendon  reflexes  are  so  often 
lost,  the  cutaneous  reflexes  are  frequently  exaggerated. 

The  loss  of  the  tendon  reflexes,  while  it  is  the  first  in  time  of  the  paralytic  symp- 
toms, appears  also  to  have  the  longest  duration.  In  cases  of  multiple  paralysis  it 
seems  to  be  the  last  to  disappear.  Thus,  Dr.  McDonnell  states  that  the  loss  of  knee- 
jerk  in  a  boy  of  fourteen  years  continued  four  months,  and  in  his  two  sisters  it  was 
still  present  when  all  other  symptoms  of  the  disease  had  disappeared. 

2.  Palatal  Paralysis. — With  the  exception  of  the  loss  of  the  tendon  reflexes 
the  most  common  form  of  diphtheritic  paralysis  is  that  in  which  the  velum  palati 
and  muscles  of  the  pharynx  are  affected.  This  form  of  paralysis  is  revealed  by  a 
nasal  intonation  of  the  voice,  slow  speech,  snoring  during  sleep,  difficult  deglutition, 
and  return  of  liquids  through  the  nares.  As  the  paralysis  increases  in  severity  and 
extent,  and  the  palato-glossus  and  constrictor  muscles  of  the  pharynx  become  para- 
lyzed, the  difficulty  in  swallowing  increases.  The  patient  finds  it  necessary  to  throw 
his  head  backward  in  swallowing  and  to  swallow  slowly  and  in  small  amount.  The 
food  descends  in  the  oesophagus  by  its  weight,  and  with  but  little  aid  from  the 
pharyngeal  muscles.  On  examining  the  fauces  we  discover  the  velum  relaxed  and 
motionless,  and  the  uvula,  deprived  of  its  tonicity,  drops  on  the  base  of  the  tongue. 
On  touching  the  uvula  with  the  point  of  a  pen  or  pencil  it  is  found  to  be  insensible, 
no  reflex  action  occurring.  Sensory  paralysis  occurs,  as  a  rule,  in  typical  cases, 
the  patient  experiencing  no  pain  when  the  parts  are  pricked  with  a  pin  or  other 
instrument.  The  fauces  should  be  inspected  and  tested  from  day  to  day  in  order 
to  determine  the  progress  of  the  paralysis.     In  mild  cases  it  may  be  limited  to  the 

^  Klinische  Vortrdge,  1887,  No.  iv.  ^  Virchow's  Archiv,  Bd.  xcix. 


358  CONSTITUTIONAL  DISEASES. 

velum  and  palate,  but  it  frequently  extends  to  the  epiglottis  and  upper  part  of  the 
larynx,  so  that  in  attempting  to  swallow  portions  of  the  food  enter  the  larynx,  excit- 
ine  a  cough.  The  affected  muscles  may  regain  their  use  in  less  than  a  week,  but 
frequently  from  one  to  two  months  elapse  before  their  function  is  restored. 

Palatal  paralysis  terminates  favorably  with  few  exceptions  if  the  patients  are 
otherwise  in  good  condition,  but  if  there  be  much  prostration  from  the  antecedent 
diphtheria  and  from  the  dysphagia,  death  may  occur  from  inanition.  Cadet  de 
Gassicourt  has  cited  two  cases  of  death  from  this  cause,  although  life  was  probably 
prolonged  by  feeding  by  means  of  an  oesophageal  tube  introduced  through  the  nos- 
trils. Rarely,  also,  death  has  occurred  from  the  descent  of  food  into  the  air-passages 
and  the  plugging  of  a  bi'onchus.  Tardieu  and  Peter  have  each  related  a  case  of 
this  mode  of  death.  As  a  chief  function  of  the  velum  palati  is  to  close  the  posterior 
nasal  fossas  during  deglutition,  food,  especially  if  liquid,  is  liable  to  be  returned 
through  the  nostrils  until  the  function  of  the  velum  is  restored. 

3.  Multiple  Paralysis. — This  form  of  paralysis  is  commonly  preceded  by 
loss  of  the  tendon  reflexes.  In  most  instances  it  begins  with  loss  of  power  in  the 
muscles  of  the  palate,  but  exceptions  occur  Cases  are  reported  in  which  the  mus- 
cles of  the  eye,  those  of  motion  and  of  accommodation,  are  first  paralyzed,  the  pal- 
atal muscles  being  unaffected  or  subsequently  attacked.  Trousseau  has  stated  that 
in  cutaneous  diphtheria  the  fii'st  loss  of  muscular  power  is  sometimes  in  the  lower 
extremities  instead  of  in  the  palate  :  and  other  observers  have  recorded  cases  in 
which  multiple  paralysis  commenced  in  one  or  more  of  the  extremities.  Therefore 
the  order  of  the  paralytic  seizures  differs  in  different  cases,  and  muscles  are  affected 
in  one  patient  that  escape  in  another.  The  degree  of  paralysis  varies  in  different 
muscles.  In  some  the  loss  of  power  is  complete,  while  in  others  it  is  partial.  When 
the  lower  extremities  are  entirely  motionless  the  patient  frequently  has  considerable 
use  of  the  upper  extremities. 

Even  in  the  severest  cases  many  groups  of  muscles  entirely  escape.  Therefore 
I  prefer  the  term  multiple  paralysis  to  the  term  general  paralysis  employed  by  some 
writers  to  designate  this  form  of  the  disease. 

Trousseau  speaks  of  what  he  designates  the  mutability  of  diphtheritic  paralysis. 
He  says  the  paralysis  which  occupies  one  limb  disappears  in  this  limb  to  manifest 
itself  in  another.  ''  The  numbness,  for  example,  which  the  patient  has  been  experi- 
encing in  one  leg  will  suddenly  cease,  and  become  greater  in  the  other  leg.  To-day 
the  right  hand  will  not  give  a  dynamometric  pressure  of  more  than  ten  to  twelve 
kilogrammes,  and  to-morrow  its  power  will  have  augmented,  while  that  of  the  left 
will  have  diminished ;  then  the  parts  which  were  first  affected  are  a  second  time  at- 
tacked and  become  more  affected."  Even  the  dysphagia  may  vary  on  different  days, 
as  Cadet  de  Gassicourt  has  stated.  He  relates  the  case  of  a  child  of  three  and  a  half 
years  in  whom  the  velum  palati  suddenly  resumed  its  function  :  the  head,  which 
had  dropped  from  paralysis  of  the  muscles  of  the  neck,  became  erect,  the  patient 
was  able  to  sit,  and  the  upper  extremities  recovered  their  power,  but  the  improve- 
ment was  of  short  duration,  the  paralysis  returning  as  at  first.  These  sudden  and 
unexplained  variations  in  the  degree  of  paralysis  resemble,  says  Trousseau,  the 
mutability  of  paralysis  in  hysteria.  Among  the  most  noteworthy  of  the  paralyses 
resulting  fi-om  diphtheria  are  those  pertaining  to  the  eye.  The  media  and  retina 
are  unaffected,  but  the  levator  palpebrae,  the  muscles  of  accommodation,  and  the 
motor  muscles  of  the  eye  are  paralyzed  in  certain  patients,  so  as  to  cause  dropping 
of  the  eyelids,  strabismus,  and  indistinct  vision.  In  addition  to  the  muscles  already 
mentioned,  various  muscles  of  the  trunk,  of  the  neck,  the  sphincter  ani,  and  the 
sphincter  vesicae  are  sometimes  paralyzed,  producing  deformity  and  incontinence  of 
urine  and  feces.  The  paralysis  of  the  muscles  of  accommodation  is  usually  such 
that  patients  become  presbyopic,  seeing  distinctly  distant,  but  not  near,  objects. 

The  muscles  of  the  face  are  also  occasionally  paralyzed.  Many  observers  have 
related  cases  of  facial  hemiplegia.  When  general  paralysis  of  the  facial  muscles 
occurs — fortunately,  a  rare  event — whatever  the  mental  state,  however  great  the 
excitement,  the  features  are  entirely  devoid  of  expression  ;  the  aspect  is  dull  and 
idiotic  ;  the  face  is  flabby  and  motionless  ;  the  lids  and  lips  droop  ;  saliva  flows  from 
the  mouth  ;  and  speech  is  slow  and  difficult.  At  the  same  time,  the  mental  faculties, 
though  deprived  of  the  usual  mode  of  expression,  are  sound  and  active. 

But  the  most  accurate  idea  of  the  symptoms  of  multiple  paralysis  can  be 
imparted  by  the  narration  of  a  case,  and  I  select  for  this  purpose  the  graphic  de- 
scription of  this  form  of  paralysis  published  by  Dr.  C.  W.  Fallis  in  the  Medical 


DIPHTHERIA. 


359 


Summary  for  January,  1888.  He  describes  the  ailment  as  it  occurred  in  his  own 
person,  as  follows  :  "  About  three  weeks  after  the  subsidence  of  the  disease  [diph- 
theria] the  paralytic  symptoms  began  to  show  themselves.  Impaired  vision  was 
the  first  trouble  noticed,  inability  to  accommodate  the  eyes  to  near  objects,  and  in 
taking  up  the  paper  to  read  one  morning  I  found  I  could  scarcely  see  a  word,  and 
soon  after,  although  distant  objects  could  be  seen  as  well  as  ever,  high-power  glasses 
were  required  to  read  any  kind  of  print.  Double  vision  was  noticed  afterward.  At 
about  the  same  time  numbness  of  the  tongue  was  felt ;  the  muscles  of  deglutition 
became  paralyzed,  so  that  swallowing  was  attended  with  strangling  and  regurgita- 
tion of  food  through  the  nose.  There  was  a  rapid  pulse,  120  to  the  minute,  show- 
ing that  the  pneumogastric  was  involved.  Weakness  of  the  limbs,  causing  a  stag- 
gering gait,  appeared ;  fingers  became  weak  and  numb,  so  that  small  objects  could 
not  be  picked  up,  the  symptoms  becoming  worse  and  worse  as  tlie  disease  progressed. 
The  muscles  of  the  left  side  of  the  face  became  afi'ected  with  all  the  symptoms  of 
facial  paralysis  from  organic  diseases.  Motion  became  more  and  more  impaired, 
till  I  could  neither  stand  nor  walk,  and  when  at  the  worst  I  was  perfectly  helpless, 
could  not  feed  myself,  had  to  be  lifted  from  chair  to  chair,  turned  in  bed,  and  could 
not  even  lift  my  hand  to  my  head  or  throw  one  limb  over  the  other.  Sensation  was 
so  impaired  that  hands  and  feet  felt  like  lifeless  weights,  and  in  the  dark  I  could  not 
tell  whether  my  feet  were  on  the  floor  or  not.  The  muscles  of  respiration  were  at 
no  time  affected  to  such  an  extent  as  to  render  breathing  difiicult,  and  the  power  of 
perfect  speech  was  retained.  Paralysis  of  the  bowels  necessitated  the  use  of  warm- 
water  injections  to  promote  their  action.  Some  of  the  symptoms  abated,  while 
others  became  more  aggravated,  those  first  to  appear  being  generally  the  first  to 
subside  :  however,  the  smaller-sized  muscles  recovered  rapidly,  while  the  large 
fleshy  ones  were  more  tardy  in  reaching  their  normal  state,  the  facial  paralysis  last- 
ing but  a  few  days,  while  locomotion  was  either  labored  or  impossible  for  many 
weeks.  The  course  of  the  disease  from  the  beginning  to  the  worst  stage  was  about 
nine  weeks,  when  it  remained  stationary  for  two  weeks.  Improvement  was  at  first 
very  slow  and  tedious,  but  after  I  could  walk  a  little  it  was  much  more  rapid,  and 
by  the  fifteenth  week,  with  the  exception  of  some  weakness,  I  was  well.'" 

Multiple  paralysis  not  infrequently  continues  from  two  to  six  months.  As 
might  be  expected,  the  prognosis  is  less  favorable  when  the  paralysis  is  multiple 
than  when  it  is  restricted  to  the  velum  and  pharynx.  In  13  cases  observed  by 
Cadet  de  Gassicourt,  6  died. 

4.  Cardiac  Paralysis  (the  cardio-pulmonary  jyaralysis  of  certain  French 
writers). — In  cases  of  the  first,  second,  and  third  forms   of  paralysis  which  have 

been  considered  above  the  vital  organs 
Fig.  47.  are  not  directly  involved.     These  paral- 

•V  '     '  -v..  Fig.  48. 


Diphtheritic  paralysis.  Fibres  from 
a  paralyzed  muscle."  Recent  prepara- 
tion.   Granular  and  fatty  degeneration. 


Changes  in  the  fibres  of  the  anterior  roots, 
piero-carmine  preparations.  {After  Meyer, 
Virchow's  Archiv,  Bd.  85.) 

a,  overgrowth  of  the  protoplasm  and  nuclei 
of  the  sheath ;  the  axis-cylinder  is  continu- 
ous, although  tlie  medullary  sheath  is  inter- 
rupted for  a  short  distance. 

6,  accumulation  of  granule  masses,  in 
places  interrupting  the  axis-cylinder,  frag- 
ments of  which  can  be  seen  between  the 
globules  of  myelin. 

e,  a  fibre  in  which  the  degenerating  white 
substance  ceases  suddenly,  leaving  the  axis- 
cylinder  only  covered  with  the  thickened 
sheath. 


360 


CONSTITUTIONAL  DISEASES. 


yses.  however  inconvenient  they  may  be,  are  not  directly  fatal.  The  paralysis  which 
we  are  about  to  consider  presents  a  very  different  clinical  aspect,  inasmuch  as  the 
organs  affected  are  among  the  most  important  in  the  system,  a  serious  impairment 
of  their  functions  rendering  death  inevitable. 

Physicians  who  have  had  experience  in  the  treatment  of  diphtheria  have  met 
cases  in  which  symptoms,  usually  of  sudden  development,  indicated   dangerous 

Fig.  49. 


Interstitial  and  parenchymatous  changes  in  the  phrenic  nerve :  osmie  acid  preparations. 
(Mever,  loc.  cit.) 

The  three  separate  fibres  show  degeneration  of  the  nerve-flbres  (segmentation  of  tlie  myelin, 
etc.).  with  some  increase  of  the  nuclei. 

The  lower  ^roup  of  fibres  is  from  one  of  the  nodular  swellings  on  the  same  nerve,  and 
shows,  in  addition  to  degeneration  of  the  fibres,  considerable  increase  in  the  interstitial  tissue. 

heart-failure.  Perhaps  the  patient  has  been  gradually  impi'oving,  the  pseudo- 
membrane  has  nearly  or  quite  disappeared,  the  temperature  is  not  far  from  normal, 
the  swallowing  is  better  and  more  nutriment  is  taken,  the  family  are  cheerful  in  the 
prospect  of  a  speedy  recover}',  and  the  physician  expects  soon  to  discharge  the 
patient  cured.  Suddenly  the  scene  changes.  The  pulse  becomes  feeble  and  ab- 
normally slow  or  rapid — it  is  usually  at  first  slow  and  subsequently  rapid — the 
respiration  is  superficial,  and  the  surface  becomes  pallid,  often  slightly  cyanotic.  In 
the  more  favorable  of  these  cases  the  patient  may  rally  by  active  stimulation,  and 
perhaps  he  eventually  recovers,  or  after  some  hours  or  a  day  of  comparative  com- 
fort he  succumbs  to  a  return  of  heart-failure.  There  is  no  other  disease  in  which 
these  sudden,  unforeseen,  and  fatal  attacks  of  heart-failure  occur  so  frequently  as 
in  diphtheria.  There  is  no  other  disease  in  which  physicians  are  so  frequently 
deceived  in  their  prognosis  for  various  reasons,  but  largely  on  account  of  the  occur- 
rence of  these  unexpected  attacks  of  heart-weakness. 

But  a  clear  and  accurate  idea  of  the  clinical  history  of  these  cases  of  sudden 
heart-failure  can  be  best  imparted  by  the  relation  of  typical  cases.  For  this  pur- 
pose I  will  briefly  narrate  cases  occurring  in  the  hospital  service  of  one  of  the  most 
trustworthy  clinical  teachers  of  the  present  time.  M.  Cadet  de  Gassicourt,  though  I 
believe  that  all  physicians  who  have  been  several  years  in  practice  where  diphtheria 
is  prevailing  can  recall  to  mind  cases  equally  striking  and  typical.  I  select  his 
cases  on  account  of  the  completeness  of  his  records  : 

A  child  of  tAvo  years  entered  Cadet  de  Gassicourt's  service  on  January  3d  with 
diphtheritic  pharyngitis  of  ten  days'  continuance.  The  tonsils  were  large,  still 
covered  with  pseudo-membrane,  and  the  submaxillary  glands  were  also  enlarged. 
He  had  no  laryngeal  symptoms  and  his  urine  was  without  albumen.  On  the  follow- 
ing day  the  velum  and  pharyngeal  muscles  were  slightly  paralyzed,  the  speech 
nasal,  and  deglutition  moderately  embarrassed.  He  was  quiet  during  the  night  of 
January  4th  and  in  the  morning  of  the  5th.  but  at  ten  a.  ji.  he  became  chilly,  his 
face  and  extremities  feebly  cyanotic,  and  slight  dyspnoea  and  dilatation  of  the  alse 
nasi  were  observed.      His  pulse,  at  first  abnormally  slow,  became   rapid  :  he  was 


DIPHTHERIA.  361 

agitated,  uttered  loud  screams  of  distress,  and  fell  back  cyanotic  and  dead.  The 
death-struggle  did  not  occupy  more  than  one  minute.  Another  infant,  also  two 
years  of  age,  entered  the  same  service,  having  diphtheritic  pharyngitis  of  two  days' 
continuance.  The  fauces  presented  the  usual  red  appearance,  the  tonsils  were 
swollen  and  covered  with  a  thick  exudate,  but  there  was  no  albuminuria  nor  croupi- 
ness.  Two  days  later  the  pseudo-membrane  had  diminished,  but  the  velum  palati 
was  paralyzed.  On  the  following  day  the  general  appearance  was  satisfactory  and 
the  pseudo-membrane  had  still  further  diminished.  At  eight  p.  m.  the  infant  was 
suddenly  seized  with  vomiting,  accompanied  with  great  dyspnoea,  rapid  pulse  (160), 
and  a  cyanotic  hue  of  the  face  and  extremities.  He  was  restless  and  uttered  cries 
of  distress.  Two  hours  later  he  screamed  loudly,  raised  himself  in  bed,  and  fell 
back  dead.  A  child  of  five  years  was  admitted  with  diphtheritic  pharyngitis  of 
two  days"  continuance,  having  enlarged  tonsils  covered  with  pseudo-membrane,  and 
enlarged  cervical  glands,  but  without  cough  or  albuminuria.  Seven  days  later, 
the  ninth  of  the  disease,  the  pseudo-membrane  had  disappeared,  but  the  velum 
palati  was  paralyzed.  On  the  following  day  there  was  little  change,  except  occa- 
sional vomiting,  but  the  general  state  was  good  and  sleep  tranquil.  At  seven  a.  m. 
on  the  following  day.  the  eleventh  of  the  disease,  after  a  calm  night,  the  child 
uttered  two  or  three  cries,  the  pulse  became  rapid,  the  respiration  embarrassed,  the 
features,  extremities,  and  finally  the  entire  surface,  cyanotic,  and  at  eight  a.  m. 
death  occurred  quietly. 

The  similarity  of  these  three  cases  is  apparent.  Paralysis  of  the  velum  and 
palate  had  continued  in  the  first  case  eighteen  hours,  in  the  second  case  thirty-six 
hours,  and  in  the  third  case  forty-eight  hours,  when  suddenly  the  heart  and  lungs 
were  greatly  embarrassed  in  their  functions,  and  death  occurred  within  one  hour 
from  the  commencement  of  the  severe  symptoms.  The  agitation,  repeated  cries  of 
distress,  and  the  shrill  cry  that  preceded  death  indicated  extreme  suifering. 

Severe  pain,  praecordial,  epigastric,  or  abdominal,  is  present  in  some  if  not  in 
most  of  these  cases  of  sudden  heart-failure,  as  we  shall  see  from  others  presently  to 
be  related.  It  was  probably  experienced  by  these  three  patients,  who  were  too 
young  to  express  clearly  the  subjective  symptoms. 

Gombault  made  a  minute  microscopic  examination  of  the  affected  organs  in 
these  three  cases  after  the  tissues  had  been  properly  hardened  by  chemical  agents. 
In  one  of  the  cases  he  examined  the  pneumogastrics  and  myocardium,  and  both 
were  found  in  their  normal  state.  As  regards  the  nervous  centres,  the  anatomical 
changes  were  alike  in  all  three.  In  the  spinal  cord  lesions  were  found  at  the  origin 
of  the  anterior  roots  of  the  spinal  nerves,  characterized  by  fragmentation  of  the 
medullary  substance  in  the  nerve-fibres,  numerous  granules  and  minute  globules 
appearing  in  this  substance  and  occupying  its  place. 

In  addition  to  this,  undue  swelling  of  the  axis-c^'linders  was  observed.  In  the 
three  cases  the  gray  substance  in  the  anterior  cornua  had  undergone  a  sort  of  rare- 
faction, the  microscopic  sections  being  more  transparent  and  the  elements  in  the  sec- 
tion being  wider  apart  than  in  the  normal  state.  Xo  meningitis  or  injury  of  the 
blood-vessels  was  observed  in  the  spinal  columns,  but  numerous  nerve-cells  wei'e 
deprived  of  their  prolongations.  The  medulla  oblongata,  the  centre  and  source  of 
the  nervous  supply  to  the  heart,  lungs,  and  stomach  through  the  pneumogastrics, 
was  also  carefully  examined  in  the  three  cases.  Nothing  abnormal  was  observed 
in  this  organ,  except  small  masses  of  leucocytes  in  the  vessels.  The  substance  of 
the  medulla  oblongata  and  the  nerve-fibres  constituting  the  roots  of  the  pneumo- 
gastrics seemed  healthy.  The  small  masses  of  leucocytes  in  the  blood-vessels  were 
not  sufBcient  to  obstruct  the  circulation,  and  the  appearance  of  the  blood-corpuscles 
was  normal.  Hence,  in  the  opinion  of  Gombault,  the  small  aggregations  of  leuco- 
cytes in  the  vessels  had  no  efl'ect  on  the  innervation  of  the  thoracic  organs  derived 
from  the  medulla.  The  points  of  special  interest  in  the  microscopic  examination 
of  the  three  cases  were  the  apparently  healthy  and  normal  state  of  the  pneumogas- 
trics and  myocardium  in  the  one  case  in  which  they  were  examined,  and  of  the  me- 
dulla oblongata  in  the  three  cases,  while  the  gray  matter  of  the  spinal  cord,  which 
has  no  immediate  nerve-connection  with  the  heart,  showed  marked  degenerative 
changes. 

The  above  are  striking  examples  of  sudden  and  fatal  heart-failure  occurring 
during  apparent  convalescence,  when  the  symptoms  of  diphtheria  appeared  to  be 
abating,  with  the  exception  of  the  paralysis  of  the  velum  and  palate.  The  follow- 
ing cases  presented  a  clinical  history  in  some  respects  different :   A  child  of  eight 


362  CONSTITUTIONAL  DISEASES. 

years  had  been  under  treatment  for  diphtheria  since  February  9,  1883.  On  Feb- 
ruary 20th  the  membrane  had  disappeared,  but  slight  paralysis  of  the  velum  and 
left  upper  extremity  was  observed,  and  the  urine  contained  a  little  albumen.  At 
three  p.  m.  she  was  seized  with  severe  abdominal  pains,  followed  by  vomiting,  slow 
respiration,  slow  and  feeble  but  regular  heart-beat,  imperceptible  pulse,  coolness  of 
surface,  and  cj^anosis.  These  symptoms  increased,  and  at  half-past  six  p.  m.  death 
occurred.  The  clinical  history  differed  from  that  in  the  three  cases  related  above  in 
the  fact  that  there  was  no  agitation  or  moaning  at  the  close  of  life,  and  that  the 
heart-beat  remained  abnormally  slow  unless  during  the  last  moments.  In  another 
case  paralysis  of  the  velum  and  palate  began  on  the  third  day  of  diphtheria,  while 
the  pharyngeal  and  nasal  inflammations  were  in  full  activity.  The  urine  was  slightly 
albuminous.  Three  days  subsequently,  in  the  morning,  the  muscles  of  the  nucha 
and  i-ight  shoulder  were  paralyzed.  At  two  p.  m.  the  child  complained  of  violent 
abdominal  pains,  followed  by  nausea  and  vomiting.  The  vomiting  was  partially 
relieved,  but  dyspnoea  and  a  rapid  heart-beat  followed.  The  cyanosis  increased  until 
it  extended  over  the  entire  surface,  and  death  occurred  three  hours  after  the  com- 
mencement of  symptoms  referable  to  heart-failure.  A  boy  of  five  years  had  diph- 
theritic croup,  for  which  tracheotomy  was  performed  and  the  canula  inserted.  lie 
subsequently  did  well  for  a  time,  but  afterward  lost  his  appetite.  On  the  eleventh 
day  of  the  disease  he  had  paralysis  of  the  velum  and  palate.  On  the  twelfth  and 
thirteenth  days  the  disease  seemed  to  be  stationary  and  the  child  was  quiet.  Sud- 
denly, at  seven  p.  m.  on  the  thirteenth  day,  multiple  paralysis  occurred.  An  hour 
later  the  muscles  of  the  nucha,  the  arms,  and  both  sides  of  the  trunk  were  paralyzed 
and  the  head  dropped.  At  seven  a.  m.  on  the  following  day  vomiting,  dj'spnoea, 
cyanosis  of  the  face  and  extremities,  and  a  very  rapid  pulse  occurred.  The  asphyxia 
increased,  the  pulse  grew  more  feeble,  the  surface  cool,  and  death  took  place  three 
hours  later. 

Cases  like  the  above  are  not  infrequent  in  severe  epidemics  of  diphtheria,  but  in 
some  instances  the  loss  of  power  in  the  heart  occurs  more  gradually.  A  boy  of 
twelve  years  had  diphtheritic  pharyngitis  from  which  he  was  apparently  convales- 
cing. Some  days  after  the  disappearance  of  the  inflammation  the  velum  palati  and 
muscles  of  the  pharynx  were  paralyzed.  Then  succeeded  paralysis  of  the  muscles 
of  the  nucha,  of  the  muscles  of  accommodation,  and  of  those  of  the  upper  and  lower 
extremities.  The  march  of  the  paralysis  was  for  a  time  progressive.  Then  it  seemed 
to  recede,  but  the  improvement  did  not  continue.  One  month  from  the  commence- 
ment of  diphtheria  the  child  uttered  plaintive  cries,  became  motionless  as  if  from 
general  paralysis,  and  a  state  of  asphyxia  slowly  occurred,  accompanied  by  cyanosis. 
During  the  following  night  the  patient  lay  in  a  stupor,  and  on  the  ensuing  morning 
the  features  presented  a  cadaverous  and  slightly  cyanotic  hue,  the  extremities  were 
cool  and  blue,  the  tongue  pallid,  moist,  and  of  a  normal  warmth,  the  respiration 
hurried  and  without  auscultatory  signs  of  disease,  the  pulse  feeble  and  rapid  (148). 
Finally,  the  sphincters  were  paralyzed,  the  urine  and  feces  escaping  involuntarily. 
Within  ten  minutes  after  the  above  notes  were  written  the  patient  died  of  cardiac 
paralysis.  The  feature  of  special  interest  in  this  case  was  the  long  continuance  of 
multiple  paralysis  when  the  cardiac  and  pulmonary  symptoms  occurred. 

Sudden  heart-failure  in  diphtheria  is  usually  fatal,  but  recovery  is  possible. 
Cadet  de  Gassicourt  in  his  large  clinical  experience  met  1  recovery  to  14  deaths. 
This  case  is  interesting,  since  the  heart-failure  preceded  the  palatal  and  other  forms 
of  paralysis,  instead  of  being  preceded  by  them,  as  is  ordinarily  the  case.  Twenty 
days  after  the  commencement  of  diphtheria,  and  when  in  apparent  convalescence, 
the  patient  was  seized  with  extreme  pain  in  the  praecordial  region,  attended  by  a 
fall  of  pulse  to  42.  He  had  cold  sweats,  rigors,  and  vomiting.  In  one  and  a  half 
hours  these  symptoms  abated.  Three  days  subsequently  another  similar  attack 
occurred,  and  subsequently  two  others,  but  less  severe  than  the  first.  On  the 
twenty-eighth  day  from  the  beginning  of  diphtheria  and  eight  days  after  the  syn- 
copal attacks  paralysis  of  the  velum  and  phaiynx  began,  soon  followed  by  paralj'sis 
of  the  vocal  cords,  of  the  muscles  of  accommodation,  and  of  those  of  the  extremities, 
which  continued  three  months,  when  recovery  was  complete.  Cases  of  recovery  from 
sudden  and  alarming  symptoms  of  prostration  have  also  been  related  by  Sanne, 
Billard,  and  others. 

AVhat  is  the  cause  of  this  sudden  loss  of  power  in  the  heart  in  diphtheria,  occur- 
ring usually  during  apparent  convalescence?  Does  it  result  from  disease  in  the 
muscular  structure  of  the  heart,  from  thrombosis  or  ante-mortem  clots  in  the  cavities 


DIPHTHERIA.  363 

of  the  heart,  or  does  it  result  frora  disease  of  the  central  organ  of  innervation,  the 
medulla  oblongata,  or  from  disease  and  deficient  conducting  power  in  the  important 
nerve  which  controls  the  heart's  action,  the  pneumogastric,  or  in  the  branches  which 
this  nerve  supplies  to  the  heart  as  well  as  the  lungs  and  the  stomach  ? — for  these 
three  organs  appear  in  most  instances  to  be  aifected  simultaneously. 

The  theory  of  MM.  Bouchut  and  Lagrave  which  attributed  sudden  heart-failure 
to  endocarditis  has  not  been  sustained  by  recent  observations,  and  does  not  appear 
to  be  tenable. 

Weakening  of  the  heart's  action  in  diphtheria,  with  sudden  death  as  a  conse- 
quence, has  with  more  probability  been  attributed  to  granulo-fatty  degeneration  in 
the  muscular  fibres  af  the  heart  consequent  upon  a  prolonged  and  severe  diphthe- 
ritic attack.  Oertel  says  :  '•  When  the  general  disease  lasts  long  and  is  very  intense, 
and  especially  in  cases  in  which  death  is  caused  suddenly  by  paralysis  of  the  heart, 
the  muscle  appears  pale,  soft,  friable,  broken  by  extravasations  of  blood,  and  on 
microscopical  examination  most  of  its  fibres  are  seen  to  be  in  an  already  advanced 
stage  of  fatty  degeneration."'^  Such  degenerative  changes,  if  occurring  in  a  con- 
siderable proportion  of  the  muscular  fibres  of  the  heart,  would  inevitably  render 
the  contractile  power  of  this  organ  feeble  and  perhaps  inadequate.  Still,  if  we 
regard  it  as  a  cause  of  sudden  heart-failure,  it  can  be  regarded  as  such  in  only  a 
relatively  small  number  of  instances,  for  in  most  cases  the  weakening  of  the  power 
of  the  heart  is  sudden  and  during  convalescence — at  a  period,  therefore,  when 
degenerative  changes  are  not  likely  to  occur.  In  most  of  the  recorded  cases  the 
contractile  power  of  the  heart  does  not  appear  to  have  been  notably  weakened  pre- 
vious to  the  attack  of  heart-failure,  as  it  would  probably  have  been  were  degenera- 
tive changes  in  the  myocardium  the  sole  or  chief  cause.  The  clinical  history  is  as 
if  the  heart  were  suddenly  overpowered  by  an  agent  of  rapid — never  slow — devel- 
opment. Moreover,  in  typical  cases  of  sudden  heart-failure  the  microscope  some- 
times reveals  a  healthy  myocardium,  as  in  one  of  the  cases  related  above.  We 
must  look,  therefore,  for  some  other  cause,  although  admitting  that  degenerative 
changes  in  the  muscular  fibres  of  the  heart,  when  present,  contribute  to  a  weakened 
action  of  this  organ. 

In  searching  for  the  cause  of  sudden  heart-failure  in  diphtheria  we  must  note 
the  fact  that,  as  a  rule,  in  typical  cases  it  is  preceded  by  palatal  and  often  multiple 
paralysis.  The  paralysis  has  continued  for  a  time,  extending  perhaps  from  one 
group  of  muscles  to  another,  when  suddenly  the  heart  passes  under  some  powerful 
influence  which  restricts  and  overpowers  its  action.  The  theory  of  deficient  inner- 
vation or  a  true  cardiac  paralysis  appears  most  tenable  under  the  circumstances. 
It  affords  the  most  satisfactory  explanation  of  those  unfortunately  not  infrequent 
cases  in  which  death  suddenly  occurs  during  apparent  convalescence  from  diphtheria, 
when  the  symptoms  are  fast  disappearing,  with  the  exception  of  the  palatal  or  other 
paralysis.  It  aifords  best  of  all  the  theories  an  explanation  of  the  occurrence  of 
sudden  death  from  heart-weakness  in  those  obscure  cases  which  have  puzzled  phy- 
sicians— cases  in  which  the  post-mortem  examination  has  revealed  an  apparently 
healthy  state  of  the  heart.  The  theory  of  an  arrested  or  deficient  innervation  of 
the  heart  also  furnishes  an  explanation  of  the  occurrence  of  concomitant  symptoms 
in  these  cases  of  sudden  heart-failure — such  symptoms  as  vomiting,  epigastric  pain, 
and  dyspnoea  or  irregular  respiration  ;  for  the  heart  derives  its  innervation  from  the 
same  source  as  the  lungs  and  the  stomach — that  is,  through  the  pneumogastric. 
For  the  reasons  now  given  we  feel  justified,  in  our  classification  of  the  forms  of 
diphtheritic  paralysis,  to  make  a  distinct  class  having  the  designation  cardiac 
paralysis,  or  to  adopt  in  our  language  the  French  expression,  cardio-pulmonary 
paralysis. 

Paralysis  :  Its  Cause. — The  four  forms  of  diphtheritic  paralysis — first. 
the  abolition  of  the  tendon  reflexes,  the  most  common,  the  earliest,  and  the 
least  dangerous  of  all ;  secondly,  palatal  paralysis,  which  may  occur  as  early 
as  the  third  day  of  diphtheria,  but  is  most  common  during  its  later  stages, 
or  in  the  period  of  convalescence ;  thirdly,  multiple  paralysis,  in  which 
various  muscles  throughout  the  system  are  paralyzed ;  and.  fourthly,  car- 
diac paralysis,  the  most   dangerous  of  all — probably  are   produced   by  the 

^  Ziemssen's  Oyelopcedia,  vol.  i. 


364  COXSTITUTIOXAL  DISEASES. 

same  cause  and  have  the  same  pathology  in  most  instances.  We  may,  there- 
fore, in  the  following  pages,  in  studying  the  cause  and  nature  of  diphtheritic 
paralysis,  regard  the  various  forms  which  it  exhibits  as  manifestations  of  one 
disease.  What  is  true  of  cardiac  paralysis  as  regards  its  cause  and  nature 
we  may  assume  to  be  true  in  reference  to  palatal  and  multiple  paralysis,  and 
even  the  abolition  of  the  tendon  reflexes.  The  most  dangerous  and  fatal 
paralysis,  the  cardiac,  is,  as  we  have  stated  above,  in  nearly  all  patients  asso- 
ciated with  the  milder  forms,  showing  that  the  same  cause  or  causes  are 
operative  at  the  same  time  in  the  individual. 

Crubler,  in  his  memoir  published  in  1860-61,  attributed  paralysis  of  the 
velum  and  palate  to  disease  of  the  terminal  nerves  produced  by  contiguity 
or  propagation  from  the  inflamed  fauces ;  and  he  held  that  the  same  injury 
of  the  nerves  and  paralysis  might  result  from  any  anginose  inflammation 
if  severe  enough.  But  this  theory  was  short-lived,  for  physicians  soon  per- 
ceived that  it  was  inadequate  to  explain  the  occurrence  of  paralysis  at  a 
distance  from  the  inflamed  surfaces :  and  palatal  paralysis  sometimes  occurs 
after  cutaneous  and  other  forms  of  diphtheritic  inflammation  in  which  both 
the  fauces  and  the  nares  have  entirely  escaped  and  remained  healthy. 

Trousseau,  impressed  with  the  inadequacy  of  Gubler's  theory,  directed 
his  attention  to  the  nervous  centres.  He  was  led  to  believe,  from  the  fact 
that  the  paralysis  usually  terminates  favorably,  and  because  in  certain  fatal 
cases  he  was  unable  to  discover  any  lesion  sufiieient  to  produce  the  paralysis 
in  the  brain,  spinal  cord,  or  meninges,  that  it  did  not  occur  from  any  struc- 
tural change  in  the  nervous  system.  Trousseau,  an  unsurpassed  clinical 
observer,  was  not  a  microscopist,  and  being  unable  to  discover  any  anatomi- 
cal cause  of  the  paralysis,  he  relates  the  case  of  the  crew  of  a  vessel  who 
were  paralyzed  by  eating  an  eel  which  contained  some  poisonous  ingredient, 
and.  after  alluding  to  instances  of  paralysis  resulting  from  smallpox,  typhoid 
and  typhus  fevers,  and  cholera,  continues  :  •'  Well.  then,  diphtheritic  paralysis 
belongs  to  the  same  category :  its  real  cause  is  the  poisoning  of  the  system 
by  the  morbific  principle  which  generates  the  malady  on  which  the  paralysis 
depends,  and  in  regard  to  the  mode  of  action  of  which  in  producing  the 
paralysis  we  shall  always  perhaps  remain  in  ignorance." 

Since  the  time  of  Trousseau  many  eminent  pathologists  have  endeavored 
to  discover  the  anatomical  characters  and  elucidate  the  nature  of  diphtheritic 
paralysis  by  patient  and  thorough  microscopic  examinations.  We  have  already 
detailed  the  microscopic  appearance  in  Cadet  de  Gassicourt's  three  memor- 
able cases.  In  1862,  Charcot  and  Yulpian  stated  that  they  had  examined 
the  nervous  filaments  in  the  velum  palati  paralyzed  by  diphtheria,  and  found 
certain  of  them  entirely  free  from  medullary  matter,  granular  bodies  occupy- 
ing its  place ;  but  partial  degeneration  is  more  common.  In  some  of  the 
fibres  the  medullary  matter  was  intact.  Lionville  in  1872  stated  that  he  had 
found  degenerative  changes  in  the  phrenic  nerve  of  a  patient  who  had  died 
of  asphyxia  following  an  attack  of  diphtheria.  The  contents  of  certain  of 
the  fibres  constituting  this  nerve  were  amorphous,  filled  with  granular  bodies 
instead  of  the  normal  nerve-substance.  Leyden  in  1872  discovered  lesions 
in  the  peripheral  nerves  and  in  the  central  organ  upon  which  he  based  his 
theory  of  an  ascending  neuritis.  Roger  and  Damaschino  in  1875  examined 
the  nervous  system  of  four  children  who  had  died  of  diphtheritic  paralysis, 
and  found  atrophy  of  the  nerve-fibres  in  the  peripheral  nerves.  The  medul- 
lary matter  appeared  granular  in  certain  points,  and  in  others  it  had  entirely 
disappeared,  while  the  axis-cylinder  was  not  notably  altered. 

Such  observations,  to  which  others  might  be  added,  have  fully  established 
the  fact  of  peripheral  nerve-lesions,  such  as  would  be  likely  to  result  from  a 
neuritis,  in  the  paralysis  of  diphtheria  ;  but  it  must  be  borne  in  mind  that 


DIPHTHERIA.  365 

the  various  observers,  while  they  report  degenerative  changes  in  certain  of 
the  nerve-fibres  or  tubes  in  the  peripheral  nerves  of  the  paralyzed  part,  also 
state  that  others  in  the  same  nerves  were  to  appearance  normal  and  capable 
of  performing  their  function.  Such  are  the  facts  upon  which  the  theory 
that  diphtheritic  paralysis  is  caused  by  peripheral  nerve-lesions,  a  peripheral 
neuritis,  is  based. 

Prognosis. — The  prognosis  of  diphtheria,  like  that  of  scarlet  fever,  varies 
greatly  in  different  cases  according  to  its  type.  In  some  epidemics  a  large 
proportion  of  the  cases  are  mild  and  recovery  occurs  with  simple  treatment. 
Between  the  mild  and  the  most  severe  cases,  attended  by  profound  blood- 
poisoning,  there  is  every  grade  of  severity.  Cases  that  are  apparently  mild 
in  the  beginning  and  seem  likely  to  recover  with  simple  measures  sometimes 
become  severe,  dangerous,  and  even  fatal.  On  the  other  hand,  cases  that  set 
in  with  severity  may  become  modified  and  end  favorably  with  simple  treat- 
ment. So  variable  is  the  type  of  diphtheria  that  in  certain  epidemics  or 
localities  a  large  proportion  recover,  as  many  even  as  90  or  95  per  cent., 
while  in  other  epidemics  or  localities  the  proportion  that  perish  is  much  larger. 

The  prognosis  is  usually  favorable  when  the  inflamed  surface  and  pseudo- 
membrane  are  of  little  extent,  the  fever  and  swelling  moderate,  and  the 
neighboring  lymphatic  glands  and  underlying  connective  tissue  but  little 
involved.  In  many  such  cases,  as  we  have  seen  from  the  description  given 
above,  the  patient  remains  in  good  general  health  or  feels  but  slightly  indis- 
posed. On  the  other  hand,  if  the  inflamed  surface  be  extensive,  the  pseudo- 
membrane  deep-seated  and  exhaling  an  ofi"ensive  odor,  while  the  adjacent 
lymphatic  glands  are  markedly  swollen,  the  patient  will  probably  perish. 
Nasal  diphtheria,  which  is  commonly  present  in  severe  cases,  and  which  pro- 
duces an  oifensive,  irritating,  and  highly  infectious  discharge,  always  involves 
great  danger.  It  is  likely  to  give  rise  to  systemic  infection,  since  the  sub- 
mucous connective  tissue  of  the  nostrils  contains  numerous  lymphatics,  which 
take  up  the  poisonous  products  and  convey  them  to  every  part  of  the  system. 
If,  while  the  local  disease  is  severe  and  extensive,  the  breath  and  exhalations 
become  off"ensive  and  the  countenance  and  surface  generally  begin  to  have  a 
dusky,  pallid  hue,  profound  blood-poisoning  has  occurred  and  the  patient  will 
probably  die. 

Physicians  of  experience  are  guarded  in  the  expression  of  a  favorable 
prognosis  in  diphtheria,  since  there  is  no  other  disease  in  which  the  prog- 
nostic signs  on  which  a  favorable  prediction  is  based  are  so  likely  to  be 
fallacious.  We  hear  much  in  medical  circles  of  the  deceptive  character  of 
diphtheria.  Errors  in  expressing  a  favorable  prognosis,  of  which  even  phy- 
sicians of  ample  experience  complain,  is  largely  due  to  the  fact  that  diphtheria 
terminates  fatally  in  several  difi'erent  ways.     Death  may  occur  from — 

1.  Diphtheritic  blood-poisoning — systemic  infection  by  the  diphtheritic 
toxine. 

2.  Septicfemia,  produced  by  absorption  from  the  under  surface  of  the 
decomposing  pseudo-membrane  or  from  gangrenous  tissues.  Very  commonly, 
in  addition  to  the  Klebs-Loefller  bacillus,  cocci  are  present,  which,  with  the 
toxines  generated  by  them,  enter  the  lymph-channels  and  blood-vessels  of 
the  neck.  Considerable  tumefaction  of  the  neck  therefore  seldom  occurs  in 
diphtheria  without  manifest  symptoms  of  septicaemia,  and  it  is  to  be  regarded 
as  a  sign  of  its  presence. 

3.  Diphtheritic  croup  or  pseudo-membranous  laryngo-tracheitis.  a  most 
important  disease,  and  fully  treated  of  in  the  proper  place. 

■1.  Uraemia  or  diphtheritic  nephritis,  also  one  of  the  most  important  of  the 
local  maladies  pertaining  to  diphtheria,  and  produced  by  the  action  of  the 
diphtheritic  poison. 


366  CONSTITUTIONAL  DISEASES. 

5.  Sudden  heart-failure.  The  action  of  the  heart  becomes  feeble  from 
cranulo-fatty  degeneration  of  its  muscular  fibres  and  degenerative  changes 
in  the  pneumogastric  and  in  the  gray  tracts  from  which  the  pneumogastric 
arises. 

G.  Suddenly-developed  passive  congestion  and  oedema  of  the  lungs,  prob- 
ably due  to  feebleness  of  the  heart's  action  or  to  paralysis  of  the  respiratory 
muscles.  Death  sometimes  occurs,  apparently  from  this  cause,  during  the 
period  of  supposed  convalescence  and  when  the  visits  of  the  physician  have 
been  discontinued.  Thus,  in  a  case  in  my  practice  symptoms  of  oedema  pul- 
monum  (abundant  moist  rales  in  both  sides  of  the  chest  and  embarrassed 
respiration)  suddenly  occurred  nearly  one  month  after  the  disappearance  of 
the  faucial  pseudo-membrane  and  inflammation.  The  urine,  which  had  con- 
tained considerable  albumen  during  the  active  period  of  the  malady,  had  for 
some  time  shown  no  trace  or  but  slight  trace  of  this  principle  by  the  proper 
tests.  By  active  stimulation  these  symptoms  entirely  disappeared  in  a  few 
hours,  and  the  heart's  action  seemed  normal,  except  that  it  was  a  little  weak- 
ened. On  the  following  day  the  symptoms  reappeared,  and  death  occurred 
before  I  was  able  to  reach  the  house. 

That  physician  is  obviously  least  likely  to  err  in  prognosis  who  recognizes 
the  fact  that  patients  are  liable  to  perish  in  any  of  these  different  ways,  and 
carefully  examines  in  reference  to  all  the  conditions  which  involve  danger. 
Many  physicians,  as  I  have  had  the  opportunity  to  observe,  are  remiss  in  not 
examining  more  frequently  the  urine  of  diphtheritic  patients  ;  for  there  is 
often  a  large  amount  of  albumen  with  granular  casts  in  the  urine  in  diph- 
theria, indicating  a  poisonous  quantity  of  urea  in  the  blood,  and  yet  the 
appearance  of  the  urine  to  the  naked  eye  is  normal. 

Among  the  symptoms  which  render  the  prognosis  unfavorable  are  repug- 
nance to  food,  vomiting,  pallor  of  countenance,  and  general  ansemia,  with 
progressive  weakness  and  emaciation,  indicating  blood-poisoning ;  a  large 
amount  of  albumen,  with  casts,  in  the  urine,  showing  uraemia,  to  which  the 
irritability  of  the  stomach  is  often  due  ;  an  abundant  irritating  discharge  of 
muco-pus  from  the  nostrils  or  occlusion  of  them  by  membranous  exudation 
or  inflammatory  thickening,  showing  that  the  Schneiderian  membrane  is 
seriously  involved  ;  hemorrhage  from  the  nostrils,  buccal  cavity,  or  fauces, 
showing  an  altered  state  of  the  blood  or  of  the  walls  of  the  capillaries,  or 
plugging  of  the  capillaries  by  masses  of  microbes  or  leucocytes.  Diphtheritic 
laryngo-tracheitis,  or  pseudo-membranous  croup,  largely  increases  the  aggre- 
gate of  deaths  from  diphtheria,  whether  it  be  treated  by  improved  inhalations, 
intubation,  or  tracheotomy.  Some  of  the  above  symptoms  have  been  present 
in  most  of  the  fatal  cases  which  I  have  observed.  On  the  other  hand,  the 
prospect  of  recovery  improves  in  proportion  to  their  absence. 

Preventive  Treatment. — Diphtheria  is  so  highly  contagious,  and  when 
epidemic  is  so  likely  to  spread  from  one  household  to  another,  and  its  severe 
forms  are  fatal  in  so  large  a  proportion  of  cases,  that  preventive  measures  are 
of  the  greatest  importance.  The  area  of  contagiousness  of  diphtheria  is  small. 
Dr.  Lancry  cites  cases  to  show  that  it  is  limited  to  a  few  feet.  Dumez  also 
relates  an  instance  showing  that  the  contagious  area  is  of  small  extent.  In 
a  school  the  boys  and  girls  on  the  same  floor  were  separated  by  an  open  space 
a  few  yards  wide.  Diphtheria  prevailed  among  the  girls,  but  did  not  affect 
the  boys.  In  this  respect,  as  in  so  many  others,  diphtheria  resembles  scarlet 
fever,  and  is  unlike  pertussis  and  measles. 

The  most  efficient  method  of  preventing  diphtheria  is  the  isolation  and 
disinfection  of  patients,  the  prompt  and  thorough  disinfection  of  the  apart- 
ments in  which  patients  have  been  treated  and  of  the  bedding  and  furniture 
in  these  apartments,  and  the  exclusion  or  prevention  of  all  noxious  gases. 


DIPHTHERIA.  367 

especially  those  ascending  from  the  sewers  and  from  filthy  accumulations  of 
all  kinds. 

Dr.  H.  B.  Baker  of  Michigan  has  published  statistics  showing  that  in  102 
outbreaks  of  diphtheria  the  average  number  of  cases  where  disinfection  and 
isolation,  one  or  both,  were  neglected  was  16,  and  the  average  deaths  3.26, 
while  in  116  outbreaks  in  which  isolation  and  disinfection  were  enforced  the 
average  number  of  cases  per  outbreak  was  2.86,  and  the  average  deaths  .QQ. 
Therefore  these  precautionary  measures  prevented  13  cases  and  2.57  deaths 
for  each  outbreak ;  in  the  total,  1545  cases,  298  deaths.  These  statistics 
relate  to  only  one  year.^ 

Loeffler  has  ascertained  in  his  experiments  with  the  Klebs-LoefHer  bacillus 
that  solutions  of  the  following  substances  in  the  strength  mentioned  are  suffi- 
ciently germicidal  to  sterilize  cultures :  corrosive  sublimate,  1  part  to  10,000 
or  even  15,000  ;  cyanide  of  mercury,  1  part  to  8000  or  10,000  ;  chlorine  water, 
1  part  to  1100  ;  thymol  1  part  to  500,  with  20  per  cent,  of  alcohol.  Loeffler 
advises  that  physicians,  nurses,  and  others  exposed  to  diphtheria  gargle  every 
three  or  four  hours  with  one  of  these  substances.  Frequent  bathing  of  the 
hands,  face,  and  head  with  a  disinfectant,  and  frequent  change  and  disinfec- 
tion of  the  clothes  worn  in  the  sick-room,  should  also,  says  Loeffler,  be  enjoined. 
G-raucher  of  Paris,  who  has  had  a  large  experience  in  the  treatment  of  diph- 
theria expresses  the  opinion  in  a  recent  paper  that  in  nearly  all  instances 
diphtheria  is  communicated  by  infected  articles  of  clothing  or  furniture.  He 
also  thinks  that  there  is  evidence  that  the  non-pathogenic  bacillus  often  pres- 
ent upon  the  healthy  buccal  surface  may,  under  exceptional  circumstances, 
become  pathogenic  so  as  to  cause  diphtheria.  Except  under  such  circum- 
stances, he  believes  that  the  spread  of  diphtheria  may  be  prevented  by  the 
prompt  and  thorough  disinfection  of  the  sick-room  and  infected  ai'ticles  and 
persons.  He  states  that  in  a  ward  set  apart  for  diphtheritic  patients  in  Paris, 
among  1741  admitted  during  a  series  of  years,  153  were  found  not  to  have 
diphtheria,  and  yet  by  the  disinfection  employed  not  one  of  them  contracted 
the  disease.  In  a  moist  atmosphere  the  Klebs-Loeffler  bacillus  is  killed  at  a 
temperature  of  60°  C.  (140°  F.),  but  in  a  dry  atmosphere  a  temperature  of 
at  least  98°  C.  (208°  F.)  is  required  to  destroy  it.  G-raucher  has  prevented 
the  spread  of  diphtheria  in  the  hospital  ward  by  the  following  prophylactic 
measures :  A  metallic  screen  surrounds  the  bed ;  all  articles  used  by  the 
patient,  as  spoons,  forks,  or  napkins,  are  disinfected  by  being  placed  in  boiling 
water  containing  sodium  carbonate,  1  ounce  (31  grammes)  ;  boiling  water  1 
pint  (480  grammes).  The  bedding  and  all  clothes  used  are  disinfected  by 
heat,  and  the  floor,  bedstead,  and  walls  are  washed  with  the  corrosive-sublimate 
solution.  Nurses  and  medical  attendants  wear  blouses  that  are  disinfected 
by  heat  each  day,  and  they  wash  themselves  with  a  solution  of  corrosive  sub- 
limate or  a  5-per  cent,  solution  of  carbolic  acid. 

That  the  schools  and  places  of  public  resort  for  children  are  largely  instru- 
mental in  disseminating  diphtheria,  and  that  the  action  of  Health  Boards 
compelling  the  non-attendance  at  school  of  children  living  in  domiciles  where 
diphtheria  is  prevailing,  is  not  only  fully  justified,  but  more  stringent  pre- 
cautionary measures  are  needed.  R.  T.  Thorne,  Lecturer  on  Public  Health 
at  St.  Bartholomew's  Hospital,  stated  in  his  third  lecture  on  diphtheria,  that 
at  Pirbright  each  time  the  schools  were  closed  diphtheria  practically  came  to 
an  end,  and  whenever  they  were  reopened  it  recommenced  suddenly  and  in  a 
fatal  form.  This  occurred  without  any  obvious  source  of  infection  although 
much  care  was  taken  to  detect  it. 

Clinical  observations  in  asylum  and  family  practice  justify  the  belief  that 
^  American  Lancet,      {^ee  Ann.   Univ.  3Ied.  Sci.,  1888.) 


368  CONSTITUTIONAL  DISEASES. 

the  following  prescription,  employed  for  purposes  of  disinfection,  has  been 
useful  in  the  treatment  of  diphtheria  as  well  as  of  scarlet  fever : 

R.  Acidi  carbolici, 

Ol.  eucalypti,  da.  31  (31  grammes).  ' 

Spts.  terebinthinse,  o"^iiJ  (^^^^  grammes). 

Add  two  tablespoonfuls  to  one  quart  of  water  in  a  tin  or  zinc  wash-basin  or  a  pan 
with  a  broad  surface,  and  maintain  a  constant  state  of  ebullition  or  simmering 
in  the  room  occupied  by  the  patient. 

A  vessel  with  a  broad  surface  is  required  for  the  purpose  of  producing  a  large 
amount  of  vapor,  and  to  prevent  ignition  of  the  turpentine,  which  has  occurred 
in  a  few  instances  when  my  directions  were  not  strictly  followed.  Observa- 
tion in  regard  to  the  use  of  this  vapor  thus  far  show  that  it  is  an  efficient 
germicide,  preventing  to  a  considerable  extent  the  propagation  of  the  disease 
to  others,  and  enabling  the  physician  to  visit  subsequent  patients  without 
risk  or  much  less  risk  of  communicating  diphtheria  through  his  infected  per- 
son or  clothing. 

In  a  paper  published  by  Charles  Smith  of  Australia,  the  use  of  this  vapor 
is  strongly  recommended,  not  only  as  a  prophylactic  but  curative  agent ;  but 
he  does  not  employ  it  in  the  manner  recommended  above.  He  prescribes 
what  he  designates  a  weak  mixture :  1  ounce  (31  grammes)  of  oil  of  euca- 
lyptus, 1  ounce  (31  grammes)  of  carbolic  acid,  and  8  ounces  (240  grammes) 
of  turpentine ;  or  a  stronger  mixture  containing  the  same  amount  of  carbolic 
acid  with  six  or  four  ounces  of  turpentine.  A  stronger  mixture  he  believes 
would  not  be  tolerated  on  account  of  its  pungency.  Smith's  directions  are 
the  following  :  "  In  the  mixture  soak  two  cloths — linen  or  otherwise — about 
a  foot  square ;  place  one  close  to  the  face,  the  other  on  the  pillow  near  the 
head,  on  pieces  of  paper,  to  avoid  unnecessary  soiling  of  the  bedclothes.  In 
adults  or  children  over  eight  or  ten  years  of  age,  one  or  two  other  cloths  of 
the  same  size  may  be  soaked  and  hung  about  the  cot,  or  cloths  soaked  with 
the  liquid  may  be  used  in  the  room." 

In  order  to  prevent  as  far  as  possible  the  spread  of  dipbtheria,  stringent 
measures  should  be  taken  to  prevent  propagation  of  the  disease  by  walking 
cases,  by  children  mildly  affected  who  are  allowed  to  attend  school  and  ride 
in  public  conveyances.  I  have  in  a  number  of  instances  seen  children  with 
diphtheria  sitting  with  other  children  in  the  clinics  at  Bellevue.  Recently  I 
saw  in  consultation  a  child  with  fatal  diphtheria,  which  apparently  was  con- 
tracted in  the  street  by  embracing  a  playmate  who  had  been  allowed  to  go 
out  for  the  first  time  after  an  attack  of  the  disease.  In  another  instance  a 
child  went  with  its  parent  to  a  Sunday  mission-school  in  one  of  the  tenement- 
house  sections  of  New  York.  Four  or  five  days  subsequently  it  had  diph- 
theria, which  was  communicated  to  other  children  of  the  family,  and  one  of 
them  died.  The  philanthropic  endeavor  to  benefit  the  poor  children  of  New 
York  by  conveying  them  to  rural  localities  in  midsummer  has,  it  is  said, 
resulted  in  the  occurrence  of  diphtheria  in  farming  sections  where  it  was  pre- 
viously unknown.  I  have  now  under  treatment  a  family  with  diphtheria, 
and  the  child  first  attacked  states  that  a  schoolmate  sitting  near  her  in  the 
school  complained  of  sore  throat  a  few  days  previously.  Certainly  the  safety 
of  the  public  requires  that  all  children  with  sore  throats  should  be  excluded 
from  the  schools  whenever  diphtheria  is  prevalent,  and  it  should  be  the  duty 
of  teachers,  acting  under  the  direction  of  health  boards,  to  see  that  this  is 
done. 

Hygienic  Treatment. — The  patient  should  be  placed  in  an  airy  room,  and 
his  evacuations  should  be  promptly  disinfected  by  chlorine,  carbolic  acid,  or 
other  disinfectant,  and  removed  from  the  room.     Purity  of  the  air  in  the 


DIPHTHERIA.  369 

apartment  is  required  ;  but  in  the  ventilation  draughts  of  air  through  the 
room  should  be  avoided,  on  account  of  the  liability  to  diphtheritic  croup, 
which  produces  about  one-third  of  the  deaths  from  diphtheria.  M.  Jules 
Simon  recommends  that  the  windows  of  the  sick-room  be  constantly  closed, 
and  that  ventilation  be  obtained  through  the  open  window  of  the  adjoining 
apartment.  In  bathing  the  patient  care  must  be  taken  that  he  be  not  chilled. 
Bathing  should  be  performed  expeditiously  in  a  warm  room,  with  perhaps 
some  increase  of  the  stimulants  administered.  The  patient  should  be  con- 
stantly in  bed,  and  the  temperature  of  the  apartment  should  be  from  70°  to 
75°  F.     A  uniform  temperature  of  the  apartment  at  about  73°  F.  is  safest. 

All  physicians  of  experience  recognize  the  importance  of  the  use  of  the 
most  nutritious  and  easily-digested  food  and  the  preservation  of  the  appe- 
tite, for  diphtheria  produces  rapid  destruction  of  the  red  corpuscles  and  loss 
of  flesh  and  strength,  and  it  may  soon  produce  a  state  of  dangerous  weak- 
ness. Beef  tea  or  the  expressed  juice  of  meat,  milk  with  farinaceous  food, 
etc.,  should  be  administered  every  two  or  three  hours  or  to  the  full  extent 
without  overtaxing  digestion.  I  have  sometimes  employed  the  pepsin  prepa- 
rations before  each  feeding,  with  apparently  good  results,  as  in  the  following 
formula  : 

R.  Pepsini  puri,  in  lamellis,  3J  ; 

Acidi  muriat.,  dilut.,  .^ij  ; 

Glycerini,  ^j  ; 

Aquae  purse,  ^iv. — Misce. 
Dose  :  One  teaspoonful  before  each  feeding. 

In  cases  of  feeble  digestion  the  predigested  foods  are  often  very  useful, 
as  the  beef  peptonoids  of  Reed  and  Carnrick,  the  sarco-peptones  of  the 
Rudisch  Company,  and  peptonized  milk.  Failure  of  the  appetite  and  refusal 
to  take  food  are  justly  regarded  as  very  unfavorable  signs.  Trousseau  says  : 
"  Alimentation  occupies  the  first  place  in  the  general  treatment ;  and  I  have 
observed  that  the  severer  the  attack  the  more  imperative  is  the  necessity  to 
sustain  the  patients  with  nourishing  food.  Loss  of  appetite — that  is,  disgust 
for  every  kind  of  food — is  one  of  the  most  alarming  prognostic  signs.  We 
must  try  to  overcome  the  loathing  of  food  by  every  possible  means ;  and  to 
get  nourishment  taken  I  sometimes  do  not  hesitate,  in  the  case  of  children, 
to  threaten  punishment.  When  the  patient  retains  his  appetite  for  food,  there 
is  good  hope  of  recovery."  ^  Occasionally,  when  great  dysphagia  is  present, 
whether  from  the  severity  of  the  pharyngitis  or  from  palatal  paralysis,  it  is 
necessary  to  resort  to  rectal  alimentation.  The  rectum  absorbs,  but  does  not 
digest,  and  it  is  capable  of  absorbing  peptonized  food  to  such  an  extent  that 
life  may  be  sustained  without  stomach  digestion  and  solely  by  rectal  alimen- 
tation. For  the  purpose  of  rectal  alimentation  I  have  usually  employed 
peptonized  milk  containing  in  solution  peptonized  beef,  as  the  sarco-peptones 
of  the  Rudisch  Company.  If  this  is  administered  through  a  No.  12  to  No. 
14  elastic  catheter  introduced  far  enough  to  reach  the  sigmoid  flexure,  and 
retained  for  half  an  hour  by  a  compress  pressed  closely  against  the  anus  by 
the  fingers,  the  result  is,  I  think,  better  than  when  we  depend,  as  Trousseau 
did,  entirely  on  stomach  digestion.  One  objection  to  the  use  of  the  brush, 
instead  of  spraying  the  fauces  with  the  atomizer,  is  that  it  is  more  likely  to 
cause  vomiting,  by  which  nutriment,  that  is  so  much  required,  is  lost.  In 
malignant  cases  of  diphtheria,  as  in  scarlet  fever  of  a  similar  type,  patients 
are  sometimes  allowed  to  slumber  too  long  without  nutriment.  It  is  the 
slumber  of  toxaemia,  and  should  be  interrupted  at  stated  times  in  order  to 
give  food  and  stimulants. 

^  American  Lancet. 
24 


370  CONSTITUTIONAL  DISEASES. 

Stimulants. — M.  Sanne,  in  his  treatise  on  diphtheria,  says  :  "  De  tous  les 
antiseptiques  donnas  a  I'interieur,  I'alcool  est  de  beaucoup  le  plus  sur.  Plus 
I'infection  est  prononcee,  plus  il  faut  insister  sur  les  composes  alcooliques." 
He  states  that  Bricheteau  reports  the  history  of  a  patient  who  took  daily 
during  diphtheria  a  bottle  and  a  half  of  the  wine  of  Bordeaux,  without  the 
least  symptom  of  intoxication  or  headache.  A  similar  case  was  related  to 
me  in  which  nearly  one  and  a  half  pints  of  brandy  wei'e  given  in  twenty-four 
hours  without  any  ill  effect,  and  with  an  apparent  good  result  on  the  general 
course  of  the  disease.  The  same  rule  holds  true  in  diphtheria  as  in  other 
acute  infectious  maladies,  that  while  mild  cases  do  well  without  alcoholic 
stimulants,  they  are  required  in  cases  of  a  severe  type,  and  should  be  admin- 
istered in  large  and  frequent  doses  whenever  pallor  and  loss  of  appetite  or 
strength  and  flesh  indicate  danger  from  the  diphtheritic  or  septic  infection. 
It  matters  little  how  the  stimulant  is  administered,  whether  milk  punch  or 
wine  whey,  provided  that  the  proper  quantity  is  employed.  If  given  early 
and  frequently  in  grave  cases — as,  for  example,  one  teaspoonful  every  half 
hour  of  brandy  or  Bourbon  whiskey — it  does  seem  to  have  a  tendency  to 
render  the  disease  more  tractable ;  but  to  be  instrumental  in  saving  life  in 
malignant  cases  it  must  be  given  boldly  from  the  start.  If  there  be  marked 
diphtheritic  toxaemia  when  its  use  is  commenced  it  will  not  save  life,  but  it 
may  prolong  it.  Although  the  liberal  employment  of  alcohol  is  apparently 
useful,  it  cannot  be  regarded  as  a  specific.  In  the  quarantine  wards  of  the 
New  York  Foundling  Asylum  were  four  children  between  the  ages  of  three 
and  five  years  who  had  been  sick  a  few  days  with  severe  diphtheria,  and  it 
was  evident  at  a  glance  that  they  must  soon  perish  with  the  ordinary 
mild  sustaining  remedies.  Quinine,  iron,  the  most  nutritious  food  and  a 
moderate  amount  of  alcoholic  stimulants  were  being  given,  and  we  deter- 
mined to  increase  the  Bourbon  whiskey  to  a  teaspoonful  every  twenty  or 
thirty  minutes  day  and  night.  Nevertheless,  whatever  the  result  might 
have  been  with  the  earlier  commencement  of  this  treatment,  the  blood-poi- 
soning was  now  too  profound,  and  one  after  the  other  died.  That  intoxica- 
tion is  almost  never  produced  in  this  disease  by  large  and  frequent  doses  of 
the  alcoholic  stimulant  is  probably  in  part  due  to  its  quick  elimination  from 
the  system,  but  more  to  the  nature  of  diphtheria. 

Quinia. — In  fulfilling  the  indication  of  sustaining  treatment  the  vege- 
table tonics  have  long  been  used,  especially  cinchona  and  its  alkaloid  principle, 
quinine.  The  compound  tincture  of  cinchona  and  the  fluid  extract  have  been 
used  and  recommended  by  physicians  of  experience,  but  of  vegetable  agents 
quinine  has  been  and  is  still  more  frequently  prescribed  than  any  other.  But 
the  doses  employed  vary  greatly  in  size  and  frequency  in  the  practice  of  dif- 
ferent physicians.  It  is  administered  for  its  antipyretic  effect  in  large  doses, 
so  that  twenty  or  thirty  grains  are  given  daily,  and  in  small  doses,  as  one  or 
two  grains  every  fourth  hour,  for  its  tonic  effect.  That  there  is  nothing 
antagonistic  in  the  action  of  quinine  to  the  diphtheritic  virus,  and  that  it  is 
beneficial  in  the  same  way  as  in  the  other  acute  infectious  diseases,  and  no 
further,  is,  I  think,  generally  admitted  by  physicians.  Large  and  frequent 
doses  do  not,  apparently,  produce  any  controlling  action  on  the  course  of  the 
disease  or  diminish  the  blood-poisoning.  Cases  might  be  cited  in  illustration. 
In  the  case  of  a  child  of  four  years  with  malignant  diphtheria  forty-eight 
grains  administered  daily  had  no  appreciable  effect  in  staying  the  fatal  prog- 
ress of  the  disease. 

Quinine  in  doses  of  three  to  five  grains  has  been  prescribed  as  an  anti- 
pyretic in  diphtheria,  as  also  in  the  other  infectious  diseases ;  but  as  an  anti- 
pyretic it  is  not  very  efficient,  and  the  temperature  after  the  first  two  or  three 
days  in  diphtheria  is  not  often  so  elevated  that  an  antipyretic  is  required. 


DIPHTHERIA.  371 

As  a  tonic  in  doses  of  one  to  two  grains  it  is  probably  to  a  certain  extent 
beneficial,  and  it  has  been  highly  recommended  by  good  observers  for  its  local 
action  upon  the  fauces  when  used  by  insufflation.  The  late  Prof.  Kochester 
of  Buffalo  recommended  and  practised  in  the  treatment  of  diphtheria  the 
insufflation  of  sulphate  of  quinine,  in  powders  of  two  grains,  upon  the  faucial 
surface,  every  two  hours.'  It  is  not  improbable  that  benefit  may  result  from 
its  local  action,  for  used  in  this  manner  it  is  antiseptic.  But  the  employment 
of  this  agent  by  insufflation  is  very  unpleasant  to  the  child,  and  is  likely  to 
be  resisted.  Given  in  solution  in  doses  of  two  grains,  as  in  the  following 
formula,  it  produces  some  local  action  on  the  fauces  if  drinks  be  withheld 
subsequently  for  a  few  minutes,  and  at  the  same  time  some  tonic  eff"ect  prob- 
ably results  from  its  use  in  this  manner : 

R.  Quinipe  sulphat.,  ,^ss  ; 

Syr.  yerbse  santse  comp.,  ^ij. — Misce. 

Give  one  teaspoonful  every  two  to  four  hours  to  a  child  of  five  years. 

I  have  often  prescribed  quinine  in  this  manner  with  apparent  benefit  in  the 
treatment  of  diphtheria. 

Tiactura  Ferri  Chloridl. — All  physicians  who  are  familiar  with  diphtheria 
have  noticed  the  pallor  and  loss  of  appetite,  flesh,  and  strength  which  com- 
mence before  the  close  of  the  first  week  in  severe  cases,  and  which  are  always 
unfavorable  symptoms,  indicating  as  they  do  rapid  and  progressive  deteriora- 
tion of  the  blood.  The  use  of  iron  is  at  once  suggested  as  the  proper  medic- 
inal agent  to  arrest  this  blood-change,  from  its  known  effect  in  increasing  the 
number  of  red  blood-corpuscles  and  the  amount  of  coloring  matter  in  these 
corpuscles.  By  its  effect  on  the  red  corpuscles,  which  are  the  carriers  of 
oxygen,  it  increases  the  functional  activity  of  organs  and  improves  the  gen- 
eral nutrition.  The  ferruginous  preparations,  therefore,  hold  an  important 
place  in  the  therapeutics  of  diphtheria.  The  one  which  has  stood  the  test  of 
experience  and  is  now  commonly  employed  is  the  tincture  of  the  chloride  of 
iron.  It  should  be  given  in  large  and  frequent  doses,  and  five  drops  hourly 
to  a  child  of  three  years. 

Ferguson  '^  regards  the  tincture  of  the  chloride  of  iron  as  the  most  valu- 
able of  all  remedies  for  diphtheria.  He  examined  the  blood  daily  or  every 
second  day  in  twenty  cases  of  diphtheria,  and  was  astonished  to  observe  how 
rapidly  the  red  blood-corpuscles  were  reduced  in  number,  those  remaining 
presenting  an  unhealthy  appearance.  He  believes  that  the  iron  partially 
arrests  the  blood-change.  He  administers  as  much  as  can  be  tolerated.  It 
■can  be  given  in  the  syrup  of  pineapple  in  the  following  formula : 

R.   Tinct.  ferri  chloridi,  .^iij  ; 

Glycerini,  §ss ; 

Syr.  ananassffi  sativa,  ^iv. — Misce. 

M.  Jules  Simon  says  :^  "  For  internal  treatment  from  three  to  six  drops  of 
the  tincture  of  the  chloride  of  iron  should  be  given  in  a  little  water  every  two 
or  three  hours ;  but  it  should  not  be  given  with  milk  or  gum-water  or  from  a 
metallic  spoon,  on  account  of  the  decomposition  which  occurs,  which  may  pro- 
duce digestive  troubles." 

The  tolerance  of  a  drug  depends  largely  on  the  manner  in  which  it  is  used. 
The  best  vehicle  for  the  tincture  of  the  chloride  of  iron  is  glycerine  and  the 
syrup  of  pineapple  (syrupus  ananassae  sativa),  or  it  may  be  conveniently  em- 
ployed with  two  or  three  times  its  quantity  of  glycerine  and  a  certain  number 

'  New  York  Medical  Journal.  ^  Canadian  Practitioner.  ^  Le  Proges  medical. 


372  CONSTITUTIONAL  DISEASES. 

of  drops  administered  in  water.  The  advice  of  Simon  should  be  borne  in 
mind  not  to  give  iron  in  gum-water,  in  milk,  nor  from  a  metallic  spoon. 

That  now  after  half  a  century  of  the  constant  use  of  iron  in  diphtheria  in 
both  hemispheres,  there  is  an  almost  unanimous  verdict  in  its  favor  renders  it 
probable  that  the  few  who  have  not  observed  its  good  effects  have  treated 
unusually  bad  cases,  or  have  given  the  medicine  in  small  and  inadequate 
doses. 

There  is  another  form  of  iron  employed,  from  which  I  have  obtained  the 
best  results.     The  following  is  the  formula : 

R.  Acidi  carbolici,  gr.  x  ; 

Liq.  ferri  subsulphatis,  giij  ; 

Glycerini,  3J . — Misce. 

To  be  applied  with  a  large  camel-hair  pencil,  from  three  to  six  hours ;  diluted 
with  two  or  three  times  its  quantity  of  water. 

It  is  destructive  in  a  high  degree  to  microbes,  and  it  congeals  the  muco- 
pus,  which  conies  away  abundantly,  to  the  great  satisfaction  of  the  friends, 
who  suppose  that  the  pseudo-membrane  is  being  detached.  This  remedy  is 
a  powerful  detergent,  so  that  if  its  use  precedes  solvents  the  latter  act  much 
more  effectually.  The  thorough  use  of  the  iron  astringent  leaves  nothing 
adventitious  to  cover  and  protect  the  pseudo-membrane  from  the  action  of 
the  solvent. 

Potassium  Chlorate. — This  agent  produces  a  curative  effect  on  buccal 
inflammations,  and  its  beneficial  action  when  employed  for  the  various  forms 
of  stomatitis  has  led  to  its  extensive  use  in  pharyngitis.  When  taken  inter- 
nally it  is  eliminated  in  part  by  the  salivary  glands,  so  that  it  continues  to 
exert  in  part  a  local  action  on  the  surface  of  the  mouth  and  fauces  until  it  is 
entirely  eliminated.  This  medicine,  the  potassium  chlorate,  has  of  late  years 
become  also  a  domestic  remedy,  but  the  laity  should  be  cautioned  in  reference 
to  its  use.  It  is  an  irritant  to  the  kidneys  in  large  doses,  producing  intense 
inflammatory  congestion  of  these  organs  and  arresting  their  function.  The 
melancholy  fate  of  Dr.  Fountaine  of  Davenport,  Iowa,  in  1861,  whose  life 
was  sacrificed  by  an  experimental  dose  of  potassium  chlorate,  is  remembered 
by  the  older  physicians.  Fountaine  took  half  an  ounce  in  a  gobletful  of 
warm  water  at  eight  A.  M.  Free  diuresis  occurred,  which  ceased  at  four 
p.  M.  Though  fatigued  and  pallid,  he  ate  a  hearty  supper.  During  the 
following  night  he  was  in  collapse,  with  vomiting  and  purging  and  severe 
abdominal  pain.  Early  in  the  following  morning  he  voided  two  ounces  of 
dark  urine,  after  which  no  urinary  secretions  occurred.  The  choleraic  symp- 
toms returned,  with  collapse,  but  he  again  rallied.  He  had  vomiting  and 
intense  and  constant  abdominal  pain  during  the  subsequent  six  days,  when 
death  occurred.  The  total  cessation  of  fecal  and  urinary  evacuations  for  six 
days  was  a  notable  fact.  At  the  autopsy  the  lesions  of  an  intense  and  gen- 
eral gastro-intestinal  inflammation  were  present,  the  mucous  membrane  hang- 
ing in  shreds  and  patches ;  the  bladder  was  empty,  and  its  mucous  membrane 
presented  a  similar  appearance  to  that  of  the  stomach  and  intestines.  The 
condition  of  the  kidneys  is  not  stated,  except  that  there  was  liquid  resembling 
urine  under  the  capsule  of  one  kidney  and  crystals  of  the  chlorate  were  in 
the  pelves  of  the  kidneys.  A  few  years  since,  in  my  practice,  a  child  of  three 
years  with  active  diphtheritic  pharyngitis  was  allowed  to  quench  its  thirst 
by  drinking  water  from  a  small  pitcher  in  which  three  drachms  of  potassium 
chlorate  had  been  dissolved,  and  which  had  been  ordered  as  a  gargle.  In 
the  morning  I  was  summoned  in  haste,  and  found  the  surface  of  the  patient 
cold  and  blue  and  pulse  feeble.    The  urine  was  totally  suppressed,  and  instead 


DIPHTHERIA.  373 

of  it  a  few  drops  of  blood  passed  from  the  urethra.  Death  occurred  before 
night. 

Jules  Simon  ^  says  that  potassium  chlorate,  acting  wonderfully  well  in  dis- 
eases of  the  mouth,  produces  no  beneficial  effect  in  diseases  of  the  fauces,  and 
it  weakens  the  little  patient  when  given  in  large  doses.  Dr.  J.  P.  Esch  says 
that  he  has  observed  that  the  potassium  chlorate  used  internally  in  diphtheria 
almost  invariably  produces  symptoms  of  nephritis. 

After  such  an  extensive  use  of  potassium  chlorate  during  nearly  half  a 
century  its  therapeutic  uses  should  be  clearly  defined,  and  any  ill  effects  which 
may  result  fully  determined.  From  what  is  now  known  of  its  action,  it  would 
be  iDetter  to  abandon  its  use  in  diphtheria,  since  it  is  a  remedy  of  doubtful  efii- 
cacy  for  throat  affections. 

Hydrargyri  CMorldum  Corrosivum  (^Hydrargyriperchloridum^  Br.  Phar.). — 
The  use  of  this  agent  in  the  treatment  of  diphtheria  is  based  on  the  theory 
of  the  microbic  origin  of  this  disease.  Corrosive  sublimate  is  the  most  active 
and  certain  of  the  germicide  agents  employed  in  medicine,  whether  used 
locally  or  internally.  It  quickly  destroys  all  micro-organisms  with  which  it 
comes  in  contact,  and  in  safe  medicinal  doses  it  is  believed  to  penetrate  all 
parts  of  the  system.  The  employment  of  corrosive  sublimate  in  the  treat- 
ment of  diphtheria  is  not  new,  since  it  appears  that  the  late  Dr.  Tappan  of 
Steubenville,  Ohio,  prescribed  it  with  apparent  benefit  in  1860-61 ;  but  it 
was  seldom  prescribed  as  a  remedy  in  this  disease  until  within  the  last  four  or 
five  years.  The  establishment  of  the  theory  of  the  microbic  origin  of  diph- 
theria, and  a  knowledge  of  the  fact  that  the  sublimate  is  the  most  efficient 
germicide,  have  made  it  the  favorite  remedy  with  many  physicians.  Of 
course  its  employment  demands  caution,  and  is  justified  only  by  the  fact  that 
the  disease  for  which  it  is  prescribed  has  hitherto  been  very  fatal  with  other 
modes  of  treatment.  Though  this  agent  is  now  widely  used  for  diphtheria, 
medical  journals  thus  far  contain  very  few  reports  of  its  supposed  toxic  or 
injurious  action,  while  many  physicians  believe  that  it  diminishes  the  virulence 
of  diphtheria  and  increases  the  percentage  of  recoveries. 

In  ordinary  cases  the  following  may  perhaps  be  regarded  as  about  the 
proper  quantities  which  should  be  administered  in  divided  doses  in  twenty- 
four  hours :  For  a  child  of  two  years,  gr.  l  (gr.  ^V  every  two  hours)  ;  for  a 
child  of  four  years,  gr.  \  (gr.  Jg  every  two  hours)  ;  for  a  child  of  sis  years, 
gr.  ^  (gr.  Jg  every  two  hours)  ;  and  for  a  child  of  ten  years,  gr.  J  (gr.  J^ 
every  two  hours).  Thus,  if  we  employ  the  vehicle  which  Dr.  Tappan  used 
a  quarter  of  a  century  ago,  the  following  prescription  might  be  written  for  a 
child  of  six  years : 

R.  Hyd.  chlor.  corros.,  gr.  j  ; 

Alcoholi,  .^ij  ; 

Elix.  bismuthi  et  pepsinii,  q.  s.  ad  ,^iv. — Misce. 
Dose  :  One  teaspoonful  every  two  hours. 

Dr.  Oatman  of  Nyack,  New  York,  has  lost  but  1  patient  in  23  by  the 
following  local  treatment :  Cotton  is  firmly  wound  around  the  end  of  a 
stick  about  the  size  of  a  lead-pencil,  being  drawn  out  as  it  is  wound,  and 
made  to  project  beyond  the  end.  This  is  dipped  into  a  solution  of  the  bichlo- 
ride of  mercury,  two  grains  to  the  pint  (1  to  3840),  and  passed  into  the  throat 
until  it  touches  the  posterior  wall  of  the  pharynx.  It  is  then  instantly  with- 
drawn and  burnt.  This  treatment  is  repeated  hourly  with  a  new  swab  each 
time,  until  the  inflammation  begins  to  subside,  which  is  usually  in  forty- 
eight  hours. 

'  Le  Proges  medical. 


374  CONSTITUTIONAL  DISEASES. 

Two  of  the  prominent  physicians  of  New  York  have  informed  me  that 
they  have  witnessed  poisonous  effects  from  the  corrosive  sublimate  in  diph- 
theria, and  I  can  add  to  the  list  fatal  poisoning  from  its  local  use  in  another 
disease.  Hence  its  cautious  local  application  in  some  such  manner  as  that 
recommended  by  Oatman  seems  preferable  in  the  majority  of  instances. 

Calomel. — Physicians  of  ample  experience  have  recommended  calomel  in 
the  treatment  of  diphtheria,  some  in  laxative  doses  and  only  at  the  beginning 
of  the  attack,  and  others  in  doses  of  the  fractional  part  of  a  grain  every  two 
to  four  hours  during  the  sickness.  The  majority  of  physicians — very  prop- 
erly, in  my  opinion — discourage  the  employment  of  calomel  in  laxative  doses, 
believing  that  it  tends  to  weaken  the  patient  and  increase  the  anaemia,  which 
in  all  cases  of  severe  diphtheria  soon  becomes  very  manifest,  whatever  the 
treatment ;  but  a  single  laxative  dose  is  perhaps  sometimes  useful.  It  may 
do  good,  as  in  other  infectious  diseases,  to  unload  the  jyrimse  vise  in  the  com- 
mencement of  the  attack,  so  that  the  remedies  to  be  employed  are  more  readily 
absorbed  and  without  alteration  by  admixture  with  chemical  products  in  the 
intestinal  tract.  What  change  calomel  undei'goes  so  that  it  can  be  absorbed 
has  not  been  clearly  ascertained. 

Trypsin  and  Papoid. — Trypsin,  unlike  pepsin,  is  an  active  solvent  in  an  alka- 
line medium,  and  it  may  be  effectually  employed  in  combination  with  alkaline 
mixtures.  Dr.  F.  C.  Fernald  relates  the  case  of  a  boy  of  six  and  a  half  years 
who  had  perforations  of  each  membrana  tympani  and  commencing  pseudo- 
membranes  upon  the  tonsilar  portions  of  the  fauces  and  the  right  auditory 
canal  was  covered  with  a  diphtheritic  exudate,  entirely  occluding  it,  so  that 
liquids  did  not  flow  from  the  external  ear  to  the  fauces  as  formerly.  The  ear 
was  filled  every  half  hour  with  the  following  mixture  : 

R.  Trj^jsin,  gr.  xxx  ; 

Sodii  bicarbonat.,  gr.  x  ; 

Aqupe  destillat.,  ^ss. — Misce. 

The  fibrinous  exudate  gradually  dissolved  and  disappeared,  the  passage 
through  the  ear  and  Eustachian  tube  became  open,  and  the  patient  recovered. 
The  literature  of  trypsin  contains  other  equally  striking  cases,  showing  the 
solvent  power  of  this  agent. 

Papoid,  also  designated  papayotin  and  vegetable  pepsin,  is  a  digestive  fer- 
ment obtained  from  the  fruit  of  the  South  American  melon  tree.  Its  diges- 
tive power  has  been  fully  investigated  by  H.  H.  Chittenden  of  the  Sheffield 
Scientijic.  He  stated  that  it  "  has  the  power  of  digesting  all  forms  of  pro- 
teid  or  albuminous  matter"  in  neutral  acid  or  alkaline  media.  In  his  opinion 
the  commercial  papoid  is  "  a  mixture  of  vegetable  globulin  albumoses  and 
peptone,  with  which  is  associated  the  ferment.".  He  details  his  experiments 
on  the  raw  blood  fibrin  which  comes  nearest  chemically  to  the  so-called  pseudo- 
membranes,  such  as  are  found  in  diphtheria. 

The  following  facts  ascertained  by  Prof.  Chittenden  are  important  in  refer- 
ence to  the  use  of  this  agent  in  pseudo-membranous  inflammations  whatever 
their  location.  Its  proteolytic  action  is  increased  by  the  presence  of  an  alka- 
line medium,  in  some  cases  greatly  increased  by  the  presence  of  2  to  4  per 
cent,  of  sodium  bicarbonate  ;  the  highest  digestive  power  is  obtained  in  the 
presence  of  sodium  bicarbonate.  We  cannot  affirm  that  any  alkaline  reacting 
fluid  will  give  the  same  increase  in  digestive  action  as  sodium  bicarbonate. 
We  will  recommend  presently  a  successful  method  of  using  trypsin  and 
papoid. 

Peroxide  of  Hydrogen,  Hydrogen  Dioxide  HjOj.— Sir  B.  W.  Richardson 
states  that  in  1857,  when  he  began  experiments  with  the  peroxide  of  hydro- 


DIPHTHERIA.  375 

gen,  it  was  a  rare  chemical  curiosity,  never  previously  used  in  medicine,  and 
he  had  therefore  no  guide  from  former  experience.  He  first  employed  it  in 
the  strength  of  four  and  five  volumes,  and  gradually  increased  the  volumes 
to  twenty  and  thirty.  He  soon  learned  that  the  action  of  oxygen  from  the 
higher  volumes,  released  in  the  presence  of  pus  and  other  substances,  was  so 
great  and  rapid  that  the  effect  was  practically  explosive,  and  after  many  trials 
he  came  to  the  conclusion  that  the  ten-volume  strength  was  the  best  for  ordi- 
nary use. 

As  frequently  happens  when  an  active  and  efficient  remedial  agent  is  first 
prescribed,  its  efficiency  and  full  value  were  not  appreciated.  The  peroxide 
was  indeed  seldom  employed  until  it  was  brought  prominently  and  favorably 
to  the  notice  of  the  profession  by  E.  R.  Squibb,  in  1889,  who  wrote:  "  It  is 
perhaps  the  most  powerful  of  all  disinfectants  and  antiseptics,  acting  both 
chemically  and  mechanically  upon  all  secretions  and  excretions  so  as  to 
change  their  character  and  reactions  instantly." 

The  new  medicine  began  to  be  used  in  surgical  and  in  those  medical  cases 
which  required  local  treatment,  and  the  laudatory  opinion  of  Squibb  was  in 
many  instances  justified  by  the  result.  But  the  pharmaceutical  peroxide 
was  soon  found  to  be  too  irritating  for  use  in  the  various  inflammations  of  the 
fauces  and  nares  in  children,  so  that  even  a  15  volume  solution  diluted  with 
two  or  more  times  its  bulk  of  water,  applied  by  spray  or  otherwise,  increased  the 
inflammatory  hyperaemia  of  the  nasal,  buccal,  and  faucial  surfaces,  sometimes 
causing  in  addition  to  the  increase  of  inflammation,  a  pellicular  exudation  of 
fibrin,  as  when  strong  ammonia  having  a  caustic  action  is  used.  Distinguished 
physicians,  whose  opinions  influence  practice  in  both  hemispheres,  related  cases 
showing  the  pernicious  eff"ects  of  the  peroxidfe  applied  by  spray  or  otherwise 
to  the  nasal  or  faucial  surface  of  the  child  in  catarrhal  or  pseudo-membranous 
inflammation,  so  as  to  increase  the  area  and  severity  of  the  inflammation  and 
sometimes  form  a  thin  fibrinous  exudate  to  which  I  have  alluded.  I  might 
mention  similar  results  in  my  own  practice  and  that  of  others,  the  induced 
catarrhal  and  pellicular  inflammation  abating  when  the  use  of  the  peroxide 
was  discontinued.  The  irritating  action  appears  to  be  due  to  the  sulphuric  and 
phosphoric  acids  used  in  the  manufacture  of  the  peroxide.  "  It  is  necessary 
that  solutions  of  hydrogen  dioxide  should  be  slightly  acid  when  they  are  to 
be  kept  for  even  a  few  hours.  If  neutral  or  alkaline  they  will  decompose  at 
the  rate  of  two  or  three  volumes  a  day,  and  the  faster  the  warmer  the  weather, 
and  the  stronger  solutions  would  soon  burst  any  ordinary  bottles.  Squibb 
states  that  the  neutralization  of  the  peroxide  by  such  alkaline  agent  as  the 
sodium  bicarbonate  does  not  diminish  its  efficiency,  "  provided  this  be  done 
very  near  the  time  of  using  ;  then  by  ordering  the  peroxide  a  little  stronger 
than  you  want,  to  compensate  the  loss  by  decomposition,  you  could  get  a 
fairly  uniform  solution  for  say  six  or  eight  hours  after  sodium  has  been 
added,  provided  the  bottle  be  kept  in  a  cool  dark  place." 

The  irritating  action  of  the  peroxide  due  to  its  hyperacidity  may  there- 
fore be  prevented  by  adding  to  it  an  alkali  as  the  sodium  bicarbonate  imme- 
diately before  its  use,  so  as  to  render  it  neutral  or  preferably  alkaline  when 
used.  By  so  doing  its  germicide  and  antiseptic  powers  do  not  appear  to  be 
diminished. 

There  can  be  no  doubt  that  the  peroxide  of  hydrogen  is  not  surpassed  as 
a  detergent,  and  it  should  be  used  every  hour  or  every  half  hour.  If  so  used 
there  is  reason  to  believe  that  the  nascent  oxygen  which  it  immediately  sets 
free  combines  with  the  toxine  generated  by  the  bacillus  and  diminishes  its 
.poisonous  properties.  The  prompt  chemical  action  of  the  nascent  oxygen 
removes  the  muco-pus  and  causes  it  to  flow  from  the  nares  or  fauces  in 
minute  bubbles,  and  there  is  reason  to  believe  that  it  changes  to  a  certain 


376  CONSTITUTIONAL  DISEASES. 

extent  the  character  of  the  bacillus  and  toxine,  if  it  be  applied  every  hour 
or  perhaps  half  hourly  as  a  spray,  rendering  them  less  noxious. 

In  order  to  complete,  the  process  of  destroying  the  membrane,  I  obtain 
very  successful  results  by  utilizing  the  digestive  action  of  trypsin  and  papoid 
according  to  the  following  formula : 

B.  Trypsin, 
Papoid, 

Sodii  bicarbonat.,  da.  .^ss  ; 

Sulphur,  sublimat.,  ^ij. 

To  be  insufflated  every  two  hours  immediately  after  the  detergent  action  of 
the  peroxide.  The  digestive  power  of  the  papoid  has  been  investigated  by 
R.  H.  Chittenden  of  the  Sheffield  Scientific  School.  He  states  ''  that  it  has 
the  power  of  digesting  all  forms  of  proteid  or  albuminous  matter  in  neutral 
acid  or  alkaline  media."  He  details  the  soluble  action  of  papoid  on  raw 
beef  fibrin  which  resembled  most  closely  the  composition  of  the  diphtheritic 
exudate. 

The  remedies  which  we  have  mentioned  are  in  my  opinion  the  most  effi- 
cacious and  safest  of  those  which  pharmacy  has  heretofore  furnished,  but  a 
new  remedy,  known  as  "  antitoxin,"  has  been  so  highly  extolled  by  many 
eminent  physicians  as  a  remedy  for  diphtheria,  that  this  new  remedy  demands 
attention  if  not  employment  wherever  this  fatal  malady  occurs.  The  distin- 
guished bacteriologist,  M.  Roux  of  Paris,  gave  a  clear  and  full,  but  at  the 
same  time  eulogistic  description  of  the  "  antitoxic  treatment "  of  diphtheria, 
at  the  meeting  of  the  Congress  at  Budapest,  as  follows :  Roux  says  that 
where  the  diphtheritic  pseudo-membrane  appears  upon  parts  that  are  not 
visible  the  disease  manifests  itself  by  blood-poisoning,  indicated  by  pallor, 
albuminuria,  and  respiratory  and  cardiac  disturbances.  If  diphtheria  be  not 
early  diagnosticated  and  be  well  advanced,  antitoxin  cannot  be  expected  to  be 
efficacious.  He  describes  the  method  of  preparing  the  serum  as  follows  :  The 
animal  furnishing  it,  usually  the  horse  or  goat,  is  rendered  immune  against 
diphtheria — that  is  to  say,  it  is  rendered  accustomed  to  the  toxin  of  diph- 
theria. The  preparation  of  antitoxin  forms  the  basis  of  the  treatment,  and 
it  is  the  more  necessary  to  describe  it  because  it  requires  a  large  quantity  of 
the  diphtheritic  toxin  to  immunize  large  animals  and  to  maintain  their  serum 
at  a  sufficient  degree  of  activity.  The  most  rapid  method  for  obtaining  the 
toxin  employed  for  inoculating  the  animal  consists  in  making  a  culture  in  a 
current  of  moist  air.  Vessels  with  flat  bottoms  and  lateral  tubes  are  used ; 
into  these  is  poured  an  alkaline  bouillon,  peptonized  to  2  per  cent.,  the  liquid 
being  spread  into  a  thin  layer.  "  After  sterilization,  recent  and  very  virulent 
diphtheria  bacilli  are  added  and  the  temperature  of  the  chamber  is  raised  to 
37°  C.  (98.6°  F.).  When  the  development  has  fully  commenced,  in  a  man- 
ner easily  imagined,  the  current  of  air  that  passes  into  the  neck  of  each  of 
the  phials   is  regulated  after  passing   through  a  wash-bottle.     After  three 

weeks  or,  at  most,  a  month,  the  culture  is  siifficiently  strong  to  use 

Since  1892  we  have  immunized  several  horses,  producing  very  efficacious 
serum.  Some  have  been  brought  to  such  a  degree  of  immunity  in  less  than 
three  months  that  they  have  borne,  without  suffering,  300  cubic  centimetres 
(92  fluidounces)  of  diphtheritic  toxin  injected  into  the  veins  at  one  time. 
The  immunization  of  horses  is  therefore  very  simple.  The  pure  toxin  is 
injected  under  the  skin,  commencing  with  1  cubic  centimetre  (151  minims) 
and  progressively  increasing  the  quantity.  At  the  end  of  a  month,  two  or 
three  times  a  week  from  20  to  30  centimetres  (5  to  8  fluidrachms)  are  injected 

at  each  sitting Horses  also  bear  very  well  inoculations  of  living  and 

very  virulent    diphtheritic    bacilli These   inoculations,  after   being 


DIPHTHERIA.  377 

repeated  a  great  number  of  times,  always  give  rise  to  the  same  symptoms, 
until  a  period  is  reached  at  which  the  fever  following  the  inoculations  is 
insignificant,  and  the  much-reduced  local  lesion  terminates  in  suppuration. 
Then  large  doses  of  virulent  culture  introduced  into  the  veins  only  provoke 
a  fleeting  rise  of  temperature."  After  the  serum  of  the  animal  is  rendered 
immune  by  repeated  injections,  extending  over  three  months  to  two  years,  it 
is  I'eady  for  the  treatment  of  patients. 

Roux  states  that  before  treating  children  with  the  serum  it  is  tested  upon 
animals.  The  serum  not  only  prevents  general  poisoning,  but  its  action  on 
the  local  lesion  is  most  marked.  That  form  of  diphtheritic  disease  in  chil- 
dren which  is  dreaded  above  all  others  by  the  laity  as  well  as  physicians — to 
wit,  pseudo-membranous  laryngo-tracheitis — experiments  have  shown  to  be 
more  amenable  to  treatment  by  the  antitoxic  serum  than  by  any  or  all  other 
medicines.  Roux  says :  '•  Rabbits  to  which  tracheal  diphtheria  has  been 
communicated  (by  injection  of  the  diphtheritic  material)  die  in  from  three 
to  five  days  if  not  treated.  Those  receiving  serum  in  sufficient  quantity, 
even  twelve  or  twenty-four  hours  after  the  injection,  recover.  Diphtheria 
associated  with  streptococci  is  the  gravest  form  met  with  ;  in  children  it  is 
the  most  frequent  determining  factor  of  broncho-pneumonia,  and  the  same 
holds  good  among  rabbits."  He  believes  that  treatment  begun  in  the  first 
twelve  hours,  by  repeated  large  injections  of  the  serum,  may  arrest  these 
cases  of  mixed  infection  in  which  both  pathogenic  germs — the  Loefiler  bacil- 
lus and  streptococcus — are  present  and  broncho-pneumonia  is  likely  to  super- 
vene. But  your  rabbits,  treated  after  twelve  hours,  have  succumbed  in  the 
great  majority  of  cases,  with  centres  of  broncho-pneumonia,  in  which  were 
found  microscopically  the  Klebs-Loelfler  bacillus  associated  with  the  strep- 
tococcus. 

Roux  gives  the  statistics  of  treatment  with  antitoxin  at  the  Hopital  des 
Enfants  Malades,  Paris.  From  February  1  to  July  24,  1894,  448  children 
were  thus  treated,  the  mortality  being  109,  or  24.33  per  cent.  The  average 
mortality  from  1890  to  1894  was  51.71  per  cent,  in  a  total  of  3971  children. 
The  benefit  from  the  antitoxin  treatment,  the  conditions  being  the  same,  was 
therefore  27.38  per  cent.  Within  the  same  period  500  cases  of  diphtheria 
were  entered  at  the  Hopital  Trousseau,  316,  or  63.20  per  cent,  of  whom 
died.  Of  the  448  children  treated  by  antitoxin,  128  were  found,  by  bacte- 
riological examination,  not  to  be  suffering  from  true  diphtheria  ;  20  other 
cases  were  in  a  dying  condition  when  brought  in.  Of  the  300  cases  remain- 
ing there  were  78  deaths,  or  26  per  cent.,  instead  of  50  per  cent.,  as  in  former 
statistics,  before  the  use  of  antitoxin.  The  serum  used  was  taken  from 
immunized  horses,  with  a  strength  of  between  50,000  and  100,000.  Of  this 
20  cubic  centimetres  (5  drachms)  were  injected  under  the  skin  of  the  thigh. 
This  was  not  renewed  if  the  patient  was  found  not  to  be  suffering  from  true 
diphtheria;  otherwise,  a  second  injection  was  made  twenty-four  hours  later. 
0.10  to  0.20  gramme  (Ih  to  3  minims)  being  used.  This  was  usually  suffi- 
cient to  bring  about  recovery.  If  the  temperature  remained  elevated,  how- 
ever, a  third  injection  of  the  same  amount  was  made.  The  average  weight 
of  the  children  being  14  kilogrammes  (28  pounds),  the  amount  of  serum 
injected,  as  a  general  rule,  equaled  yto^tt  P^''*-  °^  their  body-weight,  and  in 
exceptional  cases  y-L  part.  Under  the  influence  of  the  injections  the  gen- 
eral condition  remained  excellent;  the  false  membranes  ceased  to  form 
within  twenty-four  hours  after  the  first  treatment ;  in  thirty-six  or  at  most 
seventy-two  hours  they  became  detached.  In  only  7  of  the  cases  did  they 
persist  longer.  The  temperature  frequently  fell  suddenly  after  the  first  in- 
jection ;  if  it  remained  elevated  in  the  cases  of  severe  angina,  it  fell  only 
after  the  second  or  third   injection  in  lysis.     The  pulse  returned  to  normal 


378  CONSTITUTIONAL  DISEASES. 

less  rapidly  than  the  temperature.  A  third  of  the  cases  of  diphtheria,  ac- 
cording to  statistics,  show  albuminuria  ;  and  this  having  been  present  in  only 
54  out  of  the  120  cases  treated  with  serum,  it  seemed  evident  to  Roux  that 
the  remedy  diminished  the  frequency  of  the  symptom.  The  mortality  in 
cases  of  croup  treated  with  the  serum  was  also  much  less  than  with  other 
methods. 

In  mixed  infection,  in  which  the  streptococcus  and  Loeffler  bacillus  are 
associated,  the  antitoxic  serum  is  less  efficacious  than  in  those  cases  in  which 
the  streptococcus  is  absent.  Roux  states,  as  the  result  of  his  observations, 
that  when  the  diphtheritic  inflammation  extends  to  the  larynx  and  tracheotomy 
is  necessary  the  injections  should  be  more  abundant  and  more  numerous. 
In  the  majority  of  cases  thus  treated  the  diphtheritic  exudate  disappears 
more  rapidly  from  the  larynx  and  trachea,  and  the  cannula  can  ordinarily  be 
withdrawn  on  the  third  or  fourth  day. 

Tubage  being  an  American  invention,  the  American  reader  will  be 
pleased  when  he  reads  the  following  sentences  with  which  Roux  terminates 
his  highly-instructive  paper :  "  How  many  children  may  be  spared  trache- 
otomy if  the  serum  were  administered  sooner  ?  We  can  even  say  that,  with 
the  use  of  serum,  tracheotomy  should,  in  the  great  majority  of  cases,  be 
replaced  by  intubation.  It  is  now  no  longer  a  question  of  leaving  the  tube 
in  the  larynx  for  days.  It  will  suffice  more  frequently  to  retain  it  for 
twenty-four  or  forty-eight  hours,  to  prevent  imminent  asphyxia  and  to  give 
time  for  the  false  membranes  to  become  detached.  Intubation  is  the  com- 
plement of  the  serum  treatment  of  the  future.  Tracheotomy  will  be  the 
exception,  and  greatly  to  the  benefit  of  the  children." 

A.  I.  H.  Saw,^  of  London,  relates  six  cases  of  diphtheritic  croup  treated 
by  tracheotomy  and  Aronson's  antitoxin.  All  except  an  infant  of  eleven 
months,  moribund  on  admission,  recovered  rapidly.  At  a  meeting  of  the 
Brighton  Medico-Chirurgical  Society  held  October  4th  Richardson  and  Hollis 
each  related  two  cases  in  which  the  antitoxin  was  employed,  with  speedy 
recovery  in  all.  One  of  Hollis's  cases  was  cyanotic  from  croup  and  was 
tracheotomized  before  the  antitoxin  was  injected. 

I.  A.  Turner  '^  has  collected  the  following  statistics  of  the  antitoxin  treat- 
ment :  Behring  and  Kossel,  30  cases,  with  a  mortality  of  20  per  cent. ;  Ehr- 
lich,  Kossel,  and  Wasserman,  67  cases  with  tracheotomy,  with  a  mortality  of 
23.6  per  cent. ;  Kartz,  123  cases,  with  a  mortality  of  13.2  per  cent. ;  Weilger, 
63  cases,  with  a  mortality  of  28  per  cent ;  Aronson,  192  cases,  with  a  mor- 
tality of  13  per  cent. :  Roux,  448  cases,  with  a  mortality  of  24.3  per  cent. 
This  gives  a  total  of  1081   cases,  with  a  mortality  of  24  per  cent. 

At  a  recent  meeting  of  the  Royal  Society  of  Physicians  of  Vienna, 
Widehofer  ^  reported  the  results  obtained  in  100  severe  cases  of  diphtheria 
treated  during  October  and  November  with  antitoxin.  Of  this  number  74 
recovered,  24  died,  and  2  were  yet  under  observation.  Diphtheria  bacilli 
were  found  in  all  the  cases  except  4,  2  of  which  were  not  examined  bacterio- 
logically.    In  the  preceding  nine  months  the  mortality  had  been  52.6  per  cent. 

Prof.  Augustus  Caille  of  the  New  York  Polyclinic  stated,  in  a  paper  read 
May  27,  1895,  before  the  American  Pediatric  Society,  "  being  fortunate  in  ob- 
taining from  abroad  an  early  supply  of  the  antitoxin,  I  have  been  able  thus  far 
to  observe  its  action  in  41  cases  of  Klebs-Loeffler  diphtheria,  of  which  7 
cases  have  had  a  fatal  termination.  Of  the  34  cases  ending  in  complete 
recovery,  32  were  treated  with  Behring's  or  Aronson's  serum,  2  with  serum 
from  the  Gibier  Institute,  New  York.  In  the  majority  of  cases  one  injec- 
tion (600  units)  was  given  ;  in  one-third  of  the  cases,  two  and  three  injections 
were  administered.  Judicious  stimulation  was  carried  out  in  all  cases,  and 
1  October  13,  1894.  ^  November  24,  1894.  ^  j^Tq^  52^  1394 


DIPHTHERIA.  379 

naso-pharyngeal  irrigation  was  practised  in  all  cases,  with,  salt  water  or  mer- 
curic bichloride  1 :  5000.  Our  clinical  experience  has  so  far  upheld  the  claim 
made  for  the  antitoxin  of  diphtheria  as  to  its  specific  and  curative  powers,  for 
a  reduction  of  the  mortality  from  diphtheria  is  conceded  by  the  vast  majority 
of  unbiased  and  competent  observers." 

We  cannot  write  so  favorably  of  the  use  of  antitoxic  serum  in  the  New 
York  Foundling  Asylum.  Since  a  reliable  preparation  was  obtained  from 
the  Health  Board  31  cases  were  inoculated  with  the  serum.  The  number  of 
units  employed  varied  from  500  to  2200.  The  antitoxin  was  inserted  under 
the  skin  on  the  first  day  in  12  cases,  on  the  second  or  third  day  in  17  cases, 
and  on  the  fourth  or  fifth  day  in  2  cases.  Nineteen  received  the  injection 
once,  nine  received  it  twice,  and  three  three  times.  Microscopic  examinations 
revealed  the  presence  of  the  Loeffier  bacillus  in  all  the  cases,  and  the  strep- 
tococcus in  nearly  all  the  cases,  so  that  in  all,  or  nearly  all,  the  infection 
was  a  mixed  one.  The  physicians  who  observed  these  cases  and  wit- 
nessed the  necropsies  and  microscopic  investigations  could  not  resist  the 
conviction  that  the  broncho-pneumonia  of  which  so  many  died  was  due  to 
the  streptococcus,  which  was  abundant  in  the  lobules,  and  upon  which  microbe 
the  antitoxin  has  little  or  no  eflfeet.  Results:  Recovered,  14;  died,  17  (14 
from  broncho-pneumonia  or  broncho-pneumonia  and  croup).  In  four  or  five 
of  the  cases  the  benefit  was  very  marked  after  the  use  of  the  antitoxin. 

It  is  seen  that  statistics  thus  far  are  favorable  for  the  antitoxine  treat- 
ment, but  it  must  be  recollected  that  the  type  of  the  microbe  diseases  fre- 
quently changes,  so  that  the  experience  of  several  years  is  often  necessary  in 
order  to  determine  the  full  value  of  a  remedy. 

Albuminuria. — This  being  due  to  septic  nephritis,  patients  have  seemed 
to  be  more  benefited  by  the  tincture  of  the  chloride  of  iron,  in  frequent  and 
rather  large  doses,  than  by  any  other  remedy.  If  while  this  is  being  used  a 
marked  diminution  in  the  quantity  of  urine  occurs,  it  may  be  necessary  to 
employ  diuretics  and  laxatives,  as  in  scarlatinous  nephritis.  The  potassium 
bitartrate  or  acetate,  and  perhaps  the  more  laxative  salines,  may  be  needed 
under  such  circumstances.  But  marked  diminution  of  urine — and  especially 
anuria — in  diphtheria  ends  fatally,  with  few  exceptions,  according  to  my 
observations,  whatever  the  treatment. 

Paralysis. — The  loss  of  the  tendon  reflexes,  and  palatal  and  multiple 
paralysis,  require  the  same  stimulating  and  sustaining  remedies  which  are 
appropriate  for  the  primary  disease,  diphtheria.  Iron  and  other  tonics,  nutri- 
tious and  easily-digested  diet,  massage,  and  in  some  instances  electricity, 
suffice  to  restore  the  use  of  the  afi"ected  muscles,  but  sometimes  weeks  and 
even  months  elapse  before  their  use  is  fully  restored.  So  long  as  the  paral- 
ysis does  not  alFect  any  vital  organ,  a  favorable  prognosis  may  be  expressed, 
although  recovery  may  be  slow. 

On  the  other  hand,  it  is  evident  from  its  nature  and  from  the  cases 
which  have  been  related  that  cardiac  paralysis  is  exceedingly  dangerous, 
and  must  be  treated  promptly  and  by  the  most  active  remedies.  As  we 
have  seen,  the  attack  of  cardiac  paralysis  is  usually  sudden,  with  little  fore- 
warning, and  is  often  fatal  before  the  physician,  promptly  summoned,  is  able 
to  arrive.  The  patient  should  be  as  quiet  as  possible  in  bed,  with  the  head 
low,  and  alcoholic  stimulants  should  be  administered  at  once.  In  the  sudden 
seizures,  such  as  have  been  related  above,  hypodermic  injections  of  brandy 
act  most  promptly  in  sustaining  the  heart-action.  Ammonia,  camphor,  musk 
and  the  electrical  current  may  be  useful  auxiliaries.  The  predigested  beef 
preparations,  peptonized  milk  and  other  concentrated  foods,  designed  for  those 
with  feeble  digestion,  are  useful.  If  the  urgent  symptoms  are  relieved  by  these 
measures  such  remedies  should  be  employed  as  are  useful  in  other  forms  of 


380  CONSTITUTIONAL  DISEASES. 

diphtheritic  paralysis.  The  patient  is  ordinarily  feeble,  anajmic.  and  with 
poor  digestion.  The  beef  extracts  and  concentrated  foods  should  be  con- 
tinued. Iron,  quinine  in  moderate  doses,  and  alcoholic  stimulants  are  indi- 
cated. The  use  of  the  electric  current  is  suggested  by  the  nature  of  the 
attack.  31any  physicians  believe  that  they  have  obtained  benefit  from  its 
use  in  the  treatment  of  the  more  common  forms  of  diphtheritic  paralysis, 
while  others  speak  doubtfully  of  its  efficacy.  If  there  be  reason  from  the 
symptoms  to  suspect  the  presence  of  central  lesions  in  the  nervous  system, 
the  galvanic  current  in  short  sittings  has  been  recommended,  and  not  the 
faradic.  In  ordinary  cases  either  the  direct  or  the  induced  current  may  be 
employed. 

Strychnine  is,  however,  regarded  by  good  observers  as  the  most  efficacious 
nerve-stimulant  in  the  various  forms  of  diphtheritic  paralysis.  Oertel's 
objection,  expressed  twenty  years  ago,  to  the  use  of  strychnine  in  this  disease, 
that,  acting  as  an  excitant  of  the  spinal  cord,  it  is  likely  to  aggravate  central 
lesions,  was  founded  on  a  wrong  understanding  of  the  pathology  of  the 
paralysis.  Prof.  Henoch  cured  diphtheritic  paralysis  in  three  weeks  by 
hypodermic  injections  of  strychnine.  W.  Reinard  '  states  that  a  boy  three 
and  a  half  years  of  age  fifteen  days  after  the  appearance  of  the  diphtheritic 
patches  on  the  tonsils  had  paralysis  of  the  inferior  extremities  and  the  velum 
palati,  a  tottering  gait,  nasal  voice,  and  difficult  deglutition.  At  the  end  of 
twelve  days  death  seemed  imminent,  the  paresis  of  the  lower  extremities  had 
become  a  complete  paraplegia,  and  the  paralysis  of  the  upper  extremities  and 
of  the  muscles  of  the  nucha,  larynx,  and  thorax  was  complete.  He  was 
unable  to  sustain  himself  in  the  sitting  posture,  his  head  falling  heavily  on 
his  chest.  He  had  also  dyspnoea,  hoarse  cough,  tracheal  rales,  and  aphonia, 
probably  from  cardio-pulmonary  paralysis.  Reinard  made  a  hypodermic 
injection  each  day  of  one  milligramme  (about  one-sixty-fifth  of  a  grain)  of 
sulphate  of  strychnine  in  the  nucha.  Improvement  occurred  in  twenty-four 
hours  in  the  tonicity  of  the  muscles.  On  the  third  day  the  cardiac  and  pul- 
monary paralysis  had  so  improved  that  the  tracheal  rales  had  ceased.  The 
respiration  was  more  normal  and  deglutition  possible.  On  the  fifteenth  day 
of  this  treatment  and  after  fifteen  injections  the  patient  was  considered 
cured.  Dr.  Gerasimow  -  relates  the  case  of  a  child  six  years  of  age  who  had 
paralysis  of  the  velum,  pharynx,  larynx,  and  lower  extremities.  Six  weeks 
after  the  commencement  of  paralytic  symptoms  subcutaneous  injections  of 
strychnine  (or  about  one-thirty-first  of  a  grain),  were  given  daily.  With 
this  treatment  the  patient  improved,  and  after  seven  injections  of  this 
strength,  followed  by  twelve  of  orie-twenty-second  of  a  grain,  the  cure  was 
complete. 

With  such  strong  testimony  in  favor  of  the  use  of  strychnine,  it  is  per- 
haps remarkable  that  physicians  of  experience  state  that  they  have  not 
observed  any  marked  benefit  from  its  use  in  the  treatment  of  diphtheritic 
paralysis.  Kt  a  meeting  of  the  New  York  Clinical  Society,  held  December 
23,  1887,^  Dr.  Holt  stated  that  he  was  yet  to  be  convinced  that  strychnine 
possessed  any  specific  value  in  this  disease,  though  it  was  of  much  value  as 
a  general  tonic.  At  the  same  meeting  Dr.  A.  A.  Smith  stated  his  belief  that 
tonics  and  time  did  more  for  diphtheritic  paralysis  than  anything  else.  He 
had  used  electricity  and  strychnine,  and  had  never  been  able  to  satisfy  him- 
self that  electricity  did  any  good,  and  the  effects  of  strychnine  seemed  to  be 
not  specific,  but  those  of  a  general  tonic.  On  the  other  hand.  Dr.  Thatcher 
of  New  York  has  reported  a  case  in  which  galvanism  was  employed  on  the 
two  paralyzed  upper  extremities  alternately,  on  each  for  a  week  at  a  time. 

'  Deutsche  med.  Wochemchr.,  1885,  No.  19.  ^  Med.  Obser.,  No.  20. 

^  New  York  Medical  Jourmd,  Jan.  14,  1888. 


PERTUSSIS.  381 

It  was  invariably  found  that  the  arm  receiving  the  electricity  gained  more 
rapidly  than  the  one  untreated,  the  strength  being  tested  by  the  dynamom- 
eter. This  test  seems  to  have  been  conclusive  as  showing  the  efficacy  of 
galvanization. 


CHAPTER   VIII. 

PERTUSSIS. 

Pertussis  is  a  highly  contagious  disease  attended  and  manifested  by  a 
catarrh  of  the  air-passages.  This  catarrh  gives  rise  to  a  cough  which  does 
not  differ,  during  the  inception  and  in  the  declining  period,  from  that  in  an 
ordinary  catarrh,  but  during  the  middle  period  of  the  malady  is  spasmodic. 
Exceptionally,  the  system  is  so  mildly  affected  that  the  spasmodic  element 
of  the  cough  is  lacking  through  the  whole  course  of  the  malady  or  is  con- 
fined to  a  brief  period.  The  spasmodic  cough  has  been  attributed  to  the 
irritating  and  disturbing  action  of  the  specific  principle  on  the  nerves 
which  control  the  muscles  of  respiration.  It  is  attributed  to  the  impres- 
sion produced  upon  the  filaments  of  the  pneumogastric,  especially  upon 
those  of  the  internal  branch  of  the  superior  laryngeal  nerve,  by  the  mucus 
which  collects  in  the  larynx  and  trachea,  and  which  is  known  to  contain 
the  contagious  principle  in  abundance.  This  cough  consists  in  a  series  of 
forcible  and  loud  expirations,  followed  by  a  noisy  and  difficult  inspiration. 
Its  special  character  is  due  to  spasmodic  contraction  of  the  muscles  of 
expiration,  and  notably  of  the  small  muscles  of  the  larynx,  so  as  to  pro- 
duce narrowing  or  even  closure  of  the  aperture  of  the  glottis.  Each  paroxysm 
of  the  cough  usually  ends  (not  always)  in  the  expectoration  of  viscid  mucus. 
With  rare  exceptions  pertussis  affects  the  same  individual  but  once.  Killiet 
and  Barthez  report  a  case  of  its  second  occurrence,  and  West  another  case. 
I  have  attended  two  adult  patients,  both  women  of  intelligence,  who  stated 
that  they  had  had  previous  attacks  in  early  life.  Pertussis  usually  prevails 
as  an  epidemic,  but  is  occasionally  sporadic,  at  which  time  its  type  is  mild. 
It  is  highly  contagious  through  the  breath  of  the  patient  or  from  exhalations 
from  his  surface.  Pertussis  is  probably  a  disease  of  antiquity,  but  there  is 
no  clear  description  of  it  prior  to  the  sixteenth  century.  Some  have  thought 
that  it  was  alluded  to  in  the  writings  of  Hippocrates,  and  the  Arabian  phy- 
sician Avicenna  who  lived  in  the  tenth  century,  in  describing  the  "  violent 
cough  of  children,"  which  is  attended  by  the  spitting  of  blood  and  lividity 
of  the  face,  probably  alluded  to  it  (Rilliet  and  Barthez).  Baillon  in  1578 
described  a  cough  which  appeared  in  Paris,  attacked  chiefiy  children,  and 
was  so  violent  that  it  caused  bleeding  from  the  nose  and  mouth,  and  often 
vomiting.  Wilson  in  1682  and  Schenek  in  1695  also  described  a  convulsive 
cough  which  we  can  apparently  identify  as  pertussis.  In  the  eighteenth 
century  whooping  cough  was  described  by  many  observers  in  different  parts 
of  Europe,  among  whom  we  may  mention  Alberto  (1728),  Brendel  (1747), 
De  Basseville  (1752),  Forbes  (1755),  Cullen,  Butter,  and  Danz.  In  the 
present  century,  whooping  cough,  being  eminently  contagious  and  of  such 
a  nature  that  the  patients  are  allowed  to  mingle  in  society,  is  widely  dissemi- 
nated, and  epidemics  of  it  are  of  frequent  occurrence. 

Incubative  Period. — It  is  not  improbable  that  this  varies  in  different 
cases.  Some  writers  believe  that  it  is  usually  from  two  to  seven  days.  In 
one  instance  I  was  able  to  ascertain  it  accurately.     Mrs.  B ,  having  a 


382  CONSTITUTIONAL   DISEASES. 

cough  for  two  weeks,  which  was  afterward  ascertained  to  be  that  of  pertussis, 
came  from  Boston  to  a  family  in  New  York.  She  remained  with  this  family 
from  2  p.  M.,  January  2,  1879,  till  the  evening,  when  she  left  the  city.  During 
her  stay  she  held  and  kissed  an  infant  that  was  previously  well  and  had  never 
been  removed  from  the  floor  on  which  it  was  born.  Pertussis  was  not  at  that 
time  prevailing  in  New  York.  On  the  6th,  or  four  days  after  exposure,  the 
infant  began  to  cough,  and  this  proved  to  be  the  beginning  of  a  severe  attack. 

Age. — Most  cases  of  pertussis  are  between  the  ages  of  one  year  and  eight 
years,  but  it  occasionally  occurs  in  adults  and  even  old  people  who  have  not 
been  attacked  previously.  It  is  rare  under  the  age  of  three  months,  but 
through  the  kindness  of  Dr.  Ewing  of  New  York  I  was  enabled  to  see  a 
new-born  infant  with  pertussis  whose  mother  had  had  the  disease  during  the 
two  months  preceding  her  confinement.  This  infant  was  fifteen  minutes  old, 
and  during  the  washing  had  the  first  convulsive  seizure,  which  appeared  to 
consist  chiefly  of  a  spasm  of  the  laryngeal  muscles,  with  temporary  suspen- 
sion of  the  respiration,  and  attended  by  deep  lividity  of  the  features,  with 
some  frothing  from  the  mouth.  These  attacks  occurred  nearly  every  hour, 
with  intervals  of  complete  cessation  of  symptoms.  The  mucus  between  the 
lips  finally  became  stained  with  blood,  and  death  occurred  on  the  third  day. 
The  mother,  the  intelligent  wife  of  a  clergyman,  believes  that  the  infant  had 
similar  attacks  before  its  birth,  for  she  frequently  experienced  in  the  last 
weeks  of  gestation  what  seemed  to  be  strong  convulsive  movements  in  the 
foetus,  the  duration  of  which  corresponded  with  that  of  the  attacks  in  the 
infant.  A  similar  case  is  related  by  Rilliet  and  Barthez.^  and  another  by 
Keating.'-  These  cases  throw  light  on  the  pathology  of  pertussis,  for  they 
show  that  the  specific  principle  may  enter  the  blood. 

Causes. — Climate,  race,  and  nationality  do  not  seem  to  exert  any  decided 
influence  on  the  spread  of  pertussis.  Females  are  somewhat  more  liable  to 
be  attacked  than  males,  and,  as  we  have  seen,  a  large  majority  of  the  cases 
occur  between  the  ages  of  one  and  ten  years.  Lctzerich  about  the  year 
1870  supposed  that  he  had  discovered  the  cause  of  pertussis  in  a  microbe, 
which,  received  upon  the  surface  of  the  air-passages  in  inspiration,  increases 
rapidly  and  produces  the  spasmodic  cough  by  its  irritating  action  or  the  irri- 
tating properties  which  it  imparts  to  the  mucus.  In  the  first  stage  of  pertus- 
sis he  found  only  the  spores  of  the  microbe,  and  at  a  more  advanced  stage, 
in  addition  to  the  spores,  he  discovered  filaments.  He  placed  mucus  holding 
the  cryptogram  upon  the  fauces  of  the  rabbit,  and  witnessed  the  production 
of  pertussis  in  this  animal.  Recently,  Burger^  of  Bonn  states  "that  the 
micro-organism  of  pertussis  is  visible  with  a  power  of  340  to  600  diameters, 
appearing  as  little  rods  of  unequal  size.  AVith  a  higher  power  it  is  seen  that 
the  rods  have  the  biscuit  form.  The  groups  of  bacteria  are  irregitlarly  dis- 
seminated or  disposed  in  line,  and  bear  some  resemblance  to  the  leptothrix 
buccalis.  The  method  of  preparation  is  very  simple.  A  small  quantity  of  the 
expectoration  is  pressed  between  two  cover-glasses,  exposed  to  the  flame  of  a 
Bunsen  burner  to  coagulate  the  albumen  ;  the  coloring  matter  is  then  added 
(watery  solution  of  fuchsin  or  of  methyl  violet)  ;  it  is  then  washed  thoroughly 
in  water,  or  the  coloring  matter  removed  by  washing  in  alcohol,  the  bacteria 
alone  remaining  colored.  These  bacilli  are  not  found  in  any  other  expectora- 
tion ;  they  are  so  abundant  that  it  is  difiicult  to  contest  their  action  ;  their 
frequency  is  always  in  direct  relation  with  the  intensity  of  the  disease." 
Dr.  Poulet*  also  confirms  the  statement  of  a  special  micro-organism  in  per- 

^  Treatise  on  the  Diseases  of  Children. 

^  System  of  Medicine  by  American  Authors:  Lea  Bros.,  Philadelphia,  1885. 
^Berlin,  'klin.  Wochenschrift ;  London  Medical  Becord,  May  15,  1884. 
*  La  Scalpel;  London  Medical  Record,  May  15,  1884. 


PEBTUSSIS.  383 

tussis  from  his  examinations.  In  the  St.  Petershurgher  med.  Woch.,  1887,  a 
"  careful  observer,"  Dr.  AfanasieflP,  also  states  that  he  had  discovered  a  bacil- 
lus in  the  sputum  of  pertussis  which  differs  from  all  other  bacilli.  It  occurs 
in  the  form  of  small  rods,  single,  in  pairs,  or  in  chains.  The  length  of  the 
bacillus  is  0.6  to  2.2  micromillimetres.  Its  cultures  exhibit  peculiar  qualities. 
Inoculated  in  animals,  it  produces  symptoms  like  those  of  human  pertussis, 
and  the  air-passages  of  these  animals  exhibited  the  appearance  of  congestion 
and  catarrh.  In  the  ^S"^.  Petershurgher  med.  Woch.,  in  1888,  another  distin- 
guished Russian  observer,  Seintschenko,  writes  that  after  many  experiments 
he  is  able  to  make  the  following  statements:  1.  The  bacillus  of  Prof. 
Afanasieff  is  specific ;  2.  Bacilli  may  be  found  in  the  sputum  about  the 
fourth  day  of  the  disease,  in  some  cases  earlier ;  3.  They  multiply  in  the 
tissues  of  the  body,  and  as  they  increase  the  severity  of  the  disease  increases  ; 
4.  The  bacilli  disappear  before  the  entire  cessation  of  the  attacks  of  coughing. 
or  when  the  paroxysms  are  reduced  to  two  or  four  daily ;  5.  With  complica- 
tions— such  as,  for  example,  a  catarrhal  pneumonia — there  is  a  great  increase 
in  the  number  of  whooping-cough  bacilli  found  in  the  sputum ;  6.  A  pneu- 
monia developing  under  these  circumstances  differs  from  ordinary  attacks  of 
catarrhal  pneumonia  ;  7.  The  bacillus  of  whooping  cough  is  of  value,  not 
only  in  etiology  and  diagnosis,  but  in  the  prognosis  of  the  disease. 

After  the  lapse  of  six  or  eight  years  since  the  above  announcements  of 
the  discovery  of  the  specific  principle  of  pertussis,  the  belief  has  gained 
ground  that  Afanasieff  has  probably  made  the  genuine  discovery. 

Lesions  have  been  discovered  in  certain  fatal  cases  which  have  been  sup- 
posed to  throw  light  on  the  etiology  of  pertussis,  but  which  are  now  known 
to  have  been  merely  coincidences  or  results  of  the  disease.  Such  are  con- 
gestion of  the  spinal  cord  and  its  meninges,  hyperasmia  of  the  pneumogas- 
trics.  and  tumefaction  of  the  tracheo-bronchial  glands,  which  it  was  claimed 
produced  the  spasmodic  cough  by  compressing  the  recurrent  laryngeal  nerve. 

Pathological  Anatomy. — Catarrhal  inflammation  of  the  air-passages 
is  uniformly  present.  It  occasionally  occurs  on  the  mucous  surfaces  of  the 
nostril  and  pharynx,  but  is  often  absent  from  these  parts.  In  the  majority 
of  patients  the  inflammation  affects  the  surface  of  the  glottis  and  that  below 
the  glottis.  Herff  examined  his  own  larynx  during  paroxysms  of  pertussis. 
He  observed  a  moderate  inflammatory  hypersemia  of  the  respiratory  tract 
during  the  entire  course  of  the  disease.  The  inflammation  extended  from 
the  posterior  nares  to  the  bifurcation  of  the  trachea,  but  was  most  marked 
in  the  following  locations :  over  the  cartilages  of  Santorini,  Wrisber,  and  the 
arytenoid,  and  the  posterior  wall  of  the  larynx,  between  the  vocal  cords  and 
the  epiglottis,  and  on  the  under  surface  of  the  epiglottis.  The  vocal  cords 
themselves  were  not  affected.  During  the  paroxysm  a  pellet  of  mucus  was 
observed  upon  the  posterior  surface  of  the  larynx  on  a  level  with  the  glottis, 
and  when  this  was  removed  the  cough  ceased.  Irritation  of  this  part  of  the 
larynx  uniformly  excited  a  cough.  Sometimes  certain  alveoli  are  found  dis- 
tended by  a  thick  muco-pus,  producing  an  appearance  like  minute  tubercles. 

A  common  lesion  found  in  the  lungs  of  those  who  have  perished  with  this 
malady  is  emphysema,  affecting  chiefly  the  peripheral  portions  of  the  upper 
lobes.  It  is  usually  vesicular  emphysema,  occurring  from  over-distension  of 
the  air-cells,  but  in  some  instances  the  air  has  escaped  into  the  connective 
tissue,  causing  interstitial  emphysema.  According  to  my  recollection  of  fatal 
cases  which  have  occurred  from  time  to  time  in  the  institutions  of  New  York, 
and  in  which  I  have  made  post-mortem  examinations,  the  upper  lobes  were 
exsanguine  and  inflated  to  nearly  the  fullest  extent  possible  within  the  thorax, 
while  other  portions  of  the  lungs  presented  areas  of  pneumonic  or  more  or  less 
complete  atelectatic  solidification.      Pneumonia,  atelectasis,  and  small  extrav- 


384  CONSTITUTIONAL  DISEASES. 

asations  of  blood  in  the  lungs  are,  indeed,  common  lesions.  Hyperplasia  of 
the  bronchial  glands  is  also  common,  and  hyperplasia  has  also  been  occasion- 
ally observed  of  other  lymphatic  glands,  as  the  mesenteric.  An  ulcer  under 
the  tongue  which  observers  have  frequently  noticed  is  now  attributed  to  the 
pressure  of  the  tongue  on  the  lower  incisors  during  the  cough. 

In  fatal  cases  small  extravasations  of  blood  in  or  upon  the  brain  are  com- 
mon, as  is  also  passive  congestion  of  the  sinuses,  veins,  and  capillaries,  men- 
ingeal and  cerebral,  attended  with  more  or  less  transudation  of  serum  within 
the  ventricles  of  the  brain  and  between  the  meninges.  Large  dark  and  soft 
clots,  and  occasionally  some  that  are  white  or  yellow,  are  common  in  the  intra- 
cranial sinuses,  especially  if,  as  often  happens,  death  have  occurred  in  convul- 
sions which  supervened  upon  the  severe  spasmodic  cough. 

Symptoms. — Pertussis  consists  of  three  stages :  first,  that  of  catarrh  of 
the  air-passages ;  secondly,  the  stage  of  spasmodic  cough,  or,  for  brevity,  the 
spasmodic  stage ;  thirdly,  the  stage  of  decline. 

The  Jirst  jjeriod  is  characterized  by  the  symptoms  of  coryza  and  bron- 
chitis, which  present  nothing  peculiar  or  difi"erent  from  ordinary  catarrh  of 
the  same  parts,  unless  occasionally  the  cough  be  more  frequent  and  teasing. 
Trousseau  has  known  it  to  be  repeated  forty  or  fifty  times  per  minute.  The 
eyes  present  a  moderately  suffused  appearance,  and  there  is  sneezing,  with 
defluxion  from  the  nostrils,  but  less  than  in  the  commencement  of  measles. 
The  cough,  which  begins  as  soon  as  the  catarrh  affects  the  larynx,  is  accom- 
panied by  little  or  no  expectoration.  The  pulse  and  respiration  are  moderately 
accelerated,  and  such  other  symptoms  as  commonly  accompany  catarrh  of  a 
mild  grade  are  present — to  wit,  increased  heat  of  surface,  thirst,  and  impaired 
appetite. 

The  duration  of  the  first  stage  varies  in  diflFerent  cases.  In  severe  whoop- 
ing cough  it  may  last  only  two  or  three  days,  and  in  mild  cases  be  protracted 
to  five  or  six  weeks.  It  may  be  absent  especially  in  very  young  infants.  We 
have  alluded  above  to  the  new-born  infant,  in  whom  there  is  no  first  stage,  a 
glottic  spasm  occurring  soon  after  birth.  The  first  stage  commonly  ends  in 
from  eight  to  fifteen  days.  In  fifty-five  cases  observed  by  Dr.  West  its  aver- 
age duration  was  twelve  days  and  seven-tenths  of  a  day.  It  is  stated  above 
that  the  first  stage  in  rare  instances  continues  during  the  entire  course  of  per- 
tussis ;  at  least  no  spasmodic  cough  occurs.  In  two  such  cases  which  I  now 
recall  to  mind,  both  girls,  the  inflammatory  symptoms  abated  somewhat  after 
the  first  few  days,  and  an  occasional  easy  cough  remained,  like  that  of  simple 
bronchitis,  and  it  continued  during  a  period  corresponding  with  the  ordinary 
duration  of  pertussis.  The  diagnosis  would  have  been  doubtful,  except  for 
the  occurrence  of  pertussis,  with  its  regular  stages,  in  other  children  of  the 
same  families. 

Second  Period. — This  may  commence  quite  abruptly,  but  ordinarily  its 
beginning  is  gradual.  While  the  cough  commonly  has  the  character  present 
in  the  first  stage,  it  is  now  and  then  observed  to  be  more  severe  and  spasmodic, 
especially  at  night  and  when  the  patient  is  in  any  way  excited.  The  spasmodic 
element  increases,  so  that  in  the  course  of  a  week  all  doubt  as  to  the  nature 
of  the  disease  is  removed. 

The  severity  of  the  cough  in  the  second  stage  varies  considerably  in  dif- 
ferent cases.  It  sometimes  commences  quite  abruptly,  with  little  warning, 
but  commonly  there  is  premonition  of  it,  and  the  child  endeavors  to  repress 
it.  He  experiences  a  tickling  sensation  in  the  throat  or  median  line  of  the 
chest,  or  a  feeling  of  constriction.  He  leaves  his  playthings  and  rests  his 
head  on  his  mother's  lap  or  takes  hold  of  some  firm  object  for  support ;  his 
face  has  a  grave  or  even  anxious  appearance,  while  the  pulse  and  respiration 
are  somewhat  accelerated.     Immediately  the  cough  begins.     It  consists  in  a 


PEBTUSSIS.  385 

series  of  short  and  hurried  expirations,  which  expel  a  large  part  of  the  air 
contained  in  the  lungs,  followed  by  a  hurried  inspiration,  which  is  difficult 
and  noisy  on  account  of  the  spasmodic  contraction  of  the  laryngeal  muscles 
and  narrowing  of  the  glottic  aperture.  The  sound  which  accompanies  the 
inspiration,  and  which  is  often  absent,  especially  in  infants,  is  designated  the 
whoop.  The  forcible  expirations  and  difficulty  experienced  in  expelling  the 
air  from  the  lungs  on  account  of  the  constriction  of  the  glottis  afford  expla- 
nation of  the  emphysematous  distention  of  the  air-cells  in  the  upper  lobes 
which  we  have  seen  is  so  common  in  severe  pertussis. 

There  may  be  a  single  series  of  expirations  terminating  in  the  manner 
stated,  but  often  there  are  several  such  series  embraced  in  a  paroxysm.  The 
cough  commonly  ends  in  the  expulsion  of  frothy  mucus  from  the  bronchial 
tubes,  and  sometimes  in  vomiting.  During  the  cough  there  is  temporary 
arrest  of  blood  in  the  lungs,  leading  to  congestion  in  the  right  cavities  of  the 
heart  and  throughout  the  systemic  circulation  ;  therefore  the  face  is  flushed 
and  swollen,  and  occasionally  hemorrhage  occurs  under  the  conjunctiva  or 
from  one  of  the  mucous  surfaces.  The  most  frequent  hemorrhage  is  epis- 
taxis.  When  the  cough  ceases,  the  normal  respiration  is  restored  and  the  ful- 
ness of  the  vessels  immediately  abates  ;  but  often  puffiness  of  the  features  is 
observed,  due  to  serous  infiltration  of  the  subcutaneous  connective  tissue, 
and  continuing  for  days  or  weeks  during  the  period  when  the  cough  is  most 
severe.  The  paroxysms  last  from  a  quarter  to  a  half  or  even  a  whole  minute, 
and  in  that  time,  in  cases  of  ordinary  severity,  there  are  often  as  many  as  fif- 
teen or  twenty  series  of  expirations. 

At  the  close  of  the  paroxysm,  if  there  be  no  complication,  the  symptoms 
soon  abate  ;  the  temperature,  pulse,  and  respiration  become  normal,  and  there 
is  no  evidence  of  disease.  The  cough  in  the  second  stage  is  much  more  fre- 
quent in  one  case  than  another.  At  the  height  of  this  stage  it  is  generally 
more  severe  if  it  occur  at  long  intervals  than  when  frequent.  During  the 
week  in  which  pertussis  is  most  severe  there  is.  on  the  average,  about  one 
paroxysm  of  coughing  in   each  hour. 

The  cough  increases  in  severity  till  the  third  week  of  the  second  stage,  or 
the  thirtieth  to  the  thirty-fifth  day  of  the  disease,  after  which  it  remains  sta- 
tionary for  a  certain  time.  It  is  apt  to  be  more  frequent  in  the  night  than 
day-time.  Sometimes  it  occurs  while  the  child  is  quiet ;  it  may  even  awaken 
him  from  sleep,  but  it  is  often  also  produced,  by  mental  excitement  or  by 
physical  exertion.  Anger  or  fright  gives  rise  to  it,  and  therefore  the  child  is 
likely  to  cough  when  being  examined  by  the  physician  or  when  his  wishes  are 
not  complied  with.  The  ordinary  duration  of  the  second  stage  is  from  thirty 
to  sixty  days.  It  may,  however,  be  considerably  longer  or  shorter  than  this. 
The  third  stage,  which  commences  at  the  time  when  the  spasmodic  cough 
begins  to  abate,  is  short,  not  continuing  longer  than  two  or  three  weeks.  A 
protracted  stage  of  decline  indicates  some  complication.  While  the  sputum 
in  the  second  stage  is  mucous  and  froth}^,  that  in  the  third  stage  is  more 
opaque  and  puriform. 

In  the  third  as  in  the  second  stage,  if  there  be  no  complication,  the  pulse 
and  respiration  in  the  intervals  of  the  paroxysms  are  nearly  or  quite  natural. 
Febrile  excitement  may.  however,  now  and  then  occur  from  trifling  causes,  or. 
indeed,  without  any  apparent  cause.  The  digestion  and  the  general  health  in 
uncomplicated  pertussis  remain  unimpaired,  with  the.  exception  of  more  or 
less  emaciation,  which  is  likely  to  occur  in  all  but  the  mildest  cases  in  conse- 
quence of  the  frequent  vomiting.  After  complete  recovery  it  is  not  unusual 
for  the  spasmodic  cough  to  reappear  at  times  for  one  or  even  two  years.  The 
cough  of  ordinary  simple  laryngitis  or  bronchitis  assumes  this  character. 
Complications. — These,  like  the  symptoms,  are  chiefly  of  a  twofold 

25 


386  CONSTITUTIONAL  DISEASES. 

character — to  wit,  inflammatory  and  neuropathic.  From  the  nature  of 
the  cough  in  pertussis,  it  would  naturally  be  supposed  that  the  spasmodic 
affection  which  is  now  designated  internal  convulsions,  and  which  is  charac- 
terized by  spasm  of  certain  muscles  of  respiration,  would  be  a  frequent  com- 
plication. It  does  sometimes  occur  in  young  children,  but  it  is  not  common. 
Clonic  convulsions  affecting  the  external  muscles  are.  on  the  other  hand,  not 
infrequent.  They  occur  chiefly  in  the  second  stage,  when  the  cough  is  most 
severe,  and  in  infancy  much  more  frequently  than  in  childhood.  They  are 
likely  to  be  general  and  severe,  or,  if  not  of  this  character  at  first,  to  become 
such.  The  convulsions  commence  in  most  instances  in  or  directly  after  the 
paroxysm  of  coughing,  but  they  sometimes  occur  in  the  interval  when  the 
child  is  quiet. 

Rilliet  and  Barthez  remark  :  "  Almost  all  infants  succumb  to  this  com- 
plication, ordinarily  in  the  twenty -four  hours  which  follow  the  first  attack  ; 
nevertheless,  life  may  be  prolonged  during  two  or  three  days "  (article 
Coquehiche).  In  my  own  practice  this  complication  usually  ended  fatally 
before  bromide  of  potassium  and  chloral  were  employed,  but  with  the  proper 
use  of  these  agents  it  can  often  be  arrested.  In  the  month  of  June,  1867,  I 
was  attending  a  little  girl  two  years  and  four  months  old  who  had  reached 
the  fifth  week  of  pertussis  when  she  was  seized  with  general  clonic  convul- 
sions. The  mother,  who  was  requested  to  keep  a  record  of  the  number  of 
convulsions,  stated  that  there  were  twenty  in  all  occurring  within  forty-eight 
hours.  They  affected  both  sides,  the  shortest  lasting  only  three  or  four 
minutes,  the  longest  seventy-five  minutes.  The  treatment  in  this  case, 
which  eventuated  favorably,  will  be  noticed  hereafter. 

In  those  who  die  of  convulsions  occurring  in  whooping  cough  the  most 
constant  lesion  is  congestion  of  the  cerebral  veins  and  sinuses,  often  with 
transudation  of  serum.  This  congestion  is  due  in  part  to  the  cough  which 
precedes  the  convulsions  and  in  part  to  the  convulsions  themselves.  At  the 
autopsies  which  I  have  made  of  two  infants  who  died  in  hospital  practice 
from  whooping  cough,  accompanied  by  convulsions,  all  the  cerebral  sinuses 
were  filled  with  clots,  which  were  generally  soft  and  dark ;  but  in  the  lateral 
sinuses  clots  were  found  which  were  light-colored.  The  light  color  of  a  clot, 
either  in  a  vein  or  sinus,  indicates  its  ante-mortem  formation. 

The  gravity  of  the  convulsive  attack  can  be  ascertained  by  observing 
whether  the  patient  readily  recovers  consciousness.  Its  speedy  return  to  con- 
sciousness indicates  that  there  is  no  serious  congestion.  On  the  other  hand, 
great  drowsiness  remaining  or  a  semi-comatose  state  indicates  persistent  con- 
gestion, and  perhaps  even  the  formation  of  clots  in  the  sinuses  of  the  brain. 
Death  from  convulsions  is  usually  preceded  by  coma.  Occasionally  menin- 
geal apoplexy  supervenes  upon  the  congestion,  and  death  is  immediate. 

The  most  frequent  inflammatory  complications  are  bronchitis  and  pneu- 
monitis. Inflammation  of  the  bronchial  tubes  of  a  mild  grade,  we  have  seen, 
is  a  common  accompaniment  of  pertussis,  but  when  it  extends  to  the  minuter 
tubes  or  becomes  so  severe  as  to  cause  acceleration  of  respiration,  it  is  prop- 
erly a  complication.  Both  bronchitis  and  pneumonitis,  occurring  as  compli- 
cations, are  developed,  with  few  exceptions,  in  the  second  stage.  Bronchitis 
is  accompanied  by  accelerated  respiration  and  pulse  and  increased  tempera- 
ture.    The  danger  is  proportionate  to  the  amount  of  dyspnoea. 

Pneumonitis  is  a  less  common  complication  than  bronchitis,  but  it  occurs 
more  frequently  in  pertussis  than  in  any  other  constitutional  malady  of  early 
life,  excepting  measles.  The  congestion  which  results  and  remains  in  the  lung 
when  the  cough  is  frequent  and  severe  favors  the  development  of  pneumonia. 
The  symptoms  and  physical  signs  which  accompany  this  inflammation  and 
serve  for  its  diagnosis  are  the  same  as  in  the  primary  form  of  the  disease, 


PERTUSSIS.  387 

and  are  described  elsewhere.  Bronchitis  or  pneumonia  usually  moderates 
the  severity  of  the  spasmodic  cough,  for  when  the  inflammatory  element  in 
pertussis  increases  the  spasmodic  abates.  On  the  abatement  of  the  inflam- 
mation, however,  the  cough  usually  regains  its  former  convulsive  character. 
The  fact  may  be  stated  in  this  connection  that  any  complication  or  intercur- 
rent disease  which  is  attended  by  decided  febrile  reaction  ordinarily  renders 
the  cough  for  the  time  less  spasmodic. 

The  occurrence  of  bronchitis  or  pneumonia  is  shown  by  the  elevated  tem- 
perature, acceleration  of  pulse  and  respiration,  short  and  frequent  cough. 
These  symptoms  do  not  cease  so  long  as  the  inflammation  continues,  whereas 
in  uncomplicated  pertussis  the  patient  seems  nearly  or  quite  well  between  the 
coughs.  In  pneumonia  the  respiration  is  accompanied  by  the  expiratory 
moan,  and  in  both  bronchitis  and  pneumonia  there  is  more  or  less  depression 
of  the  inframammary  region  during  inspiration.  These  symptoms,  in  con- 
nection with  the  physical  signs,  render  diagnosis  in  most  instances  easy. 
Although  the  general  character  of  the  cough  is  changed,  a  cough  now  and 
then  occurs,  even  when  the  inflammation  is  pretty  severe,  sufBciently  spas- 
modic to  indicate  the  nature  of  the  primary  aflFection.  Capillary  bronchitis 
and  pneumonia  are  always  serious  complications. 

Not  only  is  more  or  less  emphysema  a  common  complication  of  severe 
pertussis,  but  bronchiectasis  also  occurs  in  certain  cases,  due  to  the  same 
conditions.  Emphysema  is  a  common  lesion  in  young  and  feeble  infants, 
even  when  there  is  no  history  of  any  previous  severe  disease  of  the  respira- 
tory organs.  I  have  found  it  one  of  the  most  common  lesions  in  infants  of 
feeble  constitutions  who  die  in  the  hospitals  and  asylums  of  New  York,  but 
it  is  usually  interstitial  and  confined  to  a  small  part  of  the  upper  lobes.  It 
is  not  accompanied  by  that  general  distention  of  the  alveoli  and  consequent 
enlargement  of  the  lobes  which  occur  in  the  emphysema  of  pertussis.  Its 
chief  cause  in  these  feeble  and  wasted  infants  appears  to  be  impaired  nutri- 
tion and  change  in  the  molecular  state  of  the  pulmonary  tissue.  The  same 
molecular  change  often  occurs  in  severe  and  protracted  pertussis,  and  there- 
fore serves  as  an  additional  and  efficient  cause  of  the  emphysema. 

The  following  was  a  not  unusual  case  of  this  disease  as  it  occurs  in  the 
tenement-houses  and  asylums  of  New  York.  At  the  meeting  of  the  New 
York  Pathological  Society,  October  14,  1868,  I  exhibited  emphysematous 
lungs  removed  from  an  infant  who  died  at  the  age  of  nineteen  months  at 
the  commencement  of  the  fourth  week  of  pertussis.  Death  occurred  from 
thrombosis  in  the  lateral  sinuses  of  the  cranium,  resulting  from  the  severe 
spasmodic  cough,  eclampsia,  and  feebleness  of  the  circulation,  as  the  infant 
was  previously  in  a  reduced  state  from  chronic  entero-colitis.  At  the  au- 
topsy the  superior  lobes  of  both  lungs  were  found  exsanguine,  doughy  to 
the  feel,  and  enlarged  so  as  to  rise  above  the  level  of  the  other  lobes.  The 
resiliency  and  elasticity  of  the  lung-tissue  in  these  lobes  were  evidently 
greatly  impaired,  and  their  air-cells  in  a  state  of  over-distention.  The 
other  lobes  were  healthy,  except  that  one  of  them  was  the  seat  of  catarrhal 
pneumonia.  In  this  case  there  had  been  no  disease  affecting  the  respira- 
tory apparatus  previous  to  the  pertussis,  so  that  the  incipient  vesicular 
emphysema  was  referable  to  the  severe  cough  and  impaired  nutrition  of 
the  lungs. 

Occasionally  we  meet  cases  of  severe  pertussis  in  which,  while  there  is 
over-distention  of  the  alveoli  of  the  upper  lobes,  collapse  occurs  over  a  greater 
or  less  extent  of  the  lower  lobes.  Collapse,  like  emphysema,  may  continue 
for  weeks  or  months  subsequently  to  pertussis,  and  then  gradually  disappear, 
but  in  the  following  case,  rare  in  my  experience,  it  was  permanent :  John 
O'Neil,  aged  five  and  a  half  years,  was  brought  to  the  Bureau  for  the  Relief 


388 


CONSTITUTIONAL  DISEASES. 


Fig.  50. 


of  the  Out-door  Poor  in  New  York  in  December,  1876.  He  lived  in  the 
underground  basement  of  a  tenement-house,  and  was  supported  by  charity, 
except  at  intervals,  when  his  father,  who  was  dissipated,  could  obtain  work. 
At  the  age  of  fifteen  months  he  had  a  glandular  swelling  on  the  right  side  of 
the  neck,  which  suppurated,  and  three  months  later  one  on  the  opposite  side, 
which  also  .suppurated.  At  the  age  of  two  and  a  half  years  he  had  bron- 
chitis, the  cough  of  which  did  not  abate  till  two  months  subsequently. 
When  near  the  age  of  three  years  he  had  measles,  and  the  cough  from  this 
disease  lasted  three  or  four  months.  In  the  summer  of  1875,  or  about  one 
year  subsequently  to  the  measles,  he  contracted  pertussis,  which  was  severe, 
but  was  allowed  to  run  its  course  without  treatment.  It  lasted  four  months, 
never,  however,  confining  him  to  bed  or  materially  impairing  his  appetite. 
One  morning  about  the  close  of  the  second  month  of  the  malady  the  parents 
first  observed  depression  of  the  right  side  of  the  thorax.  This  gradually 
increased  a  few  weeks,  and  has  been  permanent.  The  parents  stated  that  he 
had  never  been  confined  to  the  house  or  without  appetite  except  during  the 
week  of  measles. 

Since  his  recovery  from  pertussis  he  has  had  his  usual  appetite  and  gen- 
eral health,  but  crying  or  excitement   commonly  brings   on   a  pretty  severe 

cough.  The  depression  of  the  thorax,  examined 
in  front,  begins  quite  abruptly  in  the  line  of  the 
left  costo-chondral  articulations.  Circumferen- 
tial measurement  of  the  left  side  from  the  mid- 
dle of  the  sternum  to  the  spine,  the  tape  lying  a 
little  below  the  nipple,  gives  eleven  and  a  half 
inches,  while  corresponding  measurement  of  the 
right  side  gives  seven  and  a  half  inches  ;  pulse 
136,  sounds  of  the  heart  normal ;  respiration  44. 
On  auscultation  over  the  right  side  of  the  chest 
we  observed  bronchial  respiration  and  a  feeble 
bronchophony,  with  perhaps  slight  vocal  fre- 
mitus. The  accompanying  figure  is  from  a 
photograph  by  Mr.  Mason,  photographer  to 
Bellevue  Hospital.  My  first  impression  on  ob- 
serving this  case  was  that  it  was  one  of  unex- 
panded  lung  which  had  been  compressed  by  a 
pleuritic  effusion,  but  it  is  seen  that  the  history 
points  clearly  to  pertussis  as  the  cause  of  the 
deformity.  The  depression  occurred  somewhat 
suddenly  when  the  cough  was  most  severe  and 
when  there  was  no  fever,  loss  of  appetite,  or 
other  symptoms  of  pleuritis.  The  patient  had 
not  presented  any  marked  evidence  of  rachitis, 
but  was  decidedly  strumous. 

Pertussis  is  sometimes  complicated  by  the 
eruptive  fevers.  There  does  indeed  seem  to  be 
some  affinity  between  it  and  measles,  so  that 
many  epidemics  of  the  two  have  been  observed 
at  about  the  same  time.  During  my  term  of 
service  in  the  New  York  Foundling  Asylum,  in  May,  1878,  measles  and 
pertussis  prevailed  in  the  wards  at  the  same  time.  Eighteen  of  the  chil- 
dren who  were  having  pertussis  contracted  measles,  and  the  Sisters,  who 
were  very  intelligent  and  faithful  observers,  and  were  requested  by  me  to 
notice  the  effect  of  the  complication,  stated  that  with  few  exceptions  the 
severity  of  the   whooping  cough  was  increased  during  the  continuance  of 


PERTUSSIS.  389 

the  exanthem.  This  is  contrary  to  the  general  belief  of  the  effects  of  inter- 
current febrile  diseases. 

Diagnosis. — During  the  period  of  invasion  it  is  impossible  to  diagnosticate 
pertussis.  Its  nature  can  only  be  conjectured  from  a  known  exposure  or  from 
the  epidemic  occurrence  of  the  disease.  In  the  second  stage,  which  is  cha- 
racterized by  the  spasmodic  cough,  diagnosis  is  ordinarily  easy,  and  often  the 
parents  are  able  to  announce  the  nature  of  the  disease  when  the  physician  is 
called.  Still,  a  mistake  is  sometimes  made :  a  spasmodic  cough  very  similar 
to  that  of  pertussis  occasionally  occurs  in  other  maladies.  Young  infants 
with  bronchitis  frequently  experience  great  difficulty  in  the  expectoration  of 
mucus,  which  collects  in  the  air-passages  and  provokes  a  suffocative  cough. 
The  following  facts  will  aid  in  making  the  diagnosis  :  Bronchitis,  accompanied 
by  a  suffocative  cough,  is  an  acute  disease,  and  the  cough  occurs  at  an  early 
period,  usually  in  the  first  week.  It  lacks  the  inspiratory  sound  or  the  whoop, 
and  is  associated  with  constantly  accelerated  respiration  and  well-marked  febrile 
symptoms,  dependent  on  the  inflammation.  Moreover,  the  cough  is  occasion- 
ally suffocative,  according  to  the  amount  of  mucus  in  the  tubes.  The  spas- 
modic cough  of  pertussis,  on  the  other  hand,  is  preceded  by  the  stage  of  inva- 
sion, and  it  occurs  only  in  the  second  stage,  when  the  febrile  symptoms  have 
abated.  Again,  the  suffocative  cough  of  bronchitis  rarely  ends  in  vomiting, 
which  is  common  in  the  cough  of  pertussis. 

The  only  other  disease  with  which  there  is  much  likelihood  of  confound- 
ing pertussis  is  bronchial  phthisis.  The  points  of  differential  diagnosis  are 
the  following :  the  one  epidemic  and  spreading  by  contagion,  the  other  non- 
contagious and  isolated ;  the  one  embraced  in  three  distinct  stages  and  much 
shorter,  the  other  chronic  and  presenting  no  stages,  but  commencing  with 
mild,  non-febrile  symptoms  and  progressively  becoming  more  severe ;  in  the 
one  an  absence  of  symptoms  in  the  intervals  of  the  cough,  provided  that 
there  be  no  complication ;  in  the  other  constant  symptoms,  such  as  are  com- 
mon in  tubercular  disease.  The  previous  health  and  the  presence  or  absence 
of  a  tubercular  cachexia  should  be  considered  in  determining  the  nature  of 
the  disease.  Usually  in  bronchial  phthisis  the  lungs  are  also  affected,  so  that 
auscultation  and  percussion  may  furnish  positive  proofs  of  the  nature  of  the 
cough. 

The  attacks  of  suffocative  cough  which  are  produced  by  the  lodgement 
of  a  foreign  body  in  the  larynx  or  lower  down  in  the  air-passages  bear  a 
close  resemblance  to  those  of  pertussis.  The  diagnosis  can  be  made  by  the 
history,  for  in  the  one  case  there  is  a  preliminary  catarrhal  stage,  and  in  the 
other  the  cough  begins  abruptly,  and  usually  after  the  known  swallowing  of 
the  offending  substance,  which  produces  dyspnoea  and  a  spasmodic  cough  as 
soon  as  it  enters  the  larynx.  The  presence  of  the  body  can  also  be  deter- 
mined in  a  large  proportion  of  cases  by  the  laryngoscope  and  auscultation. 

Prognosis.— A  larger  proportion  doubtless  recover  under  the  better  ther- 
apeutics of  the  present  time  than  in  former  years.  According  to  Hirsch 
(ii.  p.  105),  72,000  persons  perished  from  this  disease  in  England  and  Wales 
between  1848  and  1855,  or  1  in  every  40  who  died  ;  and  Wilde's  reports 
show  that  it  stands  fifth  as  regards  mortality  among  the  epidemic  diseases 
of  Ireland.  In  New  York  City,  during  the  half  century  ending  with  1853, 
4840  died  of  pertussis,  or  1  died  from  this  disease  in  every  76  of  deaths 
from  all  causes.. 

As  a  rule,  the  older  the  child  the  better  the  prognosis.  Young  infants 
may  die  of  suffocation  due  to  the  glottic  spasm.  Eclampsia  with  extreme 
passive  congestion  of  the  encephalon  is  a  not  infrequent  complication  in  chil- 
dren under  the  age  of  five  years,  and  it  is  apt  to  terminate  fatally.  It  may, 
however,  be  averted  in  most  cases  by  proper  treatment  when  threatening. 


390  CONSTITUTIONAL  DISEASES. 

In  rare  instances  death  may  occur  in  or  immediately  after  a  paroxysm  of 
coughing,  in  consequence  of  rupture  of  a  cerebral  or  meningeal  vessel  and 
the  effusion  of  blood,  or  from  stasis  and  coagulation  of  blood  in  the  venous 
system,  especially  if  convulsions  have  supervened  upon  frequent  and  pro- 
tracted paroxysms  of  coughing.  Other  complications  which  are  likely  to  arise 
under  conditions  which  favor  their  development,  and  which  greatly  increase 
the  danger  aud  render  the  prognosis  unfavorable,  are  capillary  bronchitis, 
pneumonia,  diphtheria,  and  in  the  summer  season  intestinal  catarrh. 

Feebleness  of  system  and  antecedent  and  accompanying  chronic  disease 
increase  in  danger.  Pertussis  sometimes  produces  so  much  emaciation  and 
loss  of  strength,  in  consequence  of  the  severity  and  frequency  of  the  cough 
and  the  repeated  vomiting,  that  intercurrent  diseases,  which  in  favorable 
states  of  the  system  would  probably  end  in  recovery,  are  very  apt  to  prove 
fatal. 

I  usually  inform  the  family  that  the  patient  is  doing  well  if  he  seem 
entirely  well  between  the  paroxysms  ;  but  if  he  appear  ill,  whether  with  som- 
nolence, fretfulness,  fever,  loss  of  appetite,  accelerated  breathing,  or  diarrhoea, 
he  is  not  doing  well,  and  probably  has  some  complication  which  requires 
attention. 

Treatment. — In  the  catarrhal  stage  the  treatment  should  be  the  same 
as  in  mild  idiopathic  bronchitis.  Demulcent  and  soothing  cough  mixtures 
are  required.  Care  should  be  taken  to  employ  nothing  which  reduces  the 
strength  or  impairs  the  general  health.  If  there  be  much  bronchitis  with 
accelerated  breathing  and  frequent  cough,  mild  counter-irritation  to  the  chest 
and  the  use  of  the  oil-silk  jacket  are  proper. 

Therapeutic  measures  are  chiefly  indicated  in  the  second  stage  or  that 
of  convulsive  cough.  Proper  treatment  may  control  the  severity  of  the 
cough,  and  abridge  the  duration  of  the  second  stage,  and  prevent  or  control 
complications.  Pertussis  has  received  a  great  variety  of  treatment.  The 
enumeration  of  the  medicines  and  modes  of  treatment  which  have  had  their 
season  of  repute  and  been  employed  by  intelligent  physicians  would  occupy 
too  much  time.  The  treatment  should  vary  in  some  respects  according  to 
the  case,  but  a  small  number  of  medicines  suffices  even  in  the  most  severe  and 
obstinate  foi'ms  of  the  malady.  Knowledge  and  appreciation  of  the  patho- 
logical state  in  pertussis  assist  us  to  the  choice  of  the  proper  remedies.  The 
specific  principle  of  pertussis  produces  but  little  depression  of  the  vital  pow- 
ers. It  does  not  impair  the  appetite  by  its  direct  action  on  the  nutritive 
function,  nor  does  it  produce  those  profound  blood-changes  which  we  observe 
in  scarlet  fever  and  diphtheria.  It  aff"ects  the  system  injuriously  by  the  sever- 
ity of  the  cough,  the  vomitings  and  consequent  loss  of  nutriment,  and  the 
complications  which  frequently  occur,  some  of  which  involve  fatal  conse- 
quences. 

Remedies  are  required  which  diminish  the  sensitiveness  of  the  laryngo- 
tracheal surface,  which  destroy  the  specific  principle  in  those  parts  where  the 
local  manifestations  of  the  disease  occur,  or  control  its  action ;  that  is,  in  the 
larynx  and  trachea.  The  use  of  inhalations  is  at  once  suggested  as  most 
likely  to  fulfil  the  indications,  since  by  inhalation  the  medicine  employed  is 
brought  into  immediate  contact  with  the  parts  which  are  chiefly  concerned 
in  the  disease. 

Carbolic  Acid. — During  an  epidemic  of  pertussis  a  few  years  since  in  the 
New  York  Foundling  Asylum,  after  trial  of  the  older  remedies  without  any 
marked  result,  carbolic  acid,  half  a  drachm  to  eight  ounces  of  glycerin  and 
water,  was  employed  by  inhalation  from  three  to  six  minutes,  and  at  intervals 
of  two  to  six  hours  according  to  the  severity  of  the  cough.  The  result  was 
apparently  better  than  with  the  other  remedies,  since  the  cough  became  less 


PERTUSSIS.  391 

frequent  and  severe.  Carbolic  acid  seems  to  have  an  anaesthetic  effect  on 
the  laryngo-tracheal  surface.  It  is  also  an  efficient  antiseptic  and  germicide 
agent,  so  that  if  inhaled  frequently  it  probably  destroys  the  specific  principle 
in  the  mucus  and  epithelial  cells  of  the  air-passages.  It  has  been  in  my 
practice  conveniently  employed  in  the  croup-kettle.  Three  teaspoonfuls  of 
the  saturated  solution  of  carbolic  acid  are  added  to  water  sufficient  to  cover 
the  bottom  of  the  croup-kettle  to  the  depth  of  two  inches,  and  when  it  is 
brought  nearly  to  the  boiling-point,  the  vapor  is  inhaled  a  few  minutes  every 
hour  or  second  hour  through  the  tube.  If  an  equal  quantity  of  the  oil  of 
eucalyptus  be  added,  the  inhalations  are  more  agreeable  and  the  germicide 
effect  is  probably  increased.  Dr.  Keating^  recommends  the  following  formula 
for  inhalation  : 

R.   Acidi  carbolici  cryst.,  gr.  iij  ; 

Sodii  biborat., 

Sodii  bicarb. ,  da.  gr.  x  ; 

Glycerini, 
Aquae,  da.  gj. 

An  alkali,  as  in  the  above  mixture,  is  believed  to  render  the  mucus  more 
fluid,  and  water,  even  when  not  medicated,  increases  its  fluidity  and  renders 
expectoration  more  easy.  Pick  also  highly  recommends  carbolic  acid  in  the 
treatment  of  pertussis  (Archiv  f.  Kiaderheilk.,  1886),  and  believes  that  when 
not  effectual  it  is  too  much  diluted.  He  adds  fifteen  to  twenty  drops  to  a  roll 
of  cotton,  which  is  introduced  into  a  mask.  The  patient  inhales  the  vapor 
of  the  gas  several  times  each  day,  and  the  cotton  wadding  is  renewed  three 
times.  The  duration  and  severity  of  the  disease  were  diminished  by  the 
inhalation,  and  no  ill  results  occurred  in  any  case.  Miller  has  also  used  car- 
bolic acid  internally  in  doses  of  one  minim  in  children  over  the  age  of  five, 
with,  he  states,  good  results ;  but  its  use  by  inhalation  appears  to  be  equally 
or  more  effectual,  and  is  devoid  of  the  risks  which  attend  its  internal  use 
{Medical  Register,  1888). 

Cocaine. — This  has  been  quite  largely  used  as  an  application  to  the  throat 
on  account  of  its  anaesthetic  effect,  but  its  action  is  evanescent,  so  that  in 
order  to  obtain  the  full  benefit  from  its  use  it  is  necessary  to  apply  it  often. 
Labrie  states  that  the  repeated  application  to  the  throat  of  a  5  per  cent, 
solution  immediately  diminishes  the  number  of  paroxysms  {Lond.  Med.  Rev., 
1888).  Holt,  in  discussing  the  safety  of  its  use  {X.  Y.  Med.  Journ.,  1888), 
states,  "  1st.  It  must  be  used  with  great  caution  in  young  children  under  all 
circumstances  ;  2d.  The  spray  is  never  to  be  recommended,  since  an  uncertain 
quantity  is  given  ;  3d.  Solutions  stronger  than  4  per  cent,  should  not  be  used 
in  children  under  two  years ;  4th.  In  cases  where  it  was  tried  he  failed  to  see 
any  notable  benefit."  Probably  cocaine  will  not  come  into  general  use,  because 
frequent  applications  would  be  necessary  in  order  that  its  effect  be  continuous, 
and  this  would  apparently  be  dangerous  ;  still,  it  might  be  occasionally  used 
in  order  to  obtain  temporary  respite  from  the  cough  when  it  involves  danger 
in  consequence  of  its  frequency  and  .severity. 

Antipyrine. — This  agent  is  now  largely  used,  and  many  physicians  have 
written  in  its  favor.  Sonnenberger  regards  it  as  a  specific  {Therapeut.  Monat- 
schr-i/te,  1888).  He  prescribes  it  in  doses  of  as  many  centigrammes  (one-sixth 
grain)  as  the  child  is  months  old,  and  as  many  decigrammes  (one  and  a  half 
grains)  as  it  is  years  old,  three  times  daily.  He  says  that  the  earlier  it  is 
employed  the  better  is  the  result.  Genser  administers  only  one  and  a  half 
grains  daily  for  each  year  of  the  age,  and  he  found  that  it  diminished  the 
frequency  and  severity  of  the   cough   {Allgenteine  med.   Cent.  Zeit.,  1888). 

1  Medical  News,  Feb.  28,  1885. 


392  CONSTITUTIONAL  DISEASES. 

Laborderie  reports  the  complete  cure  of  pertussis  by  the  use  of  autipyrine 
iu  twelve  to  sixteen  days.  He  says  :  "  (1)  Children  take  antipyrine  without 
difl&culty,  and  as  a  rule  easily  bear  its  effects ;  (2)  The  spasmodic  condition 
is  rapidly  calmed,  and  in  a  few  days  the  disease  declines  ;  (8)  Its  action  is  so 
prompt  and  free  from  accidents  that  it  becomes  a  valuable  remedy  in  a  malady 
which  may  be  of  prolonged  duration  and  give  rise  to  many  complications  "  (^Bull. 
gen.  de  Therap.,  1888).  In  my  practice  antipyrine  has  also  in  some  cases  been 
a  ver)'  important  remedy,  reducing  the  severity  of  the  paroxysms.  I  have 
administered  it  in  small  or  moderate  doses  every  third  or  fourth  hour  in  com- 
bination with  an  alcoholic  stimulant.  Antipyrine  is  especially  useful  in  cases 
attended  by  fever.  But  the  use  of  antipyrine  is  attended  by  some  danger, 
and  it  should  be  discontinued  if  depression  or  lividity  occur.  An  editorial  in 
the  Montreal  Med.  Journ.,  Oct.,  1889,  states  that  antipyrine,  besides  being  dan- 
gerous, exerts  no  controlling  effect  over  pertussis. 

Quinine. — The  use  of  quinine  in  whooping  cough  was  strongly  recom- 
mended by  Binz,  who  attributed  the  good  effects  which  he  had  observed  to 
its  germicide  action.  It  has  been  employed  with  apparently  good  results, 
both  locally  and  internally.  Kolover  prescribes  the  following  solution  as  a 
spray  : 

R.  Quiniae  sulph.,  gr.  50; 

Acidi  sulphur.,  gtt.  30  ; 

Aquae  destillat.,  ^^f  • 

The  fauces  are  sprayed  with  this  every  two  hours  for  the  first  three  days,  and 
three  hours  for  the  rest  of  the  week,  when  treatment  is  no  longer  necessary 
(2/'  Union  Med.,  1887).  Bachen  employs  insufflation  into  the  nostrils  of  fifteen 
grains  of  a  finely  triturated  powder  of  twenty  parts  of  quinine  and  one  of 
benzoin  (^Lond.  Med.  Rec,  1887).  Swett  also  prescribed  the  insufflation  of 
quinine  morning  and  evening,  and  observed  improvement  after  the  first  day. 
Forchheimer  and  the  late  Prof.  Rochester  have  likewise  recommended  the 
local  use  of  quinine.  The  internal  use  of  quinine  has  been  supposed  to  be 
useful  by  diminishing  reflex  irritability  (Schlakow  and  Eulenberg).  It  is 
undoubtedly  a  useful  remedy  in  those  common  cases  in  which  febrile  symp- 
toms arise  from  bronchitis  or  broncho-pneumonia. 

Paulet^  recommends  the  evaporation,  over  a  suitable  fire,  of 

R.  Spirits  of  thymol,  grammes    10 

Alcohol,  "        250 

Water,  "         750 

Keating  also  recommends  the  same  agent  in  the  following  formula : 


R. 

Thymol., 

gr.  XV  ; 

Alcoholis, 

Hiij  ; 

Glycerini, 

.^ss  ; 

Aquae, 

^xxxiv.- 

— Misce. 

Internal  remedies,  formerly  much  used,  now  occupy  the  second  place  in 
the  therapeutics  of  pertussis.  Belladonna  has  been  largely  employed,  since 
it  appears  to  diminish  the  spasmodic  element  in  the  cough  of  pertussis. 
Brown-Sequard,  in  remarks  made  before  the  United  States  Medical  Associa- 
tion in  May,  1860,  maintained  that  the  duration  of  pertussis,  so  far  as  its 
nervous  element  is  concerned,  might  be  abridged  to  a  few  days  by  doses  of 
atropia  sufficiently  large  to  cause  toxical  effect ;  but  in  one  case  which  I  saw 

^  London  Medical  Record,  May  15,  1884. 


PERTUSSIS.  393 

in  consultation,  in  wliich  one  teaspoonful  of  tincture  of  belladonna  was  given  by 
mistake  to  a  child  of  about  three  years,  the  subsequent  cough,  though  mild,  did 
not  lose  its  spasmodic  element.  Children  require  a  larger  proportionate  dose 
of  belladonna  than  adults,  and  it  can  be  safely  administered  in  gradually  in- 
creasing doses  until  physiological  effects  are  produced,  when  some  mitigation 
in  the  cough  may  be  expected.  Probably  the  action  of  the  drug  is  on  the 
respiratory  centres  in  the  medulla,  and  not  directly  on  the  muscles  of  respira- 
tion. The  effect  of  belladonna  in  controlling  the  spasmodic  cough  is  most 
marked  when  physiological  symptoms  are  produced,  and  some  children  require 
larger  doses  than  others.  Thus  I  gradually  increased  the  doses  of  belladonna 
to  twelve  drops  for  a  child  of  three  and  a  half  years  who  had  severe  pertussis, 
without  producing  the  characteristic  efflorescence,  while  smaller  doses  from 
the  same  bottle  produced  this  effect  in  older  children.  Rarely  I  have  discon- 
tinued the  belladonna  on  account  of  diminished  flow  of  urine,  which  this 
agent  may  or  may  not  have  produced,  and  very  rarely  on  account  of  suddenly 
developed  muscular  weakness,  which  1  had  reason  to  think  the  belladonna 
caused.  This  occurred  in  the  case  alluded  to  above  in  which  twelve  drops 
of  the  tincture  were  given,  so  that  the  muscles  seemed  flabby  and  the  trunk 
and  head  were  supported  with  difiiculty.  The  tincture  of  belladonna  is  con- 
venient for  use,  and  most  of  that  in  the  shops  is  active  and  reliable.  The 
doses  which  I  ordinarily  found  to  be  sufficient  when  prescribing  belladonna 
for  pertussis,  and  which  also  produced  efflorescence,  were  as  follows :  to  a 
child  of  two  years  three  drops,  and  to  one  of  six  or  eight  years  eight  or 
ten  drops,  morning  and  evening.  I  always,  however,  commenced  with  a 
.smaller  number,  and  continued  to  administer  the  dose  which  produced  the 
local  effects  alluded  to,  unless  the  cough  were  moderated  by  smaller  doses. 
In  the  majority  of  cases  I  have  noticed  no  decided  effect  till  the  rash  was 
produced,  when  the  symptoms  improved,  the  cough  becoming  less  frequent 
or  less  severe.  By  the  belladonna  treatment  the  spasmodic  stage  may  not 
only  be  rendered  mild,  but  be  abridged  to  two  or  three  weeks.  In  some 
cases  the  severe  cough  begins  to  yield  almost  immediately  under  full 
doses  of  this  agent,  but  in  other  cases  its  continuance  for  some  days  is 
necessary,  with  other  remedies  as  adjuvants,  before  there  is  any  appreciable 
benefit  from  its  use.  But  since  the  germicide  treatment  of  pertussis  has 
come  into  use,  it  is  probable  that  belladonna  will  in  a  measure  be  superseded 
by  those  agents  which  are  believed  to  exert  a  destructive  effect  on  the  sup- 
posed  cause. 

Sidjjhur. — Much  benefit  is  said  to  result  from  fumigating  the  room  occu- 
pied by  the  patients  with  burning  sulphur.  The  children  having  the  disease 
are  attired  in  clean  clothes  and  removed,  and  the  room  which  they  have  occu- 
pied, containing  the  furniture,  clothes,  and  toys,  is  fumigated  five  hours  with 
burning  sulphur,  after  which  the  doors  and  windows  are  thrown  open.  The 
children  sleep  in  the  same  room  during  the  following  night.  Immediate 
improvement  is  said  to  follow.  This  treatment  of  pertussis  is  recommended 
by  Manby,  Gelhert,  Mohn,  and  others. 

The  distinguished  Brazilian  physician  Moncorvo  advises,  and  uniformly 
employs,  local  treatment  with  a  solution  of  resorcin.  In  an  interesting  paper 
read  before  the  Pediatric  Section  of  the  Ninth  International  Medical  Con 
gress  in  1887  he  states  that  he  employs  resorcin  as  a  local  antiseptic  on 
account  of  its  slight  irritating  properties,  its  great  solubility,  and  its  absence 
of  odor.  Beginning  with  a  1  per  cent,  solution,  he  had  increased  it  to  8  per 
cent.  He  first  applies  to  the  periglottic  region  a  10  per  cent,  solution  of 
hydrochlorate  of  cocaine,  which  diminishes  the  reflex  excitability  of  the 
laryngeal  mucous  membrane  and  renders  the  paroxysms  less  frequent,  and 
then  applies  the  resorcin.     I  have  largely  employed  a  10  per  cent,  solution 


394  CONSTITUTIONAL  DISEASES. 

of  resorcin  as  a  spray  from  a  barrel  atomizer  every  hour  to  two  hours.  It  is 
not  unpleasant,  and  is  apparently  useful.  I  continue  to  use  it  as  one  of  the 
most  efficient  remedies. 

Another  apparently  good  remedy  for  pertussis  is  bromoform.  This  is  a 
clear  fluid  not  disagreeable,  with  a  specific  gravity  of  2.9,  chemical  formula 
CHBrg.  Steppe  employed  it  in  70  cases  of  whooping  cough  in  children. 
In  a  few  days  the  paroxysms  diminished,  and  in  three  weeks  the  patients 
were  well. 

Cresoline,  a  product  of  coal-tar,  having  the  formula  CeHjCHjO,  vaporized 
in  the  nursery  by  a  flame  underneath,  also  has  its  advocates. 

3Iost  of  the  remedies  mentioned  above  have  apparently  been  sufficiently 
employed  to  justify  the  belief  that  when  judiciously  prescribed  they  diminish 
the  severity  and  duration  of  the  paroxysmal  stage  of  pertussis.  Additional 
observations  are  required  in  order  to  determine  the  comparative  efficiency  of 
each. 

Since  the  paroxysms  are  likely  to  be  more  severe  at  night,  and  the  patient 
consequently  is  deprived  of  the  required  sleep,  a  medicine  is  needed  which 
will  procure  some  hours  of  rest  and  thereby  diminish  the  number  of  parox- 
ysms. For  this  purpose  the  hydrate  of  chloral  is  especially  useful,  given  in 
doses  of  two  to  five  grains  according  to  the  age,  and  perhaps  repeated.  It 
does  not  seem  to  me  that  chloral  exerts  any  marked  influence  upon  the 
cough  ;  it  appears  to  be  useful  chiefly  in  the  manner  stated — to  wit,  by  pro- 
curing prolonged  sleep. 

One  of  the  chief  dangers  from  pertussis  we  have  seen  to  be  the  occur- 
rence of  passive  congestion  of  organs,  especially  of  the  brain,  with  the 
liability  to  hemorrhages,  serous  eff"usion,  and  eclampsia.  This  is  in  great 
part  prevented  by  the  action  of  the  medicines  mentioned  above,  which 
diminish  the  severity  of  the  cough  or  its  frequency.  But  when  there  are 
great  and  frequent  congestions  of  the  nervous  centres,  producing  eclampsia 
or  premonitions  of  eclampsia,  the  use  of  one  of  the  bromides  is  indicated  for 
its  prompt  and  decided  action  in  averting  the  danger.  Even  if  the  symp- 
toms be  not  urgent,  its  tranquillizing  eff"eet,  and  especially  its  prompt  action 
in  diminishing  reflex  irritability,  render  it  one  of  the  most  useful  agents  in 
pertussis.  If  there  be  sudden  twitching  of  the  muscles,  marked  stupor, 
headache  or  fretfulness,  or  adduction  of  the  thumbs  across  the  palms  of  the 
hands  during  the  cough,  I  never  fail  to  give  the  bromide  of  potassium  in 
sufficiently  large  and  frequent  doses ;  and  now  eclampsia  occurs  much  more 
rarely  in  a  case  which  I  treat  from  the  commencement  than  in  former 
years. 

The  complications  of  pertussis  require  prompt  treatment.  Whenever 
the  child  feels  ill  between  the  paroxysms,  he  should  be  carefully  examined, 
and  some  compUeation  will  probably  be  found  which  requires  treatment.  If 
the  bronchitis  have  increased  so  as  to  become  a  complication  or  pneumonia 
have  arisen,  the  whole  chest  should  be  covered  with  a  light  flaxseed  poultice 
containing  one-sixteenth  part  of  mustard,  while  quinine  and  ammonia  with 
alcoholic  stimulants  are  given  at  regular  intervals.  Ammonia  carbonate  dis- 
solved in  teaspoonful  doses  of  water  and  given  in  milk  will  be  found  useful. 
Cerebral  accidents  are  best  arrested  by  the  warm  foot-bath,  cold  to  the  head, 
and  by  the  bromide  or  chloral. 

Diphtheria  not  infrequently  supervenes  as  a  complication  in  a  locality 
where  it  is  endemic  or  epidemic,  and  if  mild  it  is  often  overlooked.  Recently 
I  have  seen  a  case  in  which  diphtheria  complicating  pertussis  had  continued 
four  days,  without  being  recognized  by  the  attending  physician,  the  symp- 
toms being  attributed  to  other  causes.  The  diphtheritic  patch  in  these  cases 
appears  upon  the  well-known  sore  under  the  tongue,  in  addition  to  its  occur- 


MUMPS.  395 

rence  upon  other  parts.  The  secondary  form  of  diphtheria  requires  the  same 
treatment  as  the  primary  form. 

Hauke  in  1862  published  experiments  which  showed  that  both  carbonic 
acid  and  ammoniacal  vapors  when  inhaled  increase  the  cough,  while  the  inha- 
lation of  oxygen  produced  no  cough  and  was  agreeable  to  the  patient.  Hence 
children  in  close  and  crowded  apartments  suifer  most  severely  from  pertussis, 
and  those  who  are  taken  to  parks  or  the  country,  where  vegetation  absorbs  the 
carbonic  acid,  not  only  obtain  benefit  from  the  general  invigorating  influence, 
but  also  as  regards  the  cough.  The  fact  that  fresh  and  pure  air  benefits  the 
cough  has  indeed  long  been  known,  and  has  influenced  practice,  for  patients 
are  almost  universally  allowed  to  be  much  of  the  time  in  the  open  air  and  are 
taken  to  the  parks  and  upon  excursions.  Nevertheless,  caution  in  this  regard 
is  required,  for  exposure  in  wet  weather  or  to  sudden  changes  of  temperature 
is  very  likely  to  develop  bronchitis  or  pneumonia. 

Prophylaxis. — Pertussis  is  very  contagious,  and  it  appears  to  be,  in  nearly 
all  instances,  if  not  in  all,  contracted  by  inhaling  the  breath  of  the  patient. 
I  have  never  observed  a  case  in  which  it  seemed  to  be  communicated  through 
a  third  person,  and  it  is  not,  I  think,  usually  contracted  by  children  living  in 
the  same  house  if  there  be  no  personal  contact.  There  is  not,  therefore,  that 
urgent  need  of  personal  disinfection  and  of  caution  on  the  part  of  the  phy- 
sician and  nurse  in  their  subsequent  intercourse  with  healthy  children,  as  in 
the  case  of  the  eruptive  fevers. 


CHAPTER    IX. 

MUMPS. 

Synonyms. — Parotitis.  Parotiditis. — Mumps  is  a  constitutional  or  blood 
disease  with  local  manifestations.  It  occurs  chiefly  in  childhood,  youth,  and 
early  manhood,  cases  being  rare  in  infancy  and  old  age.  Its  chief  character- 
istic, by  which  it  is  readily  recognized,  is  inflammation  of  the  salivary  glands, 
causing  swelling  and  tenderness. 

Etiology. — This  disease  is  highly  contagious,  and  it  commonly  occurs  as 
an  epidemic.  It  is  usually  communicated  through  the  air,  which  is  tainted 
by  the  breath  or  by  exhalations  of  a  patient,  but  cases  are  recorded  in  which 
it  seems  to  have  been  communicated  by  a  third  person  or  by  infected  articles. 
Thus  Roth  relates  a  case  in  which  it  appears  to  have  been  communicated  by 
a  physician,  and  another  case  in  which  it  was  attributed  to  the  use  of  bedding 
in  which  a  patient  with  mumps  had  slept  (^Bost.  M.  and  S.  Jonrn.,  1887). 

Mumps  is  probably  a  microbic  disease.  The  investigations  of  Ollivier  are 
confirmatory  of  those  of  Capelan  and  Charin  on  the  occurrence  of  peculiarly 
shaped  micrococci  in  the  blood  and  urine  of  patients  with  mumps  (Halde- 
mann,  in  the  Journ.  Am.  Med.  Assoc,  1887).  Pasteur  found  in  the  blood  in 
mumps  rod-shaped  bacteria  one  millimetre  broad  and  two  millimetres  long, 
but  attempts  to  inoculate  animals  were  fruitless  (^Annual  of  Med.  Sci.,  vol.  i., 
1889).  .  .    ■       . 

Incubation. — Dr.  Dukes  states  that  the  incubative  period  appeared  to  be 
from  sixteen  to  twenty  days  in  32,  and  perhaps  34,  of  42  cases.  Henoch  believes 
that  the  incubative  period  is  usually  about  fourteen  days.  Goodhart  relates 
a  case  which  occurred  fourteen  days  after  exposure,  and  in  two  others  the 
incubation  appeared  to  be  twenty-one  days.     Ringer  says  that  the  incubative 


396  CONSTITUTIONAL  DISEASES. 

period  varies  from  eiglit  to  twenty-two  days.  Flint  says  that  tLe  incubation 
varies  from  ten  to  eighteen  days.  Bristowe  states  that  the  average  is  about 
fourteen  days  ;  and  his  ojjinion,  I  think,  is  correct. 

SriiPTOMS. — Mumps  begins  with  languor  and  fever,  the  temperature  in 
some  cases  rising  to  103°,  and  if  the  fever  be  considerable  headache  and 
vomiting  are  common.  In  a  few  hours,  usually  as  early  as  the  first  visit  of 
the  physician,  the  patient  complains  of  pain  and  tenderness  in  the  depression 
below  one  ear  and  posterior  to  the  ramus  of  the  jaw.  Notwithstanding  the 
fever,  the  features  are  often  pallid.  Along  with  the  pain  and  tenderness, 
swelling  begins  in  the  site  of  the  parotid  gland  on  one  side,  and  more  fre- 
quently, it  is  said,  on  the  left  than  right.  In  most  instances  the  swelling  soon 
begins  upon  the  opposite  side,  so  that  the  disease  is  bilateral.  Exceptionally, 
it  begins  on  the  two  sides  simultaneously.  Rarely  only  one  side  is  aifected. 
The  swelling  gradually  increases ;  it  fills  the  depression  under  the  ear,  ex- 
tends forward  and  upward  upon  the  cheek,  and  downward  to  a  greater  or  less 
extent  upon  the  neck.  It  reaches  its  maximum  from  the  third  to  the  sixth 
day.  The  most  prominent  point  at  this  time  is  immediately  underneath  the 
lobule  of  the  ear,  which  is  pressed  outward  by  the  swelling  of  the  gland.  The 
tumor  yields  on  pressure,  but  is  elastic  and  tense,  and  the  fulness  immediately 
returns  when  the  pressure  is  removed.  The  skin  covering  it  preserves  its 
normal  appearance  or  it  presents  a  faint  blush.  The  fever,  more  or  less  intense, 
does  not  usually  continue  more  than  two  to  four  days,  but  occasionally  it  re- 
mains longer.  The  pressure  which  movements  of  the  jaw  and  of  the  pharyn- 
geal muscles  produce  on  the  gland  renders  mastication,  swallowing,  and  even 
speech,  painful  and  difficult.  The  submaxillary  glands,  and  also  the  sublin- 
gual, are  occasionally  involved,  so  that  the  features  are  greatly  disfigured  by 
the  swelling.  The  swelling  is  at  its  maximum  between  the  third  and  sixth 
days,  after  which  it  begins  to  decline,  and  between  the  tenth  and  twelfth  days 
it  has  entirely  disappeared. 

Occasionally,  during  an  epidemic  of  mumps,  we  observe  cases  in  which 
the  parotids  are  but  slightly  or  not  at  all  affected,  and  the  chief  manifes- 
tations of  the  disease  are  in  the  submaxillary  glands,  which  undergo  the 
characteristic  inflammatory  changes.  Rarely  the  tonsils  are  also  tumefied. 
Free  perspiration  occurs  in  certain  patients  at  the  commencement  of  conva- 
lescence. 

Anatomical  Characters. — The  opinion  expressed  by  Virchow  has  been 
generally  accepted,  that  inflammation  of  the  gland-ducts  occurs,  with  conse- 
quent oedema  of  the  connective  tissue.  The  oedema  extends  also  to  the  con- 
nective tissue  adjacent  to  the  gland. 

Complications  ;  Sequels. — The  swelling  of  the  salivary  glands  some- 
times suddenly  abates,  and  in  the  male  the  testicles  and  epididymis,  and  in 
the  female  the  mammary  glands  or  ovaries,  are  involved,  with  sometimes  more 
or  less  oedema  of  the  labia  majora.  Occasionally  these  inflammations,  which 
are  less  frequent  in  young  children  than  in  those  nearer  the  age  of  puberty, 
when  the  sexual  organs  are  becoming  more  developed,  occur  without  subsid- 
ence of  the  parotid  swelling.  They  cause  considerable  increase  in  the  fever 
and  constitutional  disturbance,  but  with  proper  treatment  decline  in  six  or 
eight  days,  pursuing  the  same  course  as  the  parotid  inflammation.  Some- 
times repellant  applications  to  the  neck  appear  to  produce  the  metastasis,  as 
in  the  following  case:  On  March  19,  1877,  I  was  requested  to  see  a  young 
gentleman  of  eighteen  years.  He  had  been  well  till  March  14th,  when  he 
complained  of  pain  below  his  ears,  and  his  mother  applied  a  towel  wrung  out 
of  cold  water  around  his  neck.  On  the  following  day  slight  swelling  was 
observed  under  the  angle  of  the  lower  jaw  on  the  right  side  (submaxillary 
gland),  and  the  cold  application  was  continued.     On  the  17th  the  swelling 


MUMPS.  397 

had  disappeared,  but  the  fever  and  headache  had  greatly  increased,  so  that 
he  was  compelled  to  lie  in  bed.  On  the  19th,  at  my  first  .visit,  he  had  such 
violent  headache  and  was  so  intolerant  of  light  and  noise  that  I  greatly  feared 
that  he  had  acute  encephalitis.  All  swelling  under  the  ears  was  gone ;  the 
left  testicle  was  tender  and  beginning  to  swell ;  axillary  temperature  102°. 
The  cold  cloths  were  removed  from  the  neck  and  applied  to  the  head,  and 
potass,  bromid.,  gr.  xsv,  administered  every  third  hour.  20th.  Axillary 
temperature  104°  ;  symptoms  unabated  and  alarming.  Ordered  six  leeches 
to  be  applied  upon  the  temples  and  left  groin,  and  a  purgative,  and  two 
drops  of  the  tincture  of  aconite  to  be  given  with  each  dose  of  the  bromide. 
21st.  Temperature  103°.  States  that  numbness  and  a  pricking  sensation 
which  he  had  felt  in  both  legs  during  the  last  forty-eight  hours  had  ceased 
(possibly  from  the  aconite).  23d.  Is  convalescent ;  has  no  return  of  the 
swelling  under  the  ears  and  the  orchitis  has  abated. 

Several  writers  mention  the  fact  that  in  rare  instances  orchitis  precedes 
the  parotiditis.  Thus,  Eustace  Smith  mentions  a  case  in  which  the  orchitis 
preceded  by  sixteen  hours  the  symptoms  referable  to  the  salivary  glands. 
The  complications  alluded  to  which  involve  the  sexual  organs  occur  more 
frequently  at  puberty  or  in  youth  than  in  childhood. 

It  is  said  that  deafness  sometimes  occurs  during  mumps,  due  to  extension 
of  inflammation  along  the  Eustachian  tube  to  the  middle  ear,  and  if  the  treat- 
ment proper  for  otitis  media  be  employed  this  form  of  deafness  abates. 
Dalby  mentions  another  foi'm  of  deafness  which  comes  on  suddenly,  and  is 
supposed  to  be  due  to  injury  of  the  auditory  nerve,  since  no  appreciable  lesion 
of  the  auditory  apparatus  is  observed.  The  impairment  of  hearing  in  this 
form  of  deafness  is  likely  to  be  permanent. 

Diagnosis. — If  the  physician  have  seen  but  few  cases  of  mumps,  there 
is  danger  that  he  may  mistake  the  swelling  for  an  inflamed  cervical  gland,  or 
vice  versa;  but  an  inflamed  cervical  gland  presents  to  the  finger  a  hardness 
almost  like  that  of  cartilage,  and  it  is  circumscribed  or  round,  and  does  not 
invest  the  ear.  These  characteristics  contrast  with  the  elasticity,  seat,  and 
shape  of  the  parotid  swelling,  which  extends  forward  upon  the  cheek  and 
surrounds  and  elevates  the  lobule  of  the  ear.  Tumefaction  resulting  from 
diphtheritic  or  any  other  form  of  faucial  inflammation,  or  from  periostitis 
aff"ecting  the  root  of  the  posterior  molar,  may  be  detected  by  examining  the 
fauces  and  interior  of  the  mouth.  Inflammation  of  the  parotid  sometimes 
occurs  in  debilitated  states  of  the  system,  as  in  or  after  severe  typhoid  fever, 
scarlet  fever,  measles,  etc.  Occurring  under  such  circumstances,  the  gland 
usually  suppurates.  The  diff"erential  diagnosis  between  this  form  of  parotid- 
itis and  mumps  can  be  made  by  the  history  of  the  case,  because  mumps 
rarely  occurs  as  a  complication  of  another  disease  and  does  not  cause  sup- 
puration. 

Prognosis. — The  result  as  regards  life  is  favorable.  The  orchitis,  if 
bilateral,  sometimes  destroys  the  virility  of  the  individual.  Permanent  im- 
pairment of  hearing  may  also  occur,  as  stated  above. 

Treatment. — This  is  simple.  In  ordinary  cases  it  sufiices  to  cover  the 
swelling  with  oakum  or  carded  wool.  If  the  tenderness  or  pain  be  consider- 
able, the  gland  should  be  covered  with  spongiopilin  soaked  in  water,  and 
gently  rubbed  with  tincture  of  belladonna  and  glycerine  in  equal  parts.  If 
the  patient  have  severe  headache,  with  high  temperature,  more  active  meas- 
ures are  required,  especially  if  delirium  be  also  present.  Saline  laxatives 
should  be  given,  a  warm  general  bath  or  mustard  foot-bath  employed,  and 
antipyrine  with  one  of  the  bromides  prescribed.  The  following  prescription 
will  be  useful  for  a  child  of  ten  years : 


398  COySTITUTIOXAL  DISEASES. 


()1.  cinnamom. , 

gtt.  V  ; 

Phenacetin, 

9ij ; 

vSodii  bromidi, 

giss; 

Cafleini  (alkaloid), 

gr.  X  ; 

Sacchr.  lactis, 

.^j. — Misce. 

Divid.  in  chart  No.  x.    Give  one  powder  every  three  hours  in  headache  or  fever. 

The  rise  of  temperature  is  a  premonitory  warning  of  a  complication,  espe- 
cially of  orchitis  in  the  male,  and  the  early  application  of  a  poultice  diminishes 
its  severity.  If  a  complication  occur,  fomentations  should  be  constantly 
applied  over  the  inflamed  part,  and  phenacetin  or  antipyrine  given  at  regu- 
lar intervals  to  reduce  the  fever. 


SEOTIOIT   III. 

OTHER   GENERAL    DISEASES. 


CHAPTER   I. 


INTERMITTENT    FEVER. 


This  is  a  constitutional  malady  produced  by  an  organism  which  exists  in 
marshy  soil.  I  have  notes  of  36  cases  of  this  disease  occurring  under  the 
age  of  three  and  a  half  years.  Several  of  these  patients  were  treated  in 
private  practice,  and  the  rest  in  institutions  with  which  I  have  been  con- 
nected. In  children  above  the  age  of  three  and  a  half  years  intermittent 
fever  differs  but  little  from  that  of  the  adult,  while  in  those  under  this  age 
it  presents  certain  peculiarities.  Of  the  36  cases  which  I  have  observed,  19 
had  the  quotidian  form,  10  the  tertian,  2  the  tertian  becoming  afterward 
quotidian,  1  the  quotidian  becoming  afterward  tertian,  while  in  the  remain- 
ing -4  cases  the  form  of  the  disease  is  not  stated.  In  quotidian  ague  the 
malaria  has  been  supposed  to  act  more  powerfully  on  the  system  or  the  sys- 
tem is  more  susceptible  to  its  influence  than  in  the  tertian  form,  and  hence 
the  fact  that  the  quotidian  is  the  prevailing  type  of  ague  in  tropical  regions, 
where  vegetation  is  luxuriant,  marshes  extensive,  and  the  heat  intense. 
According  to  this  theory,  the  feeble  resisting  power  in  the  system  of  the 
infant  explains  the  fact  that  it  has  quotidian  more  frequently  than  tertian 
intermittent,  although  the  latter  is  much  more  common  in  the  adult  in  this 
climate. 

Facts  demonstrate  that  infants  sometimes  receive  intermittent  fever  from 
their  mothers.  If  mothers  during  gestation  have  malarious  cachexia,  their 
infants,  whether  born  at  full  time  or,  as  often  happens,  prematurely,  are  apt 
to  be  small,  thin,  and  feeble,  and  occasionally  they  have  soon  after  birth  dis- 
tinct paroxysms  of  the  ague.  Dr.  Stokes  related  the  case  of  a  pregnant 
woman  with  ague  who  believed  that  she  noticed  periodical  tremors  of  her 
foetus,  but  I  suspect  that  she  was  mistaken  as  regards  the  cause,  for  the 
paroxysm  of  intermittent  in  young  children  is  not  ordinarily  accompanied 
by  tremors. 

The  youngest  infant  in  my  practice  who  apparently  derived  the  ague  from 
its  mother,  and  probably  through  the  foetal  circulation,  had  the  following  his- 
tory :  Its  mother  had  occasional  attacks  of  tertian  intermittent  during  the 
two  years  preceding  her  confinement,  and  her  baby  when  one  week  old  was 
observed  to  have  the  same  disease,  occurring  also  each  second  day,  the  cold- 
ness and  blueness  in  the  first  stage  of  the  paroxysm  lasting  from  half  an  hour 
to  one  hour. 

It  is  not  fully  ascertained  whether  a  nursing  infant  may  contract  inter- 

399 


400 


COSSTITUTIOyA L  DISEASES. 


mittent  fever  by  lactation,  but  if  it  be  admitted  that  it  is  sometimes  com- 
municated to  the  foetus  through  the  maternal  circulation,  it  does  not  seem 
improbable  that  the  specific  principle  occasionally  enters  the  milk  as  well  as 
other  secretions.  I  have  frequently  remarked  the  presence  of  the  disease  in 
nursing  infants  whose  mothers  were  affected,  and  in  one  instance  an  infant  at 
the  breast,  whose  mother  had  the  ague,  having  contracted  it  in  a  suburban 
village,  but  now  living  in  a  non-malarious  part  of  the  city,  presented  evident 
symptoms  of  the  disease.  Similar  observations  by  Frank,  Burdel.  and  others 
do  not  indeed  fully  prove  the  communicability  of  intermittent  fever  by  lacta- 
tion, but  render  it  highly  probable. 

The  period  of  incubation  in  the  infant  varies  greatly,  as  in  the  adult. 
When  the  malaria  is  concentrated  and  unusually  active  or  the  condition  of 
system  is  favorable  for  its  reception,  the  disease  may  commence  soon  after 
exposure.  Thus,  in  tropical  regions  travellers  exposed  for  a  single  night  have 
been  known  to  sicken  within  twenty -four  hoars,  but  in  our  cooler  latitude  a 
longer  incubative  period  is  the  rule.  In  the  infant,  however,  in  our  climate, 
intermittent  fever  often  begins  in  a  very  short  time  after  exposure,  though 
there  may  be  an  incubative  period  of  some  weeks.     The  following  have  been 

my  observations  relating  to  this  point :  A.  M .  female,  eight  months  old, 

remained  two  days  on  Long  Island  in  October,  1870.  and  three  days  after  her 

return  to  the  city  a  quotidian  commenced.     P.  S .  male,  eleven  months 

old,  remained  three  days  on  Long  Island,  and  a  quotidian  commenced  four 

days  after  his  return.     K ,  nine  months  old,  remained  on  Staten  Island 

one  week,  and  eleven  days  after  his  return  a  tertian  commenced.     Gr.  K , 

aged  three  years,  remained  a  day  and  a  night  on  Staten  Island  in  1870  ;  three 
weeks  afterward  intermittent  fever  commenced,  preceded  by  a  week  of  lan- 
guor.    A.  U ,  female,  aged  two  years   and  two   months,  had  the  first 

paroxysm  of  a  tertian  two  and  a  half  weeks  after  returning  from  a  visit 
of  one  week  in  Hoboken.  As  there  was  no  malaria  in  the  portions  of  the 
city  where  these  infants  resided,  the  incubative  periods  are  nearly  ascertained. 

Etiology. — The  cause  of  the  fevers,  intermittent  and  remittent,  due  to 
marsh  miasma,  is  an  organism,  designated  the  plasmodium  malarias.  Hun- 
dreds of  microscopists  had  previously  searched  for  the  malarial  microbe  in 
vain,  when  it  was  discovered  in  1880  by  M.  Laveran,  a  French  army  surgeon 
in  Algeria.  He  was  successful  in  the  discovery  because  the  technique  em- 
ployed by  him  differed  from  that  of  his  predecessors.  The  plasmodium  is 
the  most  interesting  and  remarkable  pathogenic  body  yet  discovered  in  the 
blood.  The  following  figures,  representing  stages  of  its  development,  are 
copied  from  the  paper  by  Dr.  Manson,  published  in  the  London  Lancet.  Jan- 
uary 6,  1894.     Fig.  51  represents  a  red  blood-corpuscle,  having  in  its  inte- 


FiG.  51. 


Fig.  52. 


Fig.  53. 


rior  a  pale  body  with  ill-defined  edges.  Within  this  body  are  very  black 
particles  which,  closely  examined  under  the  microscope,  are  seen  to  be 
moving,  so  as  to  change  their  relation  to  each  other.  The  shape  of  the 
shadowy  body  within    the    corpuscle  also   changes.      Fig.  52   represents    a 


INTERMITTENT  FEVER. 


401 


similar  body  which,  instead  of  being  intercellular,  floats  free  in  the  blood- 
plasma.  Fig.  53  represents  circular  disk-shaped  bodies,  transparent  except 
at  their  centres,  where  very  black  granules  are  aggregated,  some  of  which 
granules  are  agitated  and  moving.  Some  of  these  transparent  bodies  are 
intracorpuscular  and  surrounded  by  a  rim  of  hemoglobin,  but  most  of  them 
float  free  in  the  plasma,  and  are  designated  by  Manson  "  centrally  pigmented 
disks."     Fig.  54  exhibits  a  body  similar  to  the  last,   but  with   a  properly 


Fig.  54. 


Fig.  55. 


Fig.  56. 


adjusted  microscope  the  pale  peripheral  substance  external  to  the  black 
granules  is  seen  to  be  arranged  in  leaflets,  so  as  to  resemble  the  petals  of  the 
daisy.  These  ''rosettes"  occur  both  within  cells  and  free  in  the  blood- 
plasma,  but  are  not  common.  Fig.  55  represents  another  view  of  the  Plas- 
modium— to  wit,  crescenta,  with  the  horns  rounded,  and  in  some  cases  an 
indistinct  shadowy  body  lying  in  the  cup 
or  upon  the  concave  surface  with  its  edge 
presenting  the  appearance  of  a  line  with  its 
convexity  outward. 

Fig.  56  represents  a  form  of  the  Plas- 
modium which  has  most  remarkable  cha- 
racteristics, and  is  apparently  very  harmful 
to  the  blood. 

I  can  do  no  better  than  quote  Manson's 
graphic  description  of  this  remarkable  form 
of  the  malarial  parasite.  Says  he  :  "  Some- 
times in  searching  through  a  slide  of  mala- 
rial blood,  at  a  particular  point  of  the  field 
you  will  see  one  or  more  of  the  blood- 
corpuscles  moving  about  a  little  and  agi- 
tated without   any  evident  cause.     If  one 

of  the  corpuscles  happens  to  be  standing  on  edge,  you  may  see  it  bend  over 
upon  itself  as  if  pressed  down  by  some  force,  and  then  spring  up  again  as  if 
this  force  had  been  removed.  Sometimes  in  such  a  slide  you  will  see  one  or 
more  of  the  corpuscles  crushed  up,  as  it  were,  or  dashed  aside  and  tumbled 
about.  If  now  you  turn  on  the  high  power  and  inquire  as  to  the  cause  of 
this  disturbance  among  the  corpuscles,  you  will  be  brought  face  to  face  with 
one  of  the  most  striking  of  the  many  strange  sights  the  microscope  reveals 
to  us.  Imagine  a  microscopic  cuttle-fish,  or  octopus,  with  a  clear  globular 
body  in  which  a  number  of  rather  large  black  piquant  particles  are  tumbling 
and  chasing  each  other  about  in  a  state  of  incessant  motion.  Imagine,  also, 
proceeding  from  and  attached  to  this  body  one,  two,  three,  or  four  long,  slen- 
der arms,  each  of  them  three  or  four  times  the  length  of  the  diameter  of  a 
blood-corpuscle,  and  all  these  long  cuttle-fish-like  arms  whirling  about  like  so 
many  whiplashes  or  flails  in  a  state  of  frantic  activity.  This  is  what  is 
known  as  the  '  flagellated  organism  of  malarial  blood.'  The  long  arms 
thrust  the  corpuscles  about,  double  them  up,  coil  around  them,  squeeze 
26 


402  CONSTITUTIONAL  DISEASES. 

them  out  of  shape,  and  treat  them  like  so  many  india-rubber  balls.  Occa- 
sionally one  of  the  arms  breaks  away  from  the  spherical  body  it  was  attached 
to.  It  swims  about,  wriggling  its  way  among  the  corpuscles,  and  quickly 
passes  out  of  the  field.  Some  one  of  the  arms  coils  itself  up  or  starts  into 
an  extended  position,  shivering  like  a  wand  when  it  is  struck." 

The  relation  of  these  forms  of  the  plasmodium  to  each  other  is  still  a 
matter  of  conjecture.  Manson  believes  that  the  "rosette"  form  is  the  ma- 
tured organism,  and  that  the  petals  of  the  rosette  are  the  germs,  some  of 
which,  as  they  separate,  enter  the  red  blood-corpuscles,  and  others  remain  in< 
the  plasma,  where  they  develop.  It  is  believed  by  him  that  the  bronzing  of 
the  tissues  which  occurs  in  severe  cases,  attended  by  recurrences,  is  caused 
by  the  pigmentary  matter  which,  developed  in  the  organisms  which  we  have 
described  above,  are  conveyed  to  the  diiferent  tissues.  The  periodicity  of  the 
fevers  due  to  marsh  miasm  requires  explanation.  That  a  fever  produced  by 
an  animal  parasite  should  be  quotidian,  tertian,  or  quartan  cannot,  in  our 
present  knowledge,  be  satisfactorily  explained.  Another  subject  requiring 
explanation  is  the  fact  that  one  affected  by  the  malarial  miasm  remains  so 
long  under  its  influence,  so  that  attacks  of  malarial  fever  recur  even  under 
circumstances  favorable  for  its  elimination.  Thus  a  child  of  ten  years  had 
every  year  for  seven  years  attacks  of  intermittent  fever.  The  disease  was 
contracted  at  the  age  of  three  years  in  Harlem,  and  the  subsequent  residence 
of  the  family  had  been  in  a  part  of  the  city  where  no  malaria  exists. 

Sympto3IS. — In  infancy,  and  especially  prior  to  the  age  of  eighteen 
months,  the  symptoms  differ  in  certain  respects  fi'om  those  which  characterize 
the  malady  in  the  adult,  and  are  universally  known.  In  childhood  the  symp- 
toms are  similar  to  those  in  the  adult,  and  need  not  therefore  be  described  in 
this  connection. 

In  the  infant  the  type,  as  we  have  seen,  is  quotidian,  with  now  and  then 
a  tertian.  Advancing  beyond  the  age  of  eighteen  months,  we  meet  more  and 
more  cases  of  the  tertian  type,  and  in  childhood  the  tertian  is  the  common 
form.  I  have  known  the  quotidian  in  the  infant,  when  cured,- to  reappear  a 
few  weeks  later  as  a  tertian  ;  but  ordinarily  it  remains  quotidian,  unless  the 
patient  has  reached  the  age  at  which  the  tertian  type  predominates. 

The  paroxysm  in  the  young  infant  presents  three  stages,  as  in  the  adult, 
but  while  the  second,  or  febrile,  is  well  marked,  the  first  and  third  are  much 
less  pronounced.  The  patient  does  not  shake  (exceptionally  one  does  even 
within  the  first  year)  in  the  first  stage,  but  a  slight  tremor  may  or  may  not  be 
observed.  The  countenance  presents  a  sunken  appearance,  the  lips  and  fingers 
are  livid,  while  portions  of  the  surface  not  livid  are  pallid,  with  the  goose- 
flesh  appearance,  which  is,  however,  less  marked  than  in  children  of  a  more 
advanced  age.  The  blood  leaves  the  surface,  which  consequently  shrinks, 
while  it  accumulates  in  the  veins  and  internal  organs ;  the  pulse  is  feeble  and 
readily  compressed ;  the  surface  grows  cool  from  the  diminished  supply  of 
blood,  but  the  breath  is  warm,  and  the  internal  temperature,  so  far  from  being 
reduced,  is  elevated  two  or  three  degrees.  The  parents  may  be  alarmed  at  the 
sudden  sinking  of  the  vital  powers  and  seek  medical  advice,  but  in  other 
instances  the  first  stage  is  so  slight  that  it  passes  unperceived  till  they  have 
been  taught  to  watch  for  it. 

In  the  second  or  febrile  stage,  which  immediately  succeeds,  the  pulse 
becomes  full  and  rapid,  120  to  13(5  or  140  beats  per  minute,  and  the  external 
as  well  as  internal  temperature  is  elevated  as  in  few  other  diseases  (104°- 
108°).  The  face  is  flushed,  surface  dry,  and  head  painful,  as  evinced  by  the 
features.  This  stage  lasts  about  two  or  three  to  six  or  eight  hours.  The 
third  stage,  or  that  of  perspiration,  succeeds,  which  terminates  the  suffering 
of  the  patient  till  the  following  paroxysm.     In  infancy  the  perspiration  is  not 


INTERMITTENT  FEVER.  403 

abundant,  and  in  the  first  half  of  this  period  is  nearly  absent.  In  the  interval 
of  the  paroxysms  the  patient  appears  well,  except  a  degree  of  languor. 

In  24  of  the  cases  of  infantile  intermittent  which  I  have  treated  my  notes 
describe  the  character  of  the  paroxysms.  In  16  of  these  there  was  no  chill 
or  trembling  in  the  first  stage,  but  blueness  and  coolness  of  the  extremities 
and  features  and  sudden  prostration.  This  stage  lasted  from  ten  minutes  to 
one  hour.  In  the  8  remaining  cases  the  infants  were  observed  to  tremble  or 
shake  as  in  adult  cases.  The  perspiration  of  the  third  stage  was  in  nearly  all 
cases,  when  observed,  slight  and  of  short  duration,  but  in  some  it  was  not 
observed. 

During  the  cold  stage  passive  congestion  of  the  internal  organs  occurs  to 
a  greater  or  less  extent,  but  the  circulation  is  equalized  during  the  reaction 
of  the  second  stage.  The  spleen,  whose  capsule  is  distensible,  soon  enlarges 
in  many  patients  in  consequence  of  the  frequent  and  great  congestions,  con- 
stituting the  "  ague  cake."  This  enlargement  is  more  common  in  children 
than  adults.  Since  my  attention  has  been  particularly  directed  to  this  sub- 
ject I  have  been  able  to  feel  the  enlarged  spleen,  by  examination  through 
the  abdominal  walls,  in  probably  one-third  of  the  cases  under  the  age  of  ten 
years.  This  organ  returns  to  the  normal  size  after  the  ague  is  cured.  From 
the  intimate  relation  of  the  spleen  to  the  composition  of  the  blood,  it  is  evi- 
dent that  the  character  of  this  fluid  must  be  affected  if  intermittent  fever  be 
protracted.  The  blood  becomes  more  and  more  impoverished  and  a  state  of 
decided  hydraemia  supervenes.  A  few  weeks'  continuance  of  the  ague  suf- 
fices to  produce  decided  pallor  of  the  features  and  surface  generally,  and  as 
all  watery  blood  is  prone  to  transudation,  such  patients  not  infrequently 
present  more  or  less  oedema  of  the  face,  ankles,  and  other  parts.  Sometimes 
also,  especially  under  unfavorable  hygienic  circumstances,  purpuric  spots 
(purpura  haemorrhagica)  appear  under  the  skin,  affording  additional  proof  of 
the  change  which  the  blood  has  undergone. 

In  long-continued  cases  of  malarial  disease  in  the  adult  waxy  degenera- 
tion of  organs  is  apt  to  occur,  as  well  as  melanaemia.  Pigment-cells,  flakes, 
and  particles  appear  in  the  blood,  the  coats  of  the  minute  arteries,  and  in 
various  organs,  as  spleen,  liver,  etc.  In  the  child  these  results  are  more 
rare. 

Intermittent  fever  in  children,  if  proper  remedial  measures  are  employed 
at  an  early  period,  is  ordinarily  not  dangerous,  and  is  quite  amenable  to 
treatment ;  but  that  comparatively  infrequent  and  fatal  form  of  it  desig- 
nated the  ■'  pernicious  "  occurs  more  frequently  in  children  than  in  adults. 
In  New  York  City,  where  the  type  of  malarial  diseases  is  mild,  I  have  never 
met  a  case  of  pernicious  intermittent  in  the  adult,  but  I  can  recall  to  mind 
such  cases  in  children,  two  of  them  fatal.  This  form  of  the  fever  occurs  in 
a  smaller  proportionate  number  of  cases  in  infancy  than  in  childhood,  proba- 
bly because  the  cold  stage  is  less  pronounced.  In  the  pernicious  ague  the 
system  is  overpowered — it  does  not  react  in  a  degree  commensurate  with  the 
intensity  of  the  disease.  The  patient  enters  the  cold  stage,  becomes  stupid, 
and,  if  not  relieved  by  prompt  and  efiicient  measures,  passes  into  fatal  coma. 
A  type  of  the  disease,  therefore,  which  would  not  be  pernicious  in  a  robust 
individual  may  be  such  in  one  of  a  broken-down  constitution  and  feeble 
reactive  power.  In  most  cases  occurring  in  children  the  coma  is  preceded  by 
eclampsia,  which  is  apt  to  be  general  and  contracted. 

Eclampsia  increases  the  passive  congestion  of  the  cerebro-spinal  axis 
already  present  in  this  stage,  and  if  not  speedily  relieved  may  end  in  trans- 
udation of  serum  over  the  surface  of  the  brain,  and  perhaps  meningeal 
apoplexy,  causing  fatal  coma.     This  has  occurred  twice  in  my  practice. 

Sometimes  in  young  children  the  diagnosis  of  intermittent  fever  is  doubt- 


404  CONSTITUTIONAL  DISEASES. 

ful,  either  because  the  disease  has  not  continued  suflSciently  long  or  there  has 
not  been  the  characteristic  paroxysm.  The  patient  may  be  feverish  and  fret- 
ful, with  anorexia  and  evidences  of  headache,  but  without  the  usual  distinc- 
tive symptoms.  I  have  sometimes  in  such  cases  been  able  to  establish  the 
diagnosis  by  detecting  enlargement  of  the  spleen.  In  examining  for  the 
"  ague  cake  "  the  child  must  lie  quietly  on  its  back,  and  the  fingers,  placed 
midway  between  the  epigastrium  and  umbilicus,  be  carried  gently  but  with 
firm  pressure  outward  in  the  direction  of  the  spleen,  when  the  anterior  edge 
of  this  organ  will  be  felt  if  it  be  enlarged.  It  is  impossible  to  make  the 
examination  when  the  child  cries,  on  account  of  the  contraction  of  the 
abdominal  muscles. 

Treatment. — It  is  evident  that  no  time  should  be  lost  in  applying  appro- 
priate remedies  in  a  case  of  infantile  ague,  for,  although  the  first  paroxysm 
may  be  mild,  the  next  may  be  more  severe  and  attended  with  danger.  More- 
over, the  sooner  the  disease  is  cured  the  less  liable  it  seems  to  be  to  return. 
Therefore  we  prescribe  at  once  the  sulphate  of  quinia  or  cinchona,  one  and  a 
half  grains  of  the  latter  producing  the  effect  of  about  one  grain  of  the  former. 
Our  experience  in  the  children's  class  in  the  Outdoor  Department  has  been 
chiefly  with  the  sulphate  of  cinchona  on  account  of  its  cheapness,  and  there 
has  yet  been  no  case  of  ague  which  it  has  failed  to  control.  A  recent  writer 
has  published  statistics  showing  his  success  in  curing  intermittent  fever  by 
this  agent,  but  nothing  in  therapeutics  is  more  easy  than  to  cure  this  disease 
in  our  climate  by  either  of  the  sulphates  mentioned.  The  chief  difiiculty 
consists  in  preventing  a  return.  To  an  infant  of  two  years  I  presci-ibe  one 
grain  of  sulphate  of  quinia  or  the  equivalent  of  sulphate  of  cinchona  three 
times  daily,  till  all  symptoms  of  the  ague  have  disappeared ;  then  twice  a 
day  during  the  subsequent  week,  and  afterward  once  a  day  for  some  days, 
and  finally  twice  or  thrice  a  week.  It  is  only  by  the  protracted  use  of  the 
drug  in  occasional  doses  that  the  return  of  the  intermittent  fever  can  be 
prevented. 

It  is  important  in  administering  these  sulphates  to  infants  to  employ  a 
vehicle  which  will,  so  far  as  possible,  disguise  the  bitterness.  The  vehicle 
which  I  prefer  for  their  administration  is  the  elixir  adjuvans,  elixir  tarax. 
comp.,  or,  better  still,  the  syrupus  yerbse  santae  comp.  The  following  formula 
is  for  a  child  of  three  years : 

R.   Quinife  sulphat.,  gr.  xvj  ; 

Syr.  pruni  virginiani, 
Syr.  yerbse  santse  comp.,        da.  §j. — Misce. 

The  following  is  also  a  good  formula : 

R.  Quinia"  sulphat.,  gr.  xvj  ; 

Syr.  yerbje  santse  comp. ,  gij. — Misce. 

One  teaspoonful  three  to  five  times  daily. 

The  first,  dose  should  be  given  immediately  after  the  fever  abates.  In  this 
climate  two  or  three  days  suffice  to  cure  the  disease,  after  which,  by  daily 
but  gradually  diminished  use  of  medicine  in  the  manner  stated  above,  the 
return  of  the  malady  is  prevented.  Protracted  cases  attended  by  anasmia 
require  the  use  of  iron  in  addition  to  the  remedy  which  is  designed  to  con- 
trol the  disease. 

For  children  with  irritable  stomachs,  who  cannot  retain  the  salts  of  quinine 
which  are  ordinarily  prescribed,  the  tannate  may  be  employed  in  powder  or 
loz-enges  with  chocolate ;  but  in  order  to  produce  the  same  effect  the  dose 
must  be  two  and  a  half  times  greater  than  that  of  the  sulphate  or  muriate. 


REMITTENT  FEVER.  405 

The  protracted  cachexia  wliicli  follows  an  attack  of  malarial  fever  is  best 
treated  in  children,  as  it  is  in  adults,  by  arsenic,  especially  tlie  liquor  potassse 
arsenit.,  and  iron.  Quinine  is  much  less  efficient  in  curing  this  cachexia  than 
these  agents 


CHAPTER    II. 

EEMITTENT    FEVER. 

If  a  physician  were  to  consult  the  standard  treatises  on  diseases  of  children 
in  order  to  ascertain  the  nature  of  remittent  fever,  he  would  rise  from  the 
perusal  with  no  clear  idea  of  it.  One  tells  us  that  the  remittent  fever  of 
children  is  identical  with  typhoid  fever  of  adults  ;  another,  that  it  is  a  gastro- 
intestinal inflammation ;  and,  finally,  Hillier  believes  that  there  is  properly 
no  such  disease,  and  that  the  term  should  be  dropped  from  the  nosology  of 
diseases  of  children.  There  is,  however,  a  remittent  fever  of  children  as  well 
as  of  adults,  and  much  of  the  confusion  which  exists  in  reference  to  it  arises 
from  the  fact  that  writers  have  not  kept  in  view  what  constitutes  a  fever. 

Febrile  action  which  has  a  local  cause  is  not  an  essential  fever,  and  should 
not  be  described  as  such.  It  happens  that  in  children  a  symptomatic  remit- 
tent fever  arises  from  a  variety  of  local  causes,  as  dentition,  intestinal  worms, 
subacute  gastro-intestinal  inflammation,  etc.  But  all  such  cases  should  be 
excluded  from  our  consideration  of  remittent  fever  as  clearly  as  we  distin- 
guish the  continued  fever  of  pneumonia  or  bronchitis  from  that  of  typhus 
or  typhoid. 

There  is  an  essential  remittent  fever  of  children  due  to  malaria.  The 
same  conditions  which  produce  intermittent  fever  do,  in  a  certain  proportion 
of  cases,  produce  a  fever  which  does  not  intermit,  but  continues  with  more 
or  less  pronounced  exacerbations  a  certain  number  of  days,  when  it  ceases  or 
becomes  intermittent.  Those  who  practise  in  malarious  localities  notice  a 
larger  proportion  of  cases  of  remittent  fever  among  children  than  adults, 
because  their  constitutions  are  less  able  to  resist  the  malarial  poison,  so  that 
an  exposure  which  in  an  adult  would  produce  milder  disease — to  wit,  a  tertian 
ague — frequently  causes  a  quotidian  or  remittent  in  the  child. 

In  hot  countries,  where  the  malarial  poison  is  more  active  and  the  diseases 
due  to  malaria  more  severe  than  in  the  temperate  regions,  cases  of  remittent 
fever  due  to  the  marsh  miasm  are  more  common  than  in  the  temperate 
regions.  The  -jungle  fever"  of  India  is  a  malarial  remittent  fever  of  a 
severe  type. 

In  my  opinion,  the  term  "  remittent  fever,"  if  retained  in  nosology,  should 
be  restricted  to  those  fevers  of  a  remitting  type  which  are  due  to  marsh 
miasm,  so  that  it  differs  from  intermittent  fever  in  the  fact  of  a  greater 
intensity  and  not  in  its  essential  nature.  The  one  disease  is  characterized 
by  intervals  of  apyrexia,  and  the  other  by  periods  of  a  diminution,  but  not 
cessation,  of  the  febrile  symptoms. 

In  Xew  York  City,  and  probably  in  other  localities  in  the  temperate  zone, 
a  continued  fever  of  a  mild  type  not  infrequently  occurs  in  children,  espe- 
cially in  the  spring  and  autumn,  running  a  course  of  one  to  two,  three,  or 
even  four,  weeks,  with  in  many  cases  a  slight  increase  in  the  latter  part  of 
the  day.  Children  with  this  fever  are  languid,  moderately  thirsty,  and  with- 
out appetite.      They  complain  in  the  first  days  of  headache.      Their  tongue  is 


406  CONSTITUTIONAL  DISEASES. 

moderately  furred.  They  have  a  slight  cough,  no  diarrhoea,  a  temperature  of 
101°  or  1U2°,  and  many  of  them  do  not  feel  ill  enough  to  go  to  bed,  except 
at  the  usual  hours  of  sleep,  during  the  whole  progress  of  the  disease,  which 
continues  a  variable  time,  from  one  to  three  weeks.  This  disease  physicians 
of  New  York  sometimes  designate  remittent,  sometimes  malarial,  and  occa- 
sionally, the  severe  cases,  typho-malarial.  I  have  noticed  that  this  light 
form  of  fever  occasionally  occurs  in  a  household  or  asylum  in  connection 
with  typical  cases  of  typhoid  fever,  and  therefore  am  led  to  regard  it  as  a 
mild  form  of  this  disease.  Thus  in  a  family  in  West  Fifty-fourth  street  two 
children  had  this  fever  so  mildly  that  they  were  every  day  dressed  and  sitting 
quietly  in  the  room,  but  their  aunt,  a  lady  of  about  thirty  years,  who  took 
care  of  them,  sickened  with  a  severe  typical  and  protracted  typhoid  fever 
while  she  was  attending  them.  In  the  Roman  Catholic  Orphan  Asylum  of 
this  city  typhoid  fever  occurred  some  years  ago.  and  some  of  the  cases  were 
of  the  mild  form  described  above,  but  two  or  three  were  fatal,  and  the 
characteristic  lesions  of  typhoid  fever  were  discovered  at  the  autopsies. 
Therefore  this  mild  continued  fever,  having  perhaps  a  slight  but  scarcely 
appreciable  morning  remission,  should  not,  in  my  opinion,  be  designated 
remittent,  malarial,  or  typho-malarial— terms  which  have  been  applied  to  it — 
but  be  regarded  as  a  mild  typhoid  fever.  It  seems  to  me  that  typhoid  fever, 
like  diphtheria,  does  sometimes  present  so  mild  a  type  in  childhood  that  the 
patients  are  not  confined  to  bed,  and  their  sickness  terminates  in  one  or  two 
weeks,  instead  of  three  or  four,  as  stated  in  the  books. 

Symptoms. — This  disease  begins  with  chilliness  and  headache,  and  exacer- 
bations and  remissions  occur  each  day.  In  severe  cases  the  temperature 
during  certain  hours  reaches  104°  or  105°,  and  the  exacerbation  may  be 
accompanied  by  delirium  or  stupor.  The  severe  headache,  restlessness,  and 
jactitation  show  that  the  nervous  system  is  profoundly  involved  in  certain 
cases.  There  may  be  distinct  remissions  in  the  beginning,  and  afterward,  for 
a  few  days,  the  fever  be  pretty  uniform,  when  it  again  remits  or  ceases.  The 
tongue  is  covered  with  a  light  fur.  Thirst,  loss  of  appetite,  a  tendency  to 
constipation,  and  scanty,  high-colored  urine  containing  urates,  are  common 
symptoms. 

Diagnosis  ;  Prognosis. — Typhoid  fever  usually  comes  on  more  grad- 
ually than  remittent  fever,  and  is  not  attended  by  so  great  a  daily  variation 
in  temperature.  It  is  of  more  importance  to  make  the  differential  diagnosis 
between  remittent  fever  and  the  acute  local  diseases,  especially  meningitis 
and  pneumonitis  ;  but  a  careful  examination  of  the  signs  and  symptoms, 
which  will  be  considered  hereafter  in  our  remarks  on  the  local  diseases,  will 
enable  us  to  make  the  diagnosis.  The  prognosis  is  favorable  with  prompt 
and  appropriate  treatment. 

Treatment. — Prompt  treatment  by  one  of  the  salts  of  quinine  is  required. 
Formerly  it  was  thought  advisable  to  employ  first  laxative  and  diaphoretic 
remedies,  in  the  belief  that  quinine,  if  administered  immediately,  might  cause 
cerebral  congestion.  But  since  the  bromides  and  antipyrine  came  into  use, 
no  treatment  preparatory  to  the  use  of  quinine  is  required,  unless  a  single 
laxative  dose  in  the  beginning,  as  by  calomel  or  the  magnesium  citrate. 
Alternate  doses  of  quinine  and  bromide  of  potassium,  at  intervals  of  two 
hours,  will  in  a  few  days  control  the  fever.  The  bromide  will  prevent  any 
ill  effects  of  the  quinine  in  producing  cerebral  congestion,  which  was  formerly 
feared.  In  cases  attended  by  marked  pyrexia,  jactitation,  and  delirium  anti- 
pyrine should  be  added  to  the  bromide. 


TYPHOID  FEVER.  407 

CHAPTER   III. 

TYPHOID  FEVER. 

Typhus  and  typhoid  fevers  occur  in  children,  but  the  former  is  mild  and 
infrequent,  rarely  occurring  except  when  adults  of  the  same  household  are 
affected.  It  requires  little  treatment  besides  good  nursing.  Typhoid  fever, 
on  the  other  hand,  is  not  infrequent  in  children,  and,  as  it  presents  certain 
peculiarities  prior  to  the  age  of  puberty,  it  is  proper  to  describe  it  in  this  con- 
nection. This  disease  is  much  less  common  in  infancy  than  in  childhood, 
and  in  the  first  half  of  infancy  is  believed  to  be  rare.  Still,  there  can  be  no 
doubt  that  many  cases  in  the  first  years  of  life  are  not  diagnosticated,  being 
mistaken  for  subacute  and  protracted  entero-colitis.  It  is  probably  more 
common  under  the  age  of  six  years  than  is  usually  supposed,  although  the 
younger  the  child  below  this  age  the  less  frequent  does  it  appear  to  be,  while 
above  the  age  of  six  years  it  is  more  and  more  frequent  until  puberty.  In 
the  statistics  of  Cadet  de  Gassicourt,  embracing  276  children,  3  were  at  the 
age  of  two  years,  7  at  the  age  of  three  years,  8  at  four  years,  13  at  five 
years,  and  the  number  gradually  increased  in  successive  years  until  there 
were  32,  41,  and  42  cases  at  the  ages  of  twelve,  thirteen,  and  fourteen  years. 
Farnham  has  reported  a  case  occurring  in  a  girl  of  three  years  whose  father 
was  at  the  time  convalescing  from  the  fever.  She  complained  of  feeling 
tired,  and  was  listless,  but  fretful.  Her  surface  was  hot  and  face  flushed  in 
the  latter  part  of  the  day.  Her  temperature  on  the  seventh  day  reached 
104.8°,  when  she  was  put  to  bed.  The  fever  ceased  on  the  sixteenth  day, 
after  which  the  temperature  was  subnormal  for  ten  days. 

Causation. — Klebs  in  1881  announced  that  he  had  discovered  a  bacillus 
in  cases  of  typhoid  fever,  which  he  believed  to  be  the  cause  of  the  disease, 
and  which  he  designated  the  bacillus  typhosus.  Each  bacillus  contained  a 
spore  in  its  interior,  and  often  one  at  its  extremity  from  which  new  bacilli 
developed.^  About  the  same  time  Eberth  also  discovered  the  bacillus  in  the 
intestinal  mucous  membrane,  the  mesenteric  glands,  and  spleen  in  typhoid 
fever,  and  ascertained  that  it  differed  from  other  bacteria  in  the  staining.  In 
17  cases  these  bacilli  wei'e  found  in  6,  and  not  found  in  11.- 

Gaffky  announced  the  results  of  his  observations  and  experiments  with 
the  bacillus  typhosus.  He  succeeded  in  cultivating  it  in  various  substances. 
Upon  the  surface  of  potato,  sterilized  by  steam,  it  grows  abundantly,  forming- 
rods  0.2,a  thick  and  0.6,a  to  0.8,a  in  length.  The  rods  have  active  movement 
and  are  aerobic. 

The  bacillus  typhosus  is  constantly  found  at  an  early  stage  of  typhoid 
fever  in  the  spleen,  mesenteric  glands,  Peyer's  patches,  and  the  solitary 
follicles.  Occasionally  it  has  been  discovered  in  the  lungs,  liver,  and  kidneys, 
and  rarely  in  the  blood.  When  the  symptoms  pertaining  to  the  fever  begin 
to  abate,  the  bacillus  also  begins  to  disappear,  so  that  in  the  fourth  week  it 
sometimes  cannot  be  discovered,  and  is  usually  less  abundant  than  in  the  first 
and  second  weeks  ;  but  it  may  be  present  after  the  fourth  week.  The  bacilli 
occur  in  colonies  or  irregular  masses.  The  figure  represents  the  bacilli  as 
observed  in  the   spleen. 

The  bacillus  typhosus  has  not  been  discovered  in  any  other  disease  than 

typhoid  fever,  although  search  has  been  made  for  it.     Frankel  and  Simmonds 

inoculated  rabbits  with  it.     The  animals  were  sick  in  consequence,  and  in 

those  that  died  the  spleen,  the  solitary  follicles,  Peyerian  patches,  and  certain 

1  Phila.  Med.  Times,  Dec.  3,  1881.  -  Brit.  Med.  Jour.,  Nov,  26,  1881. 


408 


CONSTITUTIONAL  DISEASES. 


lymphatic  glands  were  found  tumefied.  For  the  reasons  stated,  pathologists 
for  the  most  part  agree  that  this  bacillus  is  the  cause  of  typhoid  fever,  but 
from  the  fact  that  no  bacilli,  or  but  few,  are  found  in  the  blood,  it  is  not 

Fig.  57. 


Fig 


improbable  that  the  fever  and  other  prominent  symptoms  of  the  disease  may 
be  largely  due  to  ptomaines  which  the  bacilli  produce. 

The  bacillus  typhosus  is  very  tenacious  of  life.  Prudden  found  that  it 
could  be  cultivated  after  it  had  been  frozen  in  ice  one  hundred  and  three 
days ;  also  after  it  had  been  subjected  to  a  heat  of  132.8°,  and  again  when  it 
had  been  alternately  frozen  and  thawed.^  Vidal  and  Chantemesse,  by  capil- 
lary punctures  of  the  spleen  during  the  life  of  the  patient,  obtained  the 
bacillus,  with  which  they  inoculated  mice  and  guinea-pigs,  and  subsequently 
discovered  this  organism  in  their  lungs  and  abdominal  organs.  They  also  found 
it  in  the  placenta  of  a  typhoid  patient  who  aborted  at  the  fourth  month.'^ 

Vaughan  and  Novy  obtained  cviltures  of  the  typhoid  bacillus  from  the 
water  used  by   a   considerable   number   of  typhoid-fever  patients,  and   the 

syrupy  extract  containing  the  bacillus  and  the 
ptomaines  produced  by  it,  injected  under  the  skin 
of  cats,  caused  2°  to  4.5°  of  rise  in  temperature. 
They  have  formulated  the  following  definition  of 
the  disease  :  "  An  infectious  disease  arises  when  a 
specific  pathogenic  micro-organism,  having  gained 
admittance  to  the  body,  and  having  found  the  con- 
ditions favorable,  grows  and  multiplies,  and  in  so 
doing  elaborates  a  chemical  poison  which  induces 
its  characteristic  eifects."  ^ 

The  discovery  of  the  bacillus  typhosus  and  of 
its  causal  relation  to  typhoid  fever  affords  import- 
ant aid  to  our  knowledge  of  the  manner  in  which 
typhoid  fever  is  produced.  The  theory  advocated 
by  Murchison,  that  this  disease  may  originate  de 
novo  by  exposure  to  filthy  accumulations  of  any 
kind,  is  now  known  to  be  false.  Only  such  sub- 
stances can  communicate  the  disease  as  contain 
the  specific  bacillus,  and  it  is  obviously  necessary 
'-  Lond.  Lane,  1887.       ^  Ptomaines  and  Leueomames,  1888. 


Diagrammatic  representation 
of  Peyer's  patches  in  typhoid 
fever:  a,  early  stage  witli 
swelling  of  the  patch ;  b,  later 
stage  with  sloughing;  c,  ulcer 
with  infiltrated  walls  (Thier- 
felder). 

IjY.  r.  Med.Rec.,  1887. 


TYPHOID  FEVER.  409 

that  this  bacillus  should  in  some  manner  enter  the  system,  so  as  to  infect  the 
individual.  Exhalations  from  the  most  filthy  accumulations,  and  even  inocu- 
lation with  the  most  fetid  material,  will  not  cause  typhoid  fever  unless  the 
bacillus  typhosus  be  present.  But  the  remarkable  vitality  of  this  organism, 
and  its  power  of  propagation  in  certain  substances  in  common  use,  as  water 
and  milk,  give  rise  to  epidemics  in  localities  where  it  happens  to  be  introduced. 

Typhoid  fever  is  seldom,  and  perhaps  not  at  all,  contracted  by  inhaling 
the  breath  of  a  patient  or  exhalations  from  his  surface,  but  his  urinary  and 
fecal  excreta  contain  the  bacillus  in  abundance  and  ai'e  the  most  common 
source  of  infection.  Many  instances  are  on  record  of  epidemics  caused  by 
the  use  of  water  for  culinary  or  drinking  purposes  which  had  been  in  some 
manner  polluted  by  the  excreta  of  typhoid  patients.  One  of  the  earliest 
recorded  instances  of  this  kind  was  observed  by  the  late  Prof.  Austin  Flint 
in  1843.  In  a  village  in  Western  New  York  a  traveller  with  typhoid  fever 
was  cared  for  at  the  inn,  and  his  excreta  were  deposited  near  the  well  which 
supplied  the  Avhole  village  except  one  family.  The  stranger  died,  and  within 
a  month  typhoid  fever  occurred  in  all  the  families  of  the  village  except  the 
one  that  obtained  water  from  a  different  well.  At  Pierrefonds  23  persons 
occupied  adjacent  houses.  The  water  which  they  used  was  obtained  from 
shallow  wells  into  which  it  had  percolated  through  a  porous  soil  from  a 
neighboring  stream.  This  stream  received  the  drainage  of  two  cesspools, 
one  being  thirty  and  the  other  sixty-five  feet  from  the  well,  and  the  well  was 
on  lower  ground  than  the  cesspools.  In  August  and  September,  20  of  the  23 
persons  were  attacked  with  typhoid  fever,  and  in  one  of  the  houses  4  died. 
The  water  supplying  this  house  was  examined  by  Chantemesse  in  October, 
and  was  found  to  contain  the  bacillus  of  typhoid  fever  in  abundance.  A 
month  subsequently  none  could  be  found.  Vienna,  Angouleme,  Cincinnati, 
and  Bordeaux  may  be  mentioned  among  the  places  where  the  occurrence  of 
typhoid  fever  has  been  traced  to  pollution  of  the  drinking  water.  In  1888  a 
severe  epidemic  of  typhoid  fever  occurred  at  Iron  Mountain,  Michigan,  and 
in  the  drinking  water  employed  in  families  that  had  suffered  from  the  disease 
Vaughan  and  Xovy  found  the  typhoid  bacillus.  Therefore,  sufiicient  obser- 
vations have  been  made  to  show  that  many  epidemics  of  typhoid  fever  have 
been  caused,  and  are  still  caused,  by  the  use  of  polluted  drinking  water  which 
■contained  the  specific  bacillus,  and  that  when  epidemics  arise  from  this  cause 
it  apparently  gains  admittance  into  the  system  through  the  digestive  appa- 
ratus. In  1871,  Ballard,  health  officer  of  Islington,  called  attention  to  the 
fact  that  the  use  of  infected  milk  sometimes  causes  typhoid  fever.  He  had 
investigated  an  outbreak  of  the  disease  which  was  apparently  produced  by 
rinsing  milk-cans  with  water  which  was  polhited  by  direct  communication  of 
the  tank  with  drains.  Since  then  a  considerable  number  of  epidemics  have 
been  traced  to  the  use  of  infected  milk.  The  milk  in  most  of  the  investigated 
cases  was  contaminated  by  polluted  water  employed  in  rinsing  the  cans  or 
added  to  the  milk  for  the  purpose  of  diluting  it.  Milk  may  also  receive 
the  typhoid  bacillus  from  ice  which  contains  this  organism  and  is  employed 
for  the  purpose  of  reducing  the  temperature  or  for  dilution.  Seitz,  Wolf- 
htigel,  and  Reidel  have  shown  that  the  typhoid  bacillus  grows  freely  in  milk. 
Vaughan  mixed  water  containing  the  typhoid  bacillus  with  milk,  and  sub- 
sequently was  able  to  obtain  from  the  milk  a  poisonous  extract  due  to  the 
growth  and  activity  of  the  bacillus  (^Med.  JVeics,  Jan.  28,  1888).  Therefore 
the  milk-supply  should  also  be  investigated  on  the  occurrence  of  an  epidemic. 

But  typhoid  fever  is  probably  communicated  by  the  inhalation  of  air 
which  contains  the  typhoid  bacillus,  although,  as  we  have  seen,  the  disease  is 
not  likely  to  be  contracted  by  the  attendants  of  typhoid  patients  if  there  be 
prompt  and  efficient  disinfection  of  the  excreta.     In  New  York  City  many 


410  CONSTITUTIONAL  DISEASES. 

observations  show  that  the  filthy  flowing  streams  in  the  sewers  are  infected 
with  the  typhoid  bacillus,  and  cases  occur  in  which  the  fever  seems  to  be 
due  to  the  escape  of  the  sewer  gas  into  the  houses.  Thus,  in  my  practice, 
in  a  house  whose  plumbing  was  supposed  to  be  faultless  three  children  who, 
so  far  as  known,  had  not  been  exposed  outside,  sickened  with  typhoid  fever. 
A  thorough  examination  finally  revealed  the  escape  of  sewer  gas  into  the  cel- 
lar in  a  strong  current.  The  inference  is  that  in  such  instances  the  tainted 
air  conveys  the  bacillus  to  the  lungs,  and  this  organism  enters  the  system 
through  this  organ.  But  it  is  true  that  the  bacillus  in  such  instances  may  be 
deposited  from  the  air  in  the  food  or  drink,  or  in  the  mouth  or  fauces,  and  be 
swallowed,  so  that  the  systemic  infection  may  occur  through  the  digestive 
system.  But  it  sufiices,  so  far  as  the  employment  of  preventive  measures  is 
concerned,  to  know  that  an  atmosphere  infected  by  exhalations  from  filthy 
sources  may  communicate  typhoid  fever  without  the  actual  presence  of  a 
typhoid  patient.  Between  1873  and  1885  one  hundred  and  forty-six  cases  of 
typhoid  fever  occurred  in  one  of  two  barracks  occupied  by  the  German  artil- 
lery, while  cases  did  not  occur  in  the  other  barrack,  although  the  water  and 
food  used  in  the  two  were  the  same.  Finally,  suspicion  fell  upon  the  bed- 
linen  and  clothing,  and  the  discovery  was  made  that  recent  patients  had  worn 
the  clothes  of  men  previously  attacked,  and  even  stains  of  dried  fecal  matter 
were  found  in  their  pants.  Saturation  of  the  infected  articles  and  the  barrack 
with  chlorine  gas  followed  by  dry  heat  was  now  employed,  and  no  more  cases 
occurred  (3Ied.  Press  and  Circ,  March  28,  1888).  Therefore  the  typhoid 
bacillus  gains  admittance  into  the  system  not  only  by  the  use  of  infected 
drinking  water,  milk,  and  solid  food,  but  also  by  the  inhalation  of  an  infected 
atmosphere. 

Anatomical  Characters. — Since  typhoid  fever  is  a  constitutional  dis- 
ease, we  would  expect  to  find  early  and  important  changes  in  the  blood.  No 
alteration,  however,  has  been  discovered  in  this  fluid  peculiar  to  typhoid 
fever.  The  amount  of  fibrin  is  diminished,  as  in  most  of  the  essential  fevers, 
and  its  coagulation  is  feeble,  forming,  when  the  blood  stands,  soft,  small,  and 
dark  clots.  When  the  fever  has  continued  for  some  time  a  state  of  anaemia 
more  or  less  decided  supervenes  in  which  the  amount  of  albumen  and  blood- 
corpuscles  is  diminished.  Although  there  are  often  decided  symptoms  refer- 
able to  the  nervous  system,  no  constant  changes  have  been  discovered  in  the 
brain  or  spinal  cord.  The  changes  observed  in  them  when  death  has  occurred 
in  the  course  of  typhoid  fever  have  been  for  the  most  part  due  to  other 
causes.  It  is  different  with  the  respiratory  system.  After  the  first  week  of 
typhoid  fever  mild  bronchitis  is  almost  as  constant  as  inflammation  of  the 
fauces  in  scarlet  fever,  and  accordingly  we  find  in  fatal  cases  redness  and 
thickening  of  the  bronchial  mucous  membrane,  which  is  covered  with  a  viscid 
and  ordinarily  scanty  secretion.  Hypostatic  congestion  of  the  lungs,  with 
more  or  less  oedema,  and  in  severe  and  enfeebled  cases  hypostatic  pneumo- 
nia, are  not  uncommon.  In  the  bronchitis  and  state  of  feebleness  we  have 
the  causes  of  pulmonary  collapse,  and  this  lesion  is  not  infrequent  over 
limited  portions  of  the  lungs,  especially  if  the  bronchitis  afi"ect  the  smaller 
tubes. 

The  lesions  occurring  in  the  digestive  system  are  important.  The  pharynx 
is  normal  or  slightly  aff'ected.  The  mucous  membrane  of  the  oesophagus 
and  stomach  is  sometimes  normal  or  nearly  so.  and  in  other  eases  hyperfemic. 
It  is  said  that  ulcers  have  been  occasionally  observed  in  the  cardiac  end  of 
the  oesophagus.  The  mucous  membrane  of  the  small  intestine  is  more  or 
less  injected,  and  at  an  early  period,  even  by  the  second  or  third  day,  the 
patches  of  Peyer,  solitary  glands,  and  at  the  same  time  the  mesenteric, 
begin  to  enlarge.     I  have  made  microscopic  examination  of  these  glands  in 


TYPHOID  FEVER.  411 

typhoid  fever  of  the  adult,  and  have  found  a  considerable  increase  of  the 
small  round  granular  cells  of  which  they  are  composed.  It  appears,  there- 
fore, that  the  enlargement  is  due  mainly  to  hyperplasia  of  the  cellular  ele- 
ments of  the  glands,  though  there  is  probably  infiltration  to  a  certain  extent 
of  inflammatory  products  between  the  cells.  The  mucous  meiubrane  over 
the  glands  undergoes  inflammatory  thickening  and  softening.  In  the  adult 
sloughing  of  this  membrane  is  frequent,  with  the  disintegration  of  the  glands 
and  their  elimination  into  the  intestines,  producing  ulcers,  small  and  circular, 
corresponding  with  the  site  of  the  solitary  glands,  or  large  and  oval  or  irreg- 
ular, corresponding  with  the  site  of  Peyer's  patches.  Disintegration  of  these 
glands  and  the  formation  of  ulcers  are  less  frequent  in  children  than  in 
adults.  In  the  adult  who  recovers  the  mesenteric  glands  and  the  solitary  and 
agminate  which  are  not  destroyed  return  to  their  normal  state  by  fatty  degen- 
eration, liquefaction,  and  absorption  of  the  redundant  cells.  In  the  child  this 
is  the  common  result,  instead  of  sloughing  and  disintegration,  as  regards  both 
the  solitary  and  agminate  glands,  and  the  uniform  result  as  regards  the  mesen- 
teric, and  I  may  add  bronchial  glands,  which  are  also  in  a  state  of  hyperplasia. 
The  absence  of  ulceration  or  its  slight  extent  affords  explanation  of  the  fact 
that  intestinal  pei'foration  is  very  rare  in  children.  The  inflammatory  changes 
described  above  pertain  chiefly  to  the  ileum.  The  duodenum  and  jejunum 
present  their  normal  appearance  or  are  moderately  hyperaemic  in  places  and 
their  follicles  swollen. 

The  spleen  gradually  enlarges,  often  to  twice  the  normal  size,  has  a  dark- 
red  color,  and  is  softened.  Enlargement  of  the  spleen  possesses  great  diag- 
nostic value  in  those  cases  in  which  the  diagnosis  is  obscure.  For  while  very 
similar  intestinal  lesions  may  occur  in  chronic  entero-colitis,  the  coexistence 
of  these  lesions  with  the  splenic  enlargement  and  softening  shows  the  con- 
stitutional nature  of  the  malady.  The  liver  usually  presents  its  normal 
appearance,  or  it  may  be  pale  in  consequence  of  the  angemia,  or,  on  the  other 
hand,  it  may  be  hyperaemic.  Microscopic  examination  sometimes  reveals  a 
granular  state  of  the  hepatic  cells  with  indistinct  nuclei. 

In  cases  which  are  severe  and  which  present  a  decidedly  adynamic  type 
the  muscles  become  soft  and  flabby,  the  action  of  the  heart  is  feeble,  and 
more  or  less  passive  congestion  of  the  viscera  results.  In  such  cases  con- 
gestion of  the  kidneys  and  albuminuria  are  not  infrequent.  Parenchymatous 
degeneration  of  the  kidneys  occasionally  occurs,  the  epithelium  becoming- 
granular,  the  cells  indistinct,  and  their  nuclei  invisible.  Liebermeister  states 
that  he  has  frequently  noted  the  absence  of  albuminuria  during  the  fever 
when  the  autopsy  showed  marked  degenerative  changes  in  the  kidneys. 
Inflammation  of  the  endocardium  and  pericardium  is  rare,  but  the  myo- 
cardium exhibits  structural  changes  in  severe  cases.  Atrophy  and  fatty 
degeneration  of  its  muscular  fibres  sometimes  occur,  which  may  lead  to  the 
formation  of  clots  in  the  cavities  of  the  heart,  and  consequent  emboli  in 
other  organs.  Hoffinann  demonstrated  the  occurrence  of  fatty  degeneration 
of  the  minute  arteries  in  various  organs  in  prolonged  cases  of  typhoid  fever, 
and  degenerative  changes  have  also  been  observed  in  the  voluntary  muscles. 

Pathology. — Recent  investigations  relating  to  the  acute  infectious  dis- 
eases of  childhood  render  it  probable  that  as  regards  most,  if  not  all,  of  them 
systemic  infection  occurs  through  ptomaines  or  poisonous  chemical  agents 
which  are  produced  by  the  action  of  the  microbes  which  are  the  specific 
principles.  This  is  believed  to  be  true  as  regards  typhoid  fever.  In  1885, 
Brieger  obtained  a  ptomaine  from  cultures  of  the  typhoid  bacillus  which, 
inoculated  in  guinea-pigs,  caused  salivation,  hurried  breathing,  dilated  pupils, 
diarrhoea,  paralysis,  and  death  within  one  to  two  days.^  From  such  observa- 
^  L.  Brieger,  Ueber  Plomdine,  Berlin,  1885-86. 


412  CONSTITUTIONAL  DISEASES. 

tions  and  experiments  tlie  theory  has  arisen  that  the  symptoms  which 
characterize  typhoid  fever  are  mainly  due,  not  directly  to  the  action  of  the 
bacillus,  but  to  a  ptomaine  or  ptomaines  created  by  the  bacillus  and  ab- 
sorbed into  the  system.  This  theory  also  receives  support  from  the 
observations  and  experiments  of  Hoffa.  Sirotirvin,  Beaumer  and  Peiper,  and 
others. 

Incubative  Period. — As  in  scarlet  fever  and  diphtheria,  the  incubative 
period  in  typhoid  fever  varies.  In  three  cases  detailed  by  Griesinger  the 
fever  began  twenty-four  hours  after  exposure.  In  a  school  at  Clapham,  20 
out  of  22  boys  sickened,  according  to  Murchison,  within  four  days  after 
exposure.  Authenticated  cases  of  a  longer  incubative  period  are  on  record, 
so  that  Murchison  believed  that  it  is  commonly  about  two  weeks,  and 
"William  Budd  that  it  is  in  most  instances  from  ten  to  fourteen  days,  but 
cases  have  occurred  in  which  it  seemed  to  be  as  long  as  twenty-eight 
days.^ 

Symptoms. — Typhoid  fever  has  a  prodromic  stage  of  a  few  days,  some- 
times of  a  week  or  more,  in  which  the  child  appears  languid,  indisposed  to 
play,  and  has  little  appetite,  but  complains  of  no  pain  unless  occasional 
slight  headache,  and  has  no  symptoms  which  would  lead  the  friends,  or  even 
phvsicians,  to  suspect  the  nature  of  the  disease  which  impends.  By  and  by 
a  slight  fever  occurs. 

In  exceptional  cases  typhoid  fever  begins  with  a  chill,  followed  by 
pronounced  fever.  It  occurred  in  3  of  the  14  cases  observed  by  Dr.  Jacobi 
in  Bellevue  Hospital.  This  was  a  larger  proportion  of  cases  with  such  com- 
mencement than  I  observed  in  the  epidemic  of  1882  or  have  since  observed, 
but  the  cases  in  Bellevue  seem  to  have  been  unusually  severe,  since  5  of  the 
14  died. 

The  fever,  which  gradually  becomes  more  pronounced,  remits,  but  does 
not  cease  in  the  morning,  and  it  has  evening  exacerbations.  After  the  first 
week  of  fever  the  remissions  are  less  marked,  but  the  fever  is  not  uniform 
at  any  period  in  its  course.  Hence  some  of  the  writers  on  diseases  of  children 
continue  to  designate  typhoid  fever  of  children  remittent  fever,  fully  aware 
of  its  identity  with  typhoid  fever  of  the  adult.  As  the  case  advances  the 
appetite  fails,  all  solid  food  being  refused,  and  liquid  food  being  taken  more 
from  thirst  than  hunger.  The  tongue  in  the  first  week,  and  in  some  patients 
throughout  the  course  of  the  disease,  is  covered  with  a  light  moist  fur,  while 
in  others  having  a  graver  type  of  the  fever  the  tongue  after  the  first  week  is 
dry  and  brown.  During  the  prodromic  period  and  in  the  first  week  the 
bowels  act  regularly  or  are  slightly  relaxed,  and  they  are  readily  affected  by 
purgative  medicines.  After  the  first  week  there  is  in  some  children  a  tend- 
ency to  diarrhoea,  which  requires  now  and  then  the  use  of  astringents,  the 
stools  being  watery  and  brown  or  dark  yellow.  Diarrhoea  is  less  frequent  in 
children  than  in  adults,  and  in  some  children  it  does  not  occur  during  the 
entire  sickness.  The  abdominal  walls  are  seldom  retracted,  but  prominent, 
especially  after  the  first  week,  in  consequence  of  meteorism,  which  is  present 
in  children  as  well  as  adults.  Sometimes  there  is  apparent  tenderness  when 
pressure  is  made  over  the  right  iliac  region,  but  this  must  not  be  confounded 
with  hyperassthesia,  which  is  common  in  the  commencement  of  febrile  diseases 
in  children,  and  which  is  observed  especially  upon  the  abdomen,  chest,  and 
inner  part  of  the  thighs. 

The  respiration  in  the  first  week  is  slightly  accelerated,  as  it  is  in  all 
febrile  diseases.  In  the  second  week,  and  subsequently  when  bronchitis  is 
developed,  the  respiration  is  ordinarily  more   accelerated,   though  not  in  a 

'  See  article  "  Typhoid  Fever,"  American  System  of  Practical  Medicine,  Philada., 
1885,  Lea  Bros. 


TYPHOID  FEVER.  413 

marked  degree,  unless  in  those  exceptional  instances  in  whicli  there  is  an 
abundant  collection  of  mucus  in  the  smaller  bronchial  tubes.  A  cough  is 
often  present,  dependent  on  the  bronchitis,  and  varying  in  character  accord- 
ing to  the  degree  and  stage  of  the  inflammation.  In  the  first  days  of  the 
fever  it  is  infrequent  or  lacking ;  at  a  later  stage  it  is  more  frequent  and  not 
so  dry,  though  in  cases  of  ordinary  severity  the  amount  of  expectoration  is 
inconsiderable.  Hypostatic  congestion,  oedema,  hypostatic  pneumonia,  spleni- 
zation  or  thickening  of  the  alveolar  walls,  and  collapse,  which  not  infre- 
quently occur  in  the  advanced  disease,  increase  more  or  less  the  frequency  of 
the  respiration  and  the  cough  and  modify  the  physical  signs. 

The  pulse  in  the  first  week,  in  ordinary  cases,  is  from  100  to  110  or  115. 
It  gradually  becomes  more  accelerated,  numbering  in  the  second  week  123  or 
more ;  in  grave  cases  even  160.  The  more  frequent  the  pulse,  the  greater 
the  danger  and  more  unfavorable  the  prognosis.  During  the  exacerbations 
the  number  of  pulsations  per  minute  is  fifteen  or  twenty  more  than  in  the 
remissions.  The  change  in  temperature  corresponds  with  that  of  the  pulse, 
being  from  1°  to  2°  higher  in  the  exacerbation  than  remission.  The  ex- 
tremes of  temperature  in  cases  of  ordinary  severity  are  about  101°  to  10-1°. 
A  temperature  above  105°  shows  a  grave,  perhaps  a  fatal,  type  of  the  disease 
or  else  a  serious  complication. 

There  is  great  variation  as  regards  the  symptoms  referable  to  the  nervous 
system.  Headache  is  common  in  the  prodromic  and  initial  stages,  after  which 
it  ceases.  A  few  are  delirious  even  from  an  early  period,  screaming  loudly 
or  muttering  incoherently,  but  the  majority  are  quiet,  having,  indeed,  a 
degree  of  mental  dulness,  but  being  able  to  appreciate  questions  when 
aroused  and  answering  correctly.  Subsultus  tendinum  and  carphologia, 
which  some  exhibit,  show  that  there  is  profound  disturbance  of  the  nervous 
system.  Epistaxis  occurs  occasionally  in  the  first  week,  as  in  the  adult,  but 
is  usually  slight. 

The  rose-colored  eruption  appears  in  children  as  well  as  adults  between 
the  sixth  and  twelfth  days,  but  is  more  frequently  absent  in  the  former  than 
the  latter ;  sometimes  the  number  of  spots  is  less  than  half  a  dozen.  Su- 
damina  are  common  in  the  second  and  third  weeks,  and  perspirations  may 
occur  at  any  time  in  the  course  of  the  fever,  but  without  amelioration  of 
symptoms.  More  or  less  deafness  is  common,  being  in  most  instances  a 
purely  nervous  symptom,  without,  therefore,  any  structural  change  in  the 
ear,  but  it  is  possible,  as  has  been  suggested  by  certain  writers,  that  it  some- 
times results  from  inflammatory  thickening  of  the  Eustachian  tube  or  exter- 
nal meatus,  or  from  a  weakened  and  flabby  state  of  the  muscles  of  the 
ear. 

Duration. — As  in  diphtheria,  so  in  typhoid  fever,  the  duration  varies 
greatly  in  diff"erent  cases.  Mild  forms  of  the  disease  terminate  within  one 
week,  but  cases  of  a  severe  type  may  continue  several  weeks.  Henoch 
states  that  the  duration  of  80  cases  which  he  observed  were  as  follows  : 
from  seven  to  ten  days,  11  ;  from  ten  to  fifteen  days,  26 ;  from  fifteen  to 
twenty  days,  16 ;  from  twenty  to  thirty  days,  21  ;  and  from  thirty  to 
forty-nine  days,  6  cases.  The  limits  in  the  duration  were  therefore  seven 
days  in  the  shortest  and  mildest  cases,  and  forty-nine  days  in  those  that  were 
the  most  protracted.  In  the  cases  of  short  duration  the  diagnosis  was  ren- 
dered clear  by  the  roseola,  enlargement  of  the  spleen,  and  diarrhoea.  When 
the  disease  begins  to  abate,  there  is  frequently  in  the  morning  a  complete 
apyrexia,  and  a  return  of  the  fever  in  the  latter  part  of  the  day.  This  period 
of  an  intermittent  fever  usually  varies  from  two  to  five  days.  Forchheimer, 
who  observed  a  severe  epidemic  of  typhoid  fever  in  Cincinnati,  says  that 
this  disease  in  children  sometimes  terminates  in  six  days  ( Columbus    Med. 


414  CONSTITUTIONAL  DISEASES. 

Jonr.,  1888).  In  a  discussion  relating  to  typhoid  fever  at  a  recent  session 
of  the  New  York  Medical  Association,  Dr.  E.  G.  Janeway  also  stated  that 
this  disease  sometimes  terminates  within  ten  days.  In  cases  continuing 
three  or  four  weeks  the  jDatient  becomes  progressively  more  emaciated  and 
feeble,  and  in  a  severe  form  of  the  disease  his  condition  seems  very  unprom- 
ising to  one  not  familiar  with  the  clinical  history  of  the  fever.  Pale, 
emaciated,  and  feeble,  probably  passing  his  evacuations  in  bed,  and  taking 
little  notice  of  objects  around  him,  he  presents  at  the  close  of  the  third  week 
or  in  the  fourth  an  appearance  of  helplessness,  notwithstanding  the  best 
nursing  and  the  constant  employment  of  sustaining  measures,  which  is  truly 
discouraging. 

Relapses — Second  Attacks. — Rilliet  and  Barthez  called  attention  to  the  fact 
that  relapses  sometimes  occur,  although  they  observed  only  3  such  cases  in 
111  patients.  Henoch  witnessed  21  relapses  in  137  cases,  the  relapses  occur- 
ring after  severe  and  after  mild  cases.  The  majority  of  the  cases  in  which 
relapse  occurred  were,  however,  mild.  As  a  rule,  the  relapse  occurred  between 
the  third  and  fifth  weeks,  and  after  a  complete  apyrexia  of  three  to  ten  days. 
In  one  case  even  eighteen  days  of  apyrexia  had  occurred  when  the  fever  was 
renewed.  In  some  cases  the  relapse  took  place  during  the  decline  of  the  fever, 
when  there  was  a  morning  intermission  and  an  evening  fever,  the  fever  again 
becoming  continuous.  Eichhorst,  in  examining  the  records  of  666  cases  occur- 
ring in  Zurich,  ascertained  that  second  attacks  occurred  in  28  persons,  or  in 
4.2  per  cent,  of  the  cases.  He  has  observed  cases  of  a  third  and  even  of  a 
fourth  attack,  so  that,  as  in  diphtheria,  a  first  or  even  a  second  attack  does 
not  destroy  the  susceptibility  to  the  disease. 

Complications. — The  chief  complications  of  typhoid  fever  are  broncho- 
pneumonia, already  sufiiciently  described,  enteritis,  intestinal  hemorrhage, 
peritonitis,  otitis,  parotiditis,  and  muguet.  In  one  instance  I  lost  a  patient 
about  ten  years  old,  in  whom  the  fever  had  nearly  terminated,  by  the  sudden 
accession  of  croup.  There  is,  as  we  have  seen,  in  ordinary  cases  more  or  less 
inflammation  of  the  mucous  membrane  of  the  air-passages  and  of  the  intes- 
tines, especially  in  the  vicinity  of  the  patches  of  Peyer.  It  is  easy  to  under- 
stand how,  under  circumstances  which  may  arise  in  the  fever  favorable  to  the 
development  of  mucous  inflammations,  the  bronchitis  and  enteritis  may  so 
increase  as  to  constitute  complications.  They  are  the  most  frequent  of  the 
serious  complications. 

Feeble  action  of  the  heart,  common  in  severe  cases  of  typhoid  fever,  and 
which  after  the  second  week  is  partly  attributable  to  granulo-fatty  degenera- 
tion of  the  muscular  fibres  of  the  heart,  which  is  frequent  in  grave  forms  of 
the  infectious  diseases,  obviously  favors  the  occurrence  of  bronchial  and  pul- 
monary congestion.  Hence  the  proneness  in  these  cases  of  the  inflammation 
to  extend  downward  from  the  larger  to  the  smaller  bronchial  tubes  and  to 
the  lungs,  so  that  broncho-pneumonia  becomes  an  occasional  very  grave 
complication. 

In  the  child  as  well  as  adult  with  this  disease  the  mucous  membrane 
of  the  lower  part  of  the  ileum  in  the  vicinity  of  Peyer's  patches  is  fre- 
quently thickened  and  hyperaemic — a  true  intestinal  catarrh.  We  can  readily 
understand  how  under  certain  circumstances  this  may  become  aggravated  so 
as  to  constitute  an  intestinal  inflammation  of  considerable  extent  and  gravity 
— a  severe  entero-colitis,  so  that  the  local  symptoms  predominate  over  the 
constitutional  and  aggravate  the  latter. 

In  the  adult,  as  is  well  known,  the  Peyerian  and  solitary  glands,  becom- 
ing more  and  more  prominent  by  proliferation  of  the  cellular  elements  (the 
lymphoid  cells),  begin  to  ulcerate  in  the  second  week,  and  slough  in  the  third, 
forming  the  typhoid  ulcer,  which  is  slow  in  healing  and  aids  in  keeping  up 


TYPHOID  FEVER.  415 

the  diarrhoeal  state.      Such   destructive  or  necrotic   inflammation  is  rare   in 
joung  children,  but  it  may  occur  in  those  of  a  more  advanced  age. 

Intestinal  hemorrhage  is  therefore  an  occasional  accident.  Hillier  met  4 
cases  in  30  of  the  fever.  It  indicates  the  presence  of  ulcers  upon  the  surface 
of  the  intestines.  The  younger  the  child  the  less  the  liability  to  it.  Some 
in  whom  it  has  occurred  recover,  but  others  die.  A  girl  of  nine  years  com- 
plained of  severe  abdominal  pain  on  the  seventeenth  day  of  the  fever,  which 
was  followed  by  syncope  and  death.  At  the  autopsy  one  of  Peyer's  patches 
was  found  deeply  ulcerated,  and  at  the  bottom  of  the  ulcer  was  a  perforation 
through  which  blood  had  escaped  into  the  peritoneal  cavity. 

Intestinal  perforation  is  more  rare  in  children  than  in  adults,  as  might  be 
inferred  from  the  statement  already  made  that  intestinal  ulceration  is  less 
frequent  and  extensive  in  them.  Statistics  show  that  perforation  in  children 
occurs  only  once  in  232  cases.  Therefore,  as  perforation  is  the  common  cause 
of  peritonitis  in  this  disease,  this  inflammation  is  a  rare  complication.  Peri- 
tonitis ma3^  however,  occur  in  typhoid  fever  without  perforation.  In  one 
such  case  (an  adult)  in  the  fever  wards  attached  to  Charity  Hospital  local 
peritonitis  with  fibrinous  exudation  occurred  opposite  two  ulcerated  patches 
of  Peyer,  the  ulcers  extending  nearly  to  the  peritoneum,  but  not  perforating. 
The  lesions  observed  in  this  case  throw  light  on  those  cases  of  peritonitis 
complicating  typhoid  fever  which  recover,  the  cause  of  which  has  received 
a  difl^erent  explanation. 

In  advanced  and  greatly  debilitated  cases  thrush  sometimes  appears  in 
the  interior  of  the  mouth  and  upon  the  fauces.  It  is  alwa3"s  an  unfavorable 
prognostic  symptom  in  children  sulFering  from  chronic  or  protracted  disease. 
Parotiditis  is  also  a  rare  complication.  Otitis,  commencing  with  pain  and  pro- 
ducing a  discharge  which  may  continue  for  weeks,  is  not  rare,  though  less 
frequent  than  in  scarlet  fever.  The  otitis  is  commonly  external,  but  it  may 
in  scrofulous  subjects  extend  to  the  middle  ear. 

Diagnosis. — This  is  more  difficult  in  children  than  in  adults,  and  the 
younger  the  child  the  greater  the  difficulty.  In  infants  protracted  entero- 
colitis, with  fever  and  a  dry  furred  tongue,  cannot  in  certain  cases  be  posi- 
tively diagnosticated  from  typhoid  fever  by  the  symptoms  and  clinical  history. 
Typhoid  fever  is  believed,  however,  to  be  rare  at  this  age,  for  an  infant 
nourished  at  the  breast  is  very  seldom  exposed  to  the  cause  of  the  disease. 
When,  however,  as  now  and  then  happens,  a  young  child  presents  the  symp- 
toms characteristic  of  protracted  subacute  entero-colitis  or  typhoid  fever,  and 
older  members  of  the  household  have  the  fever,  it  is  highly  probable  that  the 
case  is  one  of  the  latter  disease,  and  it  should  be  treated  accordingly. 

Even  in  older  children  typhoid  fever  is  frequently  mistaken  for  simple 
subacute  enteritis  or  entero-colitis,  or  vice  versa..  The  following  facts  aid  in 
the  differential  diagnosis :  In  typhoid  fever  there  is  a  total  loss  of  appetite, 
while  in  the  subacute  intestinal  inflammation  food  is  not  entirely  refused. 
Diarrhcea  commences  early  in  the  inflammation,  while  in  the  fever  it  does  not 
occur  ordinarily  till  after  the  lapse  of  a  few  days.  Abdominal  tenderness  in 
the  fever  is  not  appreciable  or  is  located  in  the  right  iliac  region  ;  in  the  other 
disease  it  is  general  over  the  abdomen  or  located  in  the  umbilical  region. 
In  typhoid  fever  there  is  bronchitis  with  a  cough,  which  is  absent  in  the 
inflammation.  In  typhoid  fever  there  are  certain  other  symptoms,  more 
or  fewer  of  which  are  present  in  most  cases,  and  which  do  not  occur  in  the 
intestinal  diseases,  except  as  a  coincidence ;  for  example,  headache,  epistaxis, 
stupor,  delirium,  and  perhaps  the  rose-colored  spots.  The  evening  rise  of 
temperature  and  enlargement  of  the  spleen  are  also  important  diagnostic 
symptoms.  When  it  is  very  important  to  make  a  positive  diagnosis,  cultures 
may  be  made  from  blood  drawn  from  the  spleen,  from  the  sediment  of  albu- 


416  CONSTITUTIONAL  DISEASES. 

niinous  urine,  or  from  the  feces,  and  if  the  disease  be  typhoid  fever  the 
specific  bacillus  will  be  found. 

Typhoid  fever  may  be  mistaken  for  meningitis  during  the  first  week,  but 
in  meningitis  there  is  more  constipation,  irritability  of  stomach,  and  less  ele- 
vation of  temperature.  Moreover,  in  meningitis  at  a  comparatively  early 
stage  we  are  able  to  detect  patches  of  congestion  of  the  features  coming  and 
disappearing  suddenly,  and  slight  inequality  of  the  pupils  or  their  oscilla- 
tion when  the  light  is  uniform — signs  which  are  lacking  in  typhoid  fever. 
In  a  doubtful  case  the  ophthalmoscope  might  be  employed,  which  in  menin- 
gitis discloses  congestion  of  the  vessels  of  the  retina,  oedema,  etc. — anatomi- 
cal changes  which  do  not  pertain  to  typhoid  fever. 

The  differential  diagnosis  of  typhoid  fever  and  acute  tuberculosis  may  be 
made  by  attention  to  the  following  points :  In  tuberculosis  there  is  cough, 
with  some  acceleration  of  respiration  from  the  first,  without  epistaxis.  stupor, 
or  other  nervous  symptoms,  and  without  the  abdominal  symptoms  which  are 
so  prominent  in  the  fever.  The  occurrence  of  typical  cases  in  the  same 
house  or  in  those  patients  who  have  been  similarly  exposed  has  in  certain 
instances  enabled  me  to  make  a  clear  diagnosis. 

In  localities  where  diseases  due  to  marsh  miasm  occur,  the  remittent  fever 
arising  from  this  cause  and  typhoid  fever  bear  considerable  resemblance  to 
each  other.  The  two,  indeed,  may  coexist — a  fact  observed  during  the  late 
Civil  War,  so  that  cases  in  which  this  coexistence  occurred  were  designated 
typhormalarial.  In  malarial  remittent  fever  the  commencement  is  more 
abrupt,  the  vomiting  and  headache  more  severe,  and  the  remissions  more 
marked  than  in  typhoid  fever.  Moreover,  quinine  exerts  a  decided  control- 
ling effect  in  the  fever  due  to  marsh  miasm,  while  its  efi"ect  in  typhoid  fever 
is  much  less  pronounced. 

Prognosis. — A  much  larger  percentage  of  children  recover  than  of  adults. 
Although  there  be  great  emaciation  with  loss  of  strength,  recovery  may  be 
confidently  predicted,  provided  that  no  serious  complication  occur.  Grave 
symptoms,  as  high  fever,  delirium,  severe  diarrhoea,  an  unusually  rapid  and 
feeble  pulse,  have  a  bad  import.  If  from  any  cause  the  system  is  in  a 
marked  degree  debilitated  when  the  fever  begins,  the  prognosis  is  much  less 
favorable  than  in  those  who  are  robust.  Thus  the  presence  of  hereditary 
syphilis,  of  tuberculosis,  of  severe  scrofula,  or  of  bronchial  or  intestinal 
catarrh  when  typhoid  fever  begins,  greatly  increases  the  danger.  But  in 
fatal  cases  which  I  have  met  the  unfavorable  result  occurred,  as  a  rule,  from 
the  complications  rather  than  directly  from  the  malady.  Of  the  compli- 
cations, the  most  serious  are  intestinal  ulceration,  giving  rise  to  hemor- 
rhage or  even  perforation,  and  consequent  peritonitis,  diphtheria,  pneu- 
monia, nephritis,  pleuritis  with  serous  or  purulent  effusion,  meningitis,  and 
granulo-fatty  degeneration  of  the  myocardium.  Complications  like  these 
largely  increase  the  mortality  of  typhoid  fever.  The  condition  in  which 
severe  typhoid  fever  leaves  a  patient  is  favorable  for  the  development  of 
tubercles,  and  now  and  then  they  occur,  disappointing  our  expectations  and 
prediction  of  recovery.  The  possibility  of  a  relapse  should  be  borne  in 
mind,  so  that  the  patient  should  remain  in  bed,  free  from  excitement  and 
with  plain  but  nutritious  and  easily  digested  diet,  until  convalescence  is  well 
advanced. 

Treatment. — Typhoid  fever,  like  typhus,  cannot  be  abridged  by  treat- 
ment, and  the  indication  is  to  sustain  the  vital  powers,  diminish  the  intensity 
of  the  fever,  and  arrest  if  possible  any  untoward  symptom  or  complication. 
Quinia,  so  useful  in  malarial  diseases,  may  be  administered  in  small  doses 
for  its  tonic  effect  and  as  an  aid  in  promoting  digestion.  It  is  commonly  and 
properly  prescribed  in  some  convenient  vehicle  for  this  purpose,  but  it  does 


TYPHOID  FEVER.  417 

not  antagonize  the  typhoid  as  it  does  the  malarial  poison.  Perturbating 
medicines,  and  especially  cathartics,  should  be  given  with  caution.  The 
tendency  to  intestinal  ulceration  and  hemorrhage  and  the  anaemic  nature 
of  the  fever  require  abstinence  from  or  cautious  use  of  such  agents.  A 
temperature  remaining  under  103°  usually  involves  little  danger.  If  it 
remain  above  103°  morning  and  evening,  antipyretic  measures  should  be 
employed.  I  therefore  order  the  nurse  to  bathe  frequently  the  forehead, 
face,  hands,  arms,  neck,  and  sometimes  the  chest,  with  cold  water,  to  which 
it  is  proper  to  add  alcohol  or  some  spirituous  lotion.  A  cloth  wrung  out  of 
ice-water,  or  an  ice-bag,  should  be  applied  over  the  head,  and  the  hands  may 
be  allowed  to  lie  a  considerable  time  in  a  washbowl  containing  the  lotion, 
which  is  always  grateful  to  the  patient.  The  water  treatment  thus  applied 
will  usually  reduce  the  temperature  one,  two,  or  three  degrees  within  a  few 
hours.  Cold  general  baths  are  not  so  well  tolerated  by  children  as  by  adults. 
Collapse  has  sometimes  followed  their  use,  and,  on  the  other  hand,  benefit 
has  apparently  in  some  cases  accrued  from  their  employment  when  the  tem- 
perature was  above  104°.  The  bath,  if  used,  should  be  at  a  temperature  of 
about  88°,  and  the  patient  should  not  be  immersed  in  it  longer  than  five  to 
eight  minutes  (Henoch).  It  seems  preferable,  however,  in  most  cases  of  high 
temperature,  to  endeavor  to  reduce  it  by  cold  sponging  or  cold  compresses. 
A  compress  frequently  wrung  out  of  ice-water  or  containing  broken  ice  mixed 
with  bran,  or  a  rubber  ice-bag  applied  over  the  head  and  another  over  the 
abdomen,  or  Leiter's  coils  applied  over  the  same  parts  as  the  compress,  grad- 
ually abstract  the  heat,  and  with  more  safety  to  the  patient  than  the  use  of 
the  cold  bath.  Ice  applications  should  be  discontinued  if  the  temperature 
fall  to  103°  or  if  the  patient  complain  of  chilliness.  Even  an  afternoon  tem- 
perature of  104°  does  not  require  ice  applications  or  any  active  antipyretic, 
provided  there  is  a  decided  morning  remission.  Moderate  doses  of  quinine 
and  general  sustaining  remedies  suffice  for  such  cases. 

Of  the  internal  antipyretics,  sodium  salicylate,  antipyrine,  phenacetin, 
acetanilide,  and  quinine  have  been  chiefly  employed.  The  sodium  salicylate 
is  likely  to  retard  digestion,  and  it  sometimes  causes  albuminuria.  Its  use, 
therefore,  cannot  be  recommended.  Antipyrine  efl^ectually  reduces  the  tem- 
perature, but  is  depressing.  It  may  be  given,  especially  in  the  early  stages 
of  typhoid  fever,  in  doses  of  two  to  five  grains  according  to  the  age,  along 
with  an  alcoholic  stimulant,  with  a  good  result.  Some  physicians  recommend 
the  use  of  phenacetin  instead  of  antipyrine,  as  being  equally  efi"ectual  and 
less  depressing.  It  may  be  given  in  about  half  the  dose  of  antipyrine.  Ace- 
tanilide in  one-fourth  the  dose  of  antipyrine  also  reduces  the  fever,  but  it  is 
also  depressing,  and  it  does  not,  so  far  as  I  am  aware,  possess  any  advantages 
over  antipyrine.  In  the  majority  of  cases  the  reduction  of  temperature  is 
best  effected  by  cold-water  bathing  or  cold  compresses  and  the  internal  use 
of  quinine.  Quinine  in  moderate  doses  as  a  tonic  appears  to  be  useful  during 
the  entire  course  of  the  fever,  but  in  cases  of  a  temperature  dangerously 
high  antipyrine,  acetanilide,  or  phenacetin  is  now  preferred  by  good  observers 
to  the  use  of  large  doses  of  quinine,  which  were  formerly  employed  (Yon 
Ziemssen). 

The  fact  that  in  a  large  proportion  of  cases  the  typhoid  bacillus  enters 
the  system  in  the  ingesta,  and  eifects  a  lodgement  upon  the  gastro-intestinal 
surface,  suggests  the  query  whether  the  early  use  of  antiseptics  administered 
by  the  mouth  might  not  be  destructive  to  the  bacillus,  and  thus  in  a  measure 
destroy  the  cause  of  the  disease.  The  remedy  which  has  thus  far  been  used 
for  this  purpose,  and  which  is  supposed  by  some  to  exert  a  specific  action 
upon  the  disease,  apart  from  its  purgative  or  eliminative  eff"ect,  is  calomel. 
Its  mode  of  action  is  not  fully  understood.  It  is  supposed  by  some  to  be  in 
27 


418  CONSTITUTIONAL  DISEASES. 

part  changed  into  the  bichloride  in  the  stomach  and  intestines.  Von  Ziems- 
sen  in  treating  adults  administers  early  in  the  attack  three  7  2 -grain  doses 
of  calomel  at  intervals  of  two  hours,  and  obtains  by  so  doing  a  considerable 
reduction  of  temperature  during  the  following  twelve  hours.  Liebermeister 
claims  that  the  use  of  calomel  diminishes  the  intensity  of  the  disease,  and 
Wunderlich  even  believed  at  one  time  that  it  might  abort  the  fever.  On  the 
other  hand,  Weil,  Griesinger,  and  Baumler  assert,  from  their  observations  and 
statistics,  that  the  mortality  is  not  diminished  nor  is  the  number  of  aborted 
cases  increased  by  the  use  of  calomel,  and  that  it  is  only  useful  as  a  mild, 
non-irritating  evacuant.  AVilson  says :  "  Attempts  to  fix  the  hypothetical 
specific  action  by  long-continued  calomel  treatment,  and  to  force  a  true  abor- 
tive calomel  treatment,  have  at  different  times  failed,  as  has  also  the  subli- 
mate treatment  of  typhoid  fever."  The  use  of  calomel  should  probably  be 
restricted  to  one  or  a  few  doses  at  the  commencement  of  the  attack. 

Since  it  is  impossible  to  arrest  typhoid  fever  or  abridge  its  duration  by 
any  therapeutic  measures  of  which  we  are  cognizant,  the  indication  is  to 
sustain  the  vital  powers  and  alleviate,  so  far  as  possible,  the  symptoms. 
Quinine  is  not  only  employed  in  large  doses  to  reduce  the  fever,  but  it  is 
often  prescribed  in  small  doses  during  the  subsequent  progress  of  the  disease, 
in  the  belief  that  it  may  exert  some  tonic  effect.  It  does  not  appear,  how- 
ever, to  exert  any  marked  controlling  effect  upon  the  symptoms.  Iodine, 
iodide  of  potassium,  and  carbolic  acid  have  also  been  employed  internally, 
but  their  efficacy  is  doubtful ;  but  Liebermeister  states  that  the  iodide  of 
potassium  employed  in  two  hundred  cases,  although  it  did  not  appreciably 
ameliorate  the  symptoms,  apparently  diminished  the  mortality. 

The  mineral  acids  have  also  their  advocates,  and  statistics  appear  to  show 
benefit  from  their  use.  The  late  Prof.  Austin  Flint  treated  78  patients  with 
the  acids  with  a  death-rate  of  10.25  per  cent,  and  70  patients  without  the 
acids  with  a  death-rate  of  20  per  cent.,  the  treatment  otherwise  of  the  two 
classes  being  alike.  The  mineral  acid  which,  in  my  opinion,  is  most  useful  is 
the  muriatic,  since  it  aids  digestion,  which  is  greatly  impaired  by  the  fever, 
and  since  the  digestive  ferments  in  this  disease  are  apparently  secreted  in 
insufficient  quantity.  I  usually  prescribe  this  acid  with  pepsin,  as  in  the 
following  formula : 

R.  Pepsini  puri,  in  lamellis,         3J  ; 
Acidi  muriat.  dilut.,  ^ij  ; 

Syr.  simplic,  ^j  ; 

Aquee,  Siij. — Misce. 

Give  one  teaspoonful  in  water  every  two  hours  to  a  child  of  ten  years. 

The  wine  of  pepsin  of  the  National  Formulary  may  also  be  employed,  but 
each  teaspoonful  contains  only  about  one  minim  of  the  dilute  muriatic  acid, 
so  that  the  quantity  of  the  acid  might  be  increased. 

In  all  but  the  mildest  cases  alcoholic  stimulants  are  required,  especially 
after  the  first  week.  In  the  first  week  they  may  be  withheld  in  ordinary 
cases,  but  in  attacks  of  a  severe  type  and  attended  by  early  prostration  they 
may  be  required  at  or  soon  after  the  commencement  of  the  fever.  The  indi- 
cations for  their  use  are  feeble  pulse  with  faint  systolic  sound  and  marked 
nervous  symptoms,  as  subsultus  tendinum,  stupor,  and  delirium.  In  the 
prostration  consequent  on  high  fever  and  protracted  and  obstinate  diarrhoea 
the  use  of  alcohol  is  important  as  a  cardiac  stimulant.  Still,  such  large  and 
frequent  doses  of  the  alcoholic  compounds  are  not  needed  as  are  useful  in 
diphtheria.  The  object  in  employing  them  is  to  sustain  the  flagging  pulse 
and  promote  digestion  and  assimilation.  The  preferable  mode  of  employing 
alcoholic  stimulants  is  in  the  form  of  milk  punch  or  wine  whey. 


TYPHOID  FEVER.  419 

Wakefulness,  which  is  sometimes  an  unpleasant  symptom,  and  which  may 
occur  with,  and  is  perhaps  largely  due  to,  the  headache,  may  be  relieved  by 
a  powder  of  phenacetin  and  bromide  of  potassium  or  sodium,  two  to  five 
grains  of  the  former  and  double  or  treble  its  amount  of  the  bromide.  The 
new  remedy,  sulphonal,  triturated  and  given  in  sweetened  water  or  milk, 
will  also  relieve  the  insomnia,  and  in  some  instances  it  appears  to  be  prefer- 
able to  the  other  agents  which  have  been  employed  for  the  purpose  of  procur- 
ing sleep.  An  opiate,  as  Dover's  powder,  is  also  useful  in  relieving  wakeful- 
ness, and  should  be  prescribed  if  the  patient  at  the  same  time  have  diarrhoea. 
Three  grains  may  be  given  to  a  child  of  eight  years.  For  headache,  whether 
accompanied  by  wakefulness  or  not,  I  know  no  better  remedy  than  phenacetin 
in  combination  with  the  bromide  of  potassium  or  sodium,  as  given  above.  At 
the  same  time,  cool  lotions  should  be  applied  to  the  head.  The  same  remedies 
which  are  appropriate  for  the  insomnia  are  also  useful  for  the  delirium  which 
occasionally  occurs  in  cases  of  a  grave  type.  The  constant  application  of  cold 
to  the  head  and  an  increase  in  the  stimulation  may  also  be  required. 

We  have  stated  elsewhere  that  diarrhoea  is  less  common  in  the  typhoid 
fever  of  children  than  in  that  of  adults,  but  it  sometimes  occurs,  and  should 
be  promptly  checked.  The  subnitrate  of  bismuth  in  rather  large  and  fre- 
quent doses,  along  with  an  opiate  and  vegetable  astringent,  will  usually  con- 
trol the  diarrhoea,  and  the  same  remedies  should  be  employed  in  intestinal 
hemorrhage.  Recently  in  my  practice  in  the  case  of  a  boy  of  about  fifteen 
years  near  the  close  of  the  second  week  of  typhoid  fever,  so  large  a  flow 
of  blood  occurred  from  the  intestines  that  the  condition  of  the  patient  was 
very  critical.  But  the  loss  of  blood  was  quickly  checked  by  large  doses 
of  subnitrate  of  bismuth  and  teaspoonful  doses  of  equal  parts  of  the  cam- 
phorated tincture  of  opium  and  tincture  of  catechu,  and  the  patient  recovered. 
The  constipation  which  is  sometimes  present  in  typhoid  fever,  and  more  fre- 
quently in  children  than  in  adults,  may  be  relieved  by  an  enema  of  water, 
half  a  pint  containing  one  or  two  teaspoonfuls  of  glycerin. 

The  distention  of  the  stomach  and  intestines  with  flatus  is  sometimes  so 
great  that  it  requires  treatment.  It  may  cause  a  sensation  of  fulness  and 
prevent  tlae  descent  of  the  diaphragm  in  respiration,  and  it  increases  the 
danger  of  perforation  if  a  deep  intestinal  ulcer  exist.  External  pressure 
and  manipulation  should  not  be  employed  under  such  circumstances,  since 
they  might  cause  rupture,  nor  should  the  hypodermic  needle  be  used.  Jacobi 
has  witnessed  a  fatal  peritonitis  produced  by  the  escape  of  fecal  matter 
through  the  punctures  caused  by  the  needle  (Arch,  of  Pediatrics,  Dec,  1888). 
The  proper  remedy  for  the  flatus  is  either  turpentine  or  the  aniseed  cordial 
of  the  National  Formulary. 

Sustaining  measures  are  of  the  highest  importance.  Typhoid  fever  ceases 
after  some  days  or  weeks  with  or  without  medicinal  treatment,  and  the  patient 
recovers  if  the  strength  be  adequately  supported.  Hence  the  food  should  be 
sufficient  in  quantity,  of  the  most  nutritious  kind,  and  easily  digested  and 
assimilated.  It  must  be  liquid,  since  the  repugnance  to  food  and  the  mental 
state  of  the  patient  render  it  impossible  to  feed  him  with  solids  unless  in  the 
mildest  cases.  Milk  sterilized  by  heat  or  peptonized,  the  meat  broths,  and 
gruels  with  milk  must  be  the  food  chiefly  employed.  Since  the  digestive  fer- 
ments are  apparently  secreted  in  small  quantity  during  the  fever  and  diges- 
tion is  feebly  performed,  it  is  well  to  employ  predigested  food  when  the  dis- 
ease is  unusually  severe  and  the  temperature  very  high.  Peptonized  milk 
and  the  beef  peptones  of  the  shops  are  useful  under  such  circumstances. 
Milk  with  some  farinaceous  food  long  boiled,  as  barley  flour,  should  in  most 
instances  be  employed  as  the  principal  article  of  diet.  The  mistake  is  some- 
times made  by  anxious  friends  of  giving  the  nutriment  too  frequently,  even 


420  CONSTITUTIONAL  DISEASES. 

every  half  hour.  As  in  health,  so  in  this  disease,  the  digestive  function 
requires  intervals  of  rest,  so  that,  as  a  rule,  the  food  should  not  be  given 
oftener  than  every  two  hours,  and  then  in  sufficient  quantity.  A  dose  of 
pepsin  before  each  feeding,  employed  in  the  formula  recommended  above, 
has  been  useful  in  critical  cases  in  my  practice.  So  important  is  the  diet  in 
typhoid  fever  that  the  physician  neglects  an  important  duty  if  he  do  not  give 
as  full  and  explicit  directions  in  regard  to  the  feeding  as  he  does  in  refer- 
ence to  the  use  of  medicines.  The  room  occupied  by  the  patient  should  be 
large  and  well  ventilated.  Statistics  show  that  the  result  is  far  better  if  there 
be  a  plentiful  supply  of  pure  fresh  air  than  in  closed  and  ill-ventilated  apart- 
ments ;  so  that  in  some  of  the  hospitals  patients  are  treated  in  canvas  tents 
upon  the  hospital  grounds  when  the  weather  is  suitable.  Nearly  forty  years 
ago  an  emigrant-ship  arrived  at  Perth  Amboy,  N.  J.,  with  more  than  300 
passengers,  82  of  whom  were  sick  with  fever,  and  several  had  died  at  sea. 
There  being  no  hospital  in  the  town,  the  fever  patients,  12  of  whom  were 
insensible,  were  placed  in  hastily-constructed  wooden  shanties  with  sail  roofs. 
To  add  to  their  discomfort,  a  violent  thunder-storm  occurred  which  drenched 
the  interior  of  the  shanties,  and  yet  with  simple  medicinal  treatment  and  the 
use  of  buttermilk  and  animal  broths  only  1  of  the  82  patients  died.  Four 
sailors  who  sickened  with  the  fever  after  the  arrival  of  the  vessel  were  taken 
to  a  dwelling-house,  and  two  of  them  died.  These  facts,  which  were  related 
to  the  New  York  Academy  of  Medicine  at  the  June  meeting  in  1853  by  the 
late  Dr.  John  H.  Griscom.  and  were  published  in  the  Transactions  of  the 
Academy  for  that  year,  strongly  impressed  the  profession  of  New  York  with 
the  importance  of  fresh  air  in  the  treatment  of  typhus  and  typhoid  fevers, 
and  the  knowledge  thus  obtained  has  no  doubt  been  instrumental  in  saving 
many  lives.  But  in  the  treatment  of  children  the  sudden  reduction  of  tem- 
perature and  currents  of  cold  air  should  be  avoided,  for  by  taking  cold  the 
bronchial  catarrh  which  is  ordinarily  present  in  a  mild  form  might  be  aggra- 
vated, or  a  croup  or  pneumonia  might  be  developed. 

•  Von  Ziemssen  states  that  in  severe  cases  attended  by  feeble  heart-action 
the  patient  should  not  be  allowed  to  move  without  assistance  or  get  out  of 
bed,  for  sudden  heart-failure  and  death  "  frequently  result  from  a  neglect  of 
this  rule  "  (Annual  of  Med.  Sci.,  vol.  i.,  1888).  The  occurrence  of  bed-sores 
should  be  guarded  against  by  change  of  position  and  the  use  of  a  soft  mat- 
tress or  water-bag.  In  severe  cases  attended  by  much  prostration  the  patient 
should  not  be  allowed  to  leave  the  bed  until  some  days  after  the  fever  has 
ceased  and  the  strength  is  in  a  measure  restored. 

Prophylaxis. — The  duty  of  the  physician  does  not  cease  with  the  care  of 
the  patient.  He  should  employ  efficient  measures  to  prevent  the  propaga- 
tion of  the  disease.  Especial  attention  should  be  given  to  the  disinfection 
of  the  excreta.  This  may  be  accomplished  by  adding  six  ounces  of  chloride 
of  lime  to  one  gallon  of  water,  and  mixing  one  quart  of  this  solution  with 
each  fecal  evacuation  and  a  less  quantity  with  each  urinary  discharge.  Crude 
carbolic  acid  (one  part  to  ten  or  fifteen  of  water),  sulphate  of  copper  (one 
part  to  twenty  of  water),  or,  best  of  all,  corrosive  sublimate  (one  part  to  two 
hundred  to  four  hundred  of  water)  may  be  employed  for  the  same  purpose. 
The  disinfected  discharge  should  be  allowed  to  stand  a  few  moments  before 
it  is  emptied  into  the  water-closet,  and  the  closet  should  be  thoroughly 
flushed  out.  In  country  practice  great  care  must  be  taken  that  the  dis- 
charges be  not  emptied  in  such  a  place  that  they  can  by  any  possibility 
percolate  into  the  well  which  supplies  the  drinking-water  to  the  families  or 
neighbors.  A  pound  or  more  of  corrosive  sublimate  in  solution  should  be 
sprinkled  in  the  vault,  and  chloride  of  lime  should  be  dusted  over  the  con- 
tents.    The  milk   used  in   the  family  should  be  sterilized  by  steaming  two 


CEREBROSPINAL  FEVER.  421 

hours  at  a  temperature  of  180°  to  190°,  or  by  boiling,  and  the  drinking- 
water  should  be  boiled  or  distilled.  Care  should  be  taken  to  disinfect 
promptly  the  clothing  worn  by  the  patient  and  the  bedding.  This  may  be 
accomplished  by  placing  them  immediately  when  removed  in  boiling  water 
or  by  immersing  them  in  a  solution  of  corrosive  sublimate  (one  part  to  one 
thousand),  or  carbolic  acid  (one  part  to  fifty),  or  sulphate  of  copper  or 
chloride  of  lime  (one  part  to  one  hundred). 


CHAPTER    IV. 

CEEEBRO-SPINAL  FEVER. 

Definition. — Probably  a  microbic  disease.  It  is  manifested  chiefly  by 
the  occurrence  of  cerebro-spinal  meningitis.  Its  prominent  symptoms  are 
such  as  meningitis  gives  rise  to — to  wit,  fever,  headache,  tonic  contraction 
of  the  muscles  of  the  nucha,  hypersesthesia,  and  neuralgic  pains  in  the  trunk 
and  extremities.  It  is  non-contagious,  or  contagious  in  a  very  low  degree, 
and,  as  with  most  of  the  microbic  diseases,  its  victims  are  chiefly  the  young. 
It  is  ordinarily  a  primary  disease,  but  it  sometimes  occurs  as  a  complication 
of  other  acute  as  well  as  chronic  maladies.  It  begins  abruptly  or  without  a 
premonitory  stage,  and  it  is  often  speedily  fatal  from  the  intense  hypergemia 
of  the  nervous  centres  or  the  severity  of  the  cerebro-spinal  meningitis.  In 
other  cases,  after  weeks  or  months  of  sufi"ering  and  progressive  loss  of  flesh 
and  strength,  death  occurs  in  a  state  of  extreme  prostration.  In  those  who 
recover  convalescence  is  protracted  and  slow. 

This  disease  has  been  designated  by  diff"erent  terms  in  diflFei'ent  countries, 
as  spotted  fever,  cerebro-spinal  fever,  malignant  purpuric  fever,  typhus 
petechialis,  typhus  syncopalis,  and  febris  nigra,  expressive  of  its  constitu- 
tional nature.  Those  who  employ  such  terms  regard  it  as  a  general  or 
systemic  disease,  with  the  meningitis  as  its  local  manifestation,  just  as 
pharyngitis  is  a  local  manifestation  of  scarlet  fever  or  bronchitis  of  measles 
or  pertussis.  This  opinion  of  its  nature  receives  strong  support  from  the 
clinical  fact  that  in  severe  forms  of  the  disease  extravasations  of  blood  occur 
early  under  the  skin,  indicating  a  profoundly  altered  state  of  the  blood  and 
systemic  infection.  The  disease  has  also  been  designated  by  terms  expressive 
of  its  local  nature,  as  epidemic  meningitis,  epidemic  cerebro-spinal  menin- 
gitis, typhoid  meningitis,  malignant  meningitis.  We  will  treat  hereafter  of 
the  nature  of  this  malady,  and  endeavor  to  justify  the  opinion  which  has  led 
to  the  use  of  terms  that  indicate  its  constitutional  character. 

History. — Whether  cerebro-spinal  fever  occurred  previously  to  the  pres- 
ent century  is  uncertain.  If  it  did  it  was  confounded  with  other  diseases. 
Vieussens  in  1805  was  apparently  the  first  who  wrote  a  clear  and  unmistak- 
able description  of  it,  designating  it  "  a  malignant  non-contagious  fever."  He 
described  an  epidemic  of  it  which  appeared  in  Geneva,  Switzerland,  in  a 
family  of  3  children,  of  whom  2  died  in  twenty-four  hours.  Two  weeks 
later  4  children  in  another  family  died  of  it,  after  an  illness  of  less  than  a 
day,  and  a  young  man  in  another  house  died  with  similar  symptoms  after  an 
equally  brief  illness,  his  surface  having  a  deeply  congested  or  violet  appear- 
ance. In  these  and  subsequent  cases  the  attack  began  in  the  latter  part  of 
the  day  or  at  night,  and  was  attended  by  vomiting,  violent  headache,  con- 
vulsions, dysphagia,  petechiee,  and  tonic  contraction  of  the  posterior  muscles 


422  CONSTITUTIONAL  DISEASES. 

of  the  neck  and  trunk,  producing  retraction  of  the  head  and  opisthotonos. 
Thirtv-three  lost  their  lives  during  this  epidemic,  after  a  sickness  varying 
from  twelve  hours  to  five  days.  Within  the  next  two  years  epidemics  of 
cerebro-spinal  fever  occurred  in  Bavaria,  Holland,  Germany,  and  at  about  the 
same  time  or  soon  after  in  parts  of  England. 

The  first  American  cases  of  the  disease,  so  far  as  is  now  known,  were  at 
Medfield,  Massachusetts,  in  1806.  From  1806  to  1816  occasional  outbreaks 
of  it  occurred  in  England,  France,  and  America  in  several  localities.  It 
appeared  in  both  Canada  and  the  United  States.  From  1816  to  1828,  so  far 
as  is  now  known,  only  two  epidemics  of  it  occurred,  and  they  were  limited 
to  small  areas  and  were  of  brief  duration.  The  one  was  at  Middletown,  Con- 
necticut, and  the  other  at  Vesoul,  France.  In  1828  it  occurred  in  Trumbull 
county,  Ohio,  in  1830  at  Sunderland,  England,  and  in  1833  at  Naples.  After 
the  Naples  epidemic  a  respite  from  the  disease  appears  to  have  occurred,  in 
both  the  Eastern  and  Western  Hemispheres,  until  1837.  In  that  year  it 
appeared  in  the  south  of  France,  in  and  around  Bayonne,  and  gradually 
extended  to  isolated  localities  over  almost  the  whole  of  France.  It  occurred 
at  this  time  among  troops  in  their  barracks  as  well  as  civilians,  and  in  some 
localities,  of  the  troops  affected  from  50  to  75  per  cent.  died.  Even  Versailles 
and  Paris  did  not  escape.  During  the  twelve  years  from  1837  to  1849, 
France  suffered  far  more  than  any  other  country  from  this  disease.  It  was 
especially  common  and  fatal  among  the  soldiers  in  many  localities,  and  at 
some  of  the  military  stations  in  France  several  successive  epidemics  occurred. 
In  the  decade  from  1839  to  1849  cerebro-spinal  fever  extended  to  Naples, 
the  Romagna,  Sicily,  Gibraltar,  Algeria,  and  various  places  in  Denmark, 
England,  and  Ireland. 

In  1842  the  United  States  was  again  visited  by  cerebro-spinal  fever  in 
localities  at  a  distance  from  the  seaboard,  and  therefore,  apparently,  not  by 
communication  from  Europe.  In  1842—43  it  occurred  in  Kentucky,  Tennes- 
see, Alabama,  Illinois,  Mississippi,  and  Arkansas.  From  1840  to  1850  it 
visited  Montgomery  in  Alabama,  Beaver  county  in  Pennsylvania,  Cayuga 
county  in  New  York,  and  New  Orleans  in  Louisiana.  Between  1850  and 
1854  there  is  no  record  of  its  occurrence  in  either  hemisphere,  but  from 
1854  to  1860  it  ravaged  the  Scandinavian  peninsula  and  caused  more  than 
four  thousand  deaths. 

Since  1860  certain  localities  in  nearly  every  civilized  country  have  been 
severely  visited  by  this  disease.  In  all  these  countries  it  is  justly  regarded 
as  one  of  the  most  fatal  and  important  of  the  epidemic  maladies. 

An  interesting  fact  in  regard  to  these  many  epidemics  on  both  continents, 
which  have  been  reported  by  competent  observers,  is  that  they  have  occurred 
in  isolated  localities  far  apart  and  without  the  least  evidence  of  transporta- 
tion. Cerebro-spinal  fever  has  not,  so  far  as  I  am  aware,  in  any  instance 
extended  from  one  locality  to  an  adjacent  one  in  the  manner  of  contagious 
diseases.  The  cause  of  the  malady  has  evidently  arisen  or  been  created  in 
the  places  where  the  cases  have  occurred,  and  is  not  susceptible  of  transpor- 
tation so  as  to  produce  the  disease  elsewhere.  Cerebro-spinal  fever  resembles 
in  this  respect  the  diseases  due  to  marsh  miasm. 

But  since  1860  this  disease  has  appeared  in  this  country  in  another  phase. 
It  has  become  or  is  being  established — or,  to  use  the  phrase  commonly  em- 
ployed in  medical  literature,  naturalized — in  the  cities  of  the  United  States. 
For  some  years  not  a  week  has  passed  without  the  report  of  deaths  from  this 
cause  in  New  York,  Philadelphia,  Jersey  City,  and  Chicago.  It  is  probably 
already  permanently  established  in  Cincinnati,  St.  Louis,  Minneapolis,  Newark, 
and  San  Francisco,  since  deaths  from  it  have  been  reported  in  these  cities 
during  many  consecutive  weeks. 


CEREBROSPINAL  FEVER.  423 

In  New  York  City  prior  to  1866  only  4  deaths  occurred  from  what  was 
perhaps  cerebro-spinal  fever,  since  in  1838,  2  deaths  were  reported  from  so- 
called  spotted  fever,  1  in  1850  and  1  in  1861.  What  was  the  nature  of  this 
spotted  fever  is  now  a  matter  of  conjecture.  In  1866,  18  patients  died  of 
cerebro-spinal  fever  within  the  city  limits,  and  not  a  year  has  passed  since, 
and  in  the  last  few  years  not  a  week,  without  deaths  from  it.  From  1866  to 
1872  the  annual  deaths  from  this  disease  in  New  York  varied  from  18  to  48. 
Commencing  in  December,  1871.  and  continuing  during  the  first  half  of  1872, 
a  severe  epidemic  occurred,  producing  a  large  mortality.  Many  who  recovered 
permanently  lost  their  hearing  and  some  their  sight  from  the  attack.  In  this 
epidemic  the  physicians  of  New  York  were  fully  aroused  to  the  importance 
of  the  disease  which  was  causing  so  much  suifering,  and  which  attacked  the 
lower  animals,  especially  the  jaded  horses  of  the  city  car-  and  stage-lines,  not 
a  few  of  them  dropping  down  in  harness,  so  suddenly  did  the  attacks  occur. 
In  1872,  782  deaths,  chiefly  of  children,  resulted  from  cerebro-spinal  fever 
within  the  city  limits.  This  epidemic  appeared  to  produce  a  greater  dissemi- 
nation of  the  disease  and  more  firmly  established  it  in  the  city,  for  since  then 
the  annual  deaths  from  it  have  varied  between  97  in  1878  and  461  in  1881. 
In  Philadelphia  cerebro-spinal  fever  began  in  1863,  causing  49  deaths  in  that 
year,  and  it  has  never  been  absent  from  that  city  since.  Prof.  Stille  states 
that  between  1863  and  1882  it  has  caused  2049  deaths  within  the  city  limits. 
In  Philadelphia,  as  in  New  York,  it  has  for  some  years  produced  a  nearly 
uniform  weekly  mortality.  The  prevalence  of  cerebro-spinal  fever  in  the 
United  States  and  its  probable  importance  in  the  future  may  be  inferred  from 
the  fact  that  it  has  recently  occurred  also  in  Cincinnati,  Minneapolis,  Denver, 
Norfolk,  Boston,  Worcester,  New  Haven,  Albany,  Syracuse,  Auburn,  Mil- 
waukee, Wilmington,  Detroit,  Baltimore,  Charleston,  Toledo,  Mobile,  Salt 
Lake,  Grand  Rapids,  Providence,  Chattanooga,  Hartford,  New  Orleans,  Fall 
River,  Richmond,  Knoxville,  and  Nashville. 

Etiology. — That  this  disease  is  produced  by  a  micro-organism  is  generally 
believed.  Dr.  A.  Frankel  and  other  European  microscopists  have  carefully 
examined  the  bacteria  found  in  the  blood  and  tissues  of  those  affected  by  it. 
At  a  meeting  of  the  Berlin  Medical  Society,  held  February  12,  1883,  Herr 
Leyden  showed  under  the  microscope  specimens  of  micrococci  found  in  a 
case  of  cerebro-spinal  fever.  They  had  an  oval  shape,  were  mostly  in  pairs, 
and  were  faintly  tremulous.  They  resembled  those  found  in  pneumonia 
and  erysipelas,  but  Leyden  did  not  think  them  identical.  At  the  same 
meeting  Herr  Baginsky  related  cases  which  seemed  to  show  that  in  some 
instances  the  cause  of  cerebro-spinal  fever  and  that  of  pneumonia  might  be 
identical.^ 

Dr.  V.  0.  PushkarefF,  connected  with  one  of  the  barrack-infirmaries  of 
St.  Petersburg,  states  that  in  five  cases  of  croupous  pneumonia  in  which 
cerebro-spinal  meningitis  occurred  as  a  complication  he  discovered  in  the  pus 
taken  from  the  cerebral  meninges  swarms  of  micrococci  whose  appearance 
under  the  microscope  seemed  identical  with  that  of  Friedlander's  pneumococ- 
cus.  They  were  either  isolated  or  in  groups  of  two,  seldom  in  four,  having 
distinct  capsules,  and  they  were  absent  from  the  fluid  taken  from  the  men- 
inges in  simple  pneumonia.  Pushkareff'  was  able  to  cultivate  the  micrococ- 
cus taken  from  the  meningeal  pus,  and  the  cultivated  microbes,  like  their 
parents,  presented  an  appearance  identical  with  that  of  the  pneumococcus.^ 
Moreover,  Eberth,  in  a  case  of  meningitis  following  pneumonia,  believes  that 
he  found  the  same  micrococcus  in  the  lungs  and  in  the  liquid  exuded  from 
the  inflamed  pia  mater.     Frankel  also  states  that  he  obtained  from  the  puru- 

^Deutsch.  med.  Wochenschr .,  April  4,  1883. 
^  Ejen.  klin.  Gazeta,  April  21,  1885. 


424  CONSTITUTIONAL  DISEASES. 

lent  exudation  in  the  pia  mater,  in  a  case  of  meningitis  occurring  with  pneu- 
monia, a  microbe  resembling  that  in  the  pneumonic  exudation/ 

From  the  investigations  of  so  many  competent  microscopists,  therefore, 
it  appears  that  the  microbe  found  in  the  exudate  of  the  meninges  in  cerebro- 
spinal fever,  and  which  is  supposed  to  sustain  a  causal  relation  to  this  dis- 
ease, bears  a  close  resemblance  in  form  to  the  pneumococcus,  if  it  be  not 
identical  with  it.  But  we  would  infer,  from  the  fact  that  croupous  pneu- 
monia is  so  universal  a  disease  occurring  in  localities  where  there  is  no 
cerebro-spinal  fever,  that  the  cause  of  the  two  must  be  diflPerent,  or,  if  there 
be  a  form  of  croupous  pneumonia  which  is  produced  by  the  same  microbe  as 
that  of  cerebro-spinal  fever,  the  pneumonia  which  is  universal  must  have  a 
different  origin.  The  microbic  causation  of  cerebro-spinal  fever  needs 
further  investigation,  which  it  will  doubtless  receive,  before  positive  state- 
ments can  be  made. 

Among  the  conditions  which  are  favorable  for  the  occurrence  of  cerebro- 
spinal fever,  and  may  therefore  be  regarded  as  predisposing  to  it,  we  may 
mention  the  winter  season.  Statistics  collected  in  Europe  and  the  United 
States  show  that  while  166  epidemics  occurred  in  the  six  months  commencing 
with  December,  only  50  were  in  the  remaining  six  months  of  the  year.  Ac- 
cording to  the  statistics  of  Prof.  Hirsch,  which  were  collected  mainly  from 
Central  Europe,  57  epidemics  were  in  winter  or  in  winter  and  spring,  11  in 
spring,  5  between  spring  and  autumn,  4  commenced  in  autumn  and  extended 
into  winter  or  into  winter  and  the  ensuing  spring,  and  6  lasted  the  entire 
year.  I  suspect  that  the  opinion  expressed  by  Prof.  Hirsch  is  correct,  that 
the  excess  of  epidemics  in  the  winter  months  is  due  mainly  to  the  greater 
crowding  and  less  ventilation  in  the  domiciles  during  the  cold  than  during 
the  warm  months,  especially  among  European  peasantry.  In  New  York 
City,  where  the  state  of  the  domiciles  is  about  the  same  the  year  round, 
the  season  appears  to  exert  little  influence  on  the  prevalence  of  the 
disease. 

The  fact  has  repeatedly  been  observed  that  antihygienic  conditions  in- 
crease the  liability  to  cerebro-spinal  fever.  Soldiers  in  barracks  and  the  poor 
in  tenement-houses  suffer  most  severely  when  the  epidemic  is  prevailing.  In 
New  York  City  the  fact  is  often  remarked  that  multiple  cases  occur  for  the 
most  part  where  obvious  insanitary  conditions  exist,  as  in  apartments  which 
are  unusually  crowded  and  filthy  or  in  tenement-houses  around  which  refuse 
matter  has  collected  or  which  have  defective  drainage.  The  interesting  chart 
prepared  under  the  direction  of  Dr.  Moreau  Morris  for  the  Health  Board 
shows  that  comparatively  few  cases  occurred  in  the  epidemic  of  1872  in  those 
portions  of  the  city  where  the  sanitary  conditions  were  good.  Antihygienic 
conditions  probably  predispose  to  cerebro-spinal  fever  in  the  same  way  that 
they  do  to  other  grave  epidemic  disease,  as,  for  example,  to  Asiatic  cholera, 
whose  ravages  are  chiefly  where  hygienic  requirements  are  most  neglected. 
We  will  presently  relate  striking  examples  which  show  how  foul  air  increases 
the  number  and  malignancy  of  cases.  Insanitary  conditions  not  only  ener- 
vate the  system  and  render  it  more  liable  to  contract  any  prevailing  dis- 
ease, but  probably  promote  the  development  and  activity  of  the  specific 
principle. 

Is  Cerebro-Spinal  Fever  Contagious  ? 

It  is  the  almost  unanimous  opinion  of  those  who  are  most  competent  to 
judge  from  their  observations  that  it  is  either  not  contagious  or  is  contagious 
in  a  very  slight  degree.     It  is  certain  that  the  vast  majority  of  cases  occur 
^  Deutsch.  med.  Wochenschr.,  Nov.  13,  1886. 


CEREBROSPINAL  FEVER.  425 

without  the  possibility  of  personal  communication.  Thus,  in  the  commence- 
ment of  an  epidemic  the  first  patients  are  affected  here  and  there  at  a  dis- 
tance from  each  other,  often  miles  apart,  and  throughout  an  epidemic  usually 
only  one  is  seized  in  a  family.  Children  may  be  around  the  bedside  of  the 
patient,  passing  in  and  out  of  the  room  without  restriction,  and  yet  we  can 
confidently  predict  that  none  of  them  will  contract  the  malady  if  there  be 
proper  ventilation  and  cleanliness  and  none  of  the  conditions  of  insalubrity 
exist  within  or  around  the  domicile.  Moreover,  when  multiple  cases  occur 
in  a  family  the  disease  begins  at  such  irregular  intervals  in  the  different 
patients  that  there  can  be  little  doubt  in  most  instances  that  it  is  not  com- 
municated from  one  to  the  other,  but,  like  the  fevers  from  marsh  miasm,  is 
produced  by  exposure  to  the  same  morbific  cause,  existing  outside  the  indi- 
viduals, but  within  or  around  the  premises.  Thus,  in  the  Brown  family 
treated  by  the  late  Dr.  John  Gr.  Sewell  ^  of  New  York,  the  first  child  sick- 
ened January  30th,  and  subsequently  the  remaining  five  children  at  intervals 
respectively  of  five,  seven,  eleven,  twenty-five,  and  forty-five  days.  That  so 
many  were  affected  in  one  family  was  attributed  by  the  doctor  to  the  filthy 
state  of  the  house  and  the  bad  plumbing,  which  allowed  the  free  escape  of 
sewer-gas.  In  my  own  practice,  in  the  family  which  suffered  the  most 
severely  of  all,  four  patients  were  seized  in  succession,  and  yet  I  could  see 
no  evidence  of  contagiousness.  The  family  occupied  a  small  plot  of  ground, 
not  more  than  thirty  feet  by  one  hundred,  and  their  occupation  was  to  pre- 
pare for  the  meat-market  what  is  known  as  head-cheese.  They  lived  on  the 
second  floor  of  the  two-story  wooden  house  in  which  the  work  was  carried 
on.  At  the  time  of  the  sickness  the  shop  contained  four  hundred  heads  of 
animals  from  which  the  meat  for  the  cheese  was  obtained,  and  it  was  evident 
that  decaying  animal  matter  was  present.  The  occupation  and  surroundings 
of  this  family  afforded  sufficient  explanation  of  the  fact  that  so  many  were 
attacked.  Two  workmen  contracted  the  disease  within  about  one  week  of 
each  other,  and  were  removed  from  the  house.  On  January  26th,  four 
weeks  after  the  commencement  of  the  malady  in  the  workman  who  was  first 
attacked,  one  child  sickened  with  it,  and  died  on  February  1st.  Fifteen 
days  subsequently  (February  16th)  a  second  child  was  attacked,  and,  after 
a  tedious  sickness,  finally  recovered.  The  long  and  irregular  intervals 
between  these  cases  indicate  that  the  disease  was  not  contracted  by  one 
from  the  other.  The  important  factor  in  causing  so  severe  an  outbreak  of 
cerebro-spinal  fever  in  this  family  was  probably  the  miasm  produced  by  such 
an  occupation  in  the  house  where  the  family  resided,  with  neglect  of  ventila- 
tion and  cleanliness. 

But  the  strongest  evidence  that  cerebro-spinal  fever  is  either  noncon- 
tagious or  very  feebly  contagious  is  afforded  by  the  fact  that  a  large  majority 
of  the  cases  occur  singly  in  families,  although  there  is  no  isolation  of  the 
patients.  The  following  are  the  statistics  relating  to  this  point  in  the  cases 
which  I  have  observed  since  cerebro-spinal  fever  commenced  in  New  York, 
in  1871  :  Single  cases  occurred  in  seventy  families  ;  dual  cases  occurred  in 
nine  families ;  three  cases  occurred  in  one  family,  and  four  cases  in  one 
family.  Intercourse  with  the  sick-room  was  unrestricted  in  all  these  fami- 
lies, so  that  children  frequently  went  out  and  in,  and  sometimes  assisted  in 
the  nursing. 

The  most  striking  example  of  apparent  contagiousness  which  has  come 
to  my  knowledge  was  related  by  Hirsch,  and  is  quoted  by  Von  Ziemssen. 
A  young  man  sickened  with  cerebro-spinal  fever  on  February  8th.  The 
woman  who  nursed  him  returned  to  her  home  in  a  neighboring  village,  and 
there  died  of  the  same  disease  on  February  26th.  To  her  funeral  mourners 
1  Medical  Record,  July,  1872. 


426  CONSTITUTIONAL  DISEASES. 

came  from  a  neighboring  township,  and  after  their  return  home  three  of  them 
died  with  the  same  disease — one  within  twenty-four  hours,  another  on  March 
4th,  and  a  third  on  the  7th. 

In  one  instance  only  in  my  practice  did  the  facts  point  to  contagiousness. 
A  boy  of  twelve  years  died  of  cerebro-spinal  fever,  and  was  buried  on  Satur- 
day or  Sunday.  On  Monday  the  mother  washed  the  linen  and  bedclothes  of 
the  boy,  which  had  accumulated  and  were  in  a  very  filthy  state.  Two  days 
subsequently  she  was  attacked,  and  her  infant  soon  afterward,  both  perishing. 
The  state  of  the  bedding  and  apartments  in  this  house,  as  seen  by  myself, 
was  such  as  would  be  likely  to  concentrate  and  intensify  the  poison,  render- 
ing it  peculiarly  active,  for  they  were  very  dirty,  and  the  mother,  exhausted 
by  her  long  and  incessant  watching  and  lack  of  sleep,  and  depressed  by  grief, 
rendered  her  system  more  liable  to  the  disease  by  her  self-imposed  duties  on 
the  day  after  the  funeral.  One  in  her  state  of  mind  and  body,  standing  for 
a  considerable  part  of  a  day  over  the  bedclothes  and  bedding  of  her  child 
soiled  by  the  excreta,  would  certainly  be  in  a  condition  to  contract  the  disease 
if  it  were  contagious  in  any,  even  in  the  lowest,  degree.  In  the  present  state 
of  our  knowledge,  therefore,  upon  this  important  subject  the  evidence  leads 
us  to  believe  that  with  proper  ventilation  and  cleanliness  and  the  suppression 
of  antihygienic  conditions  in  an  infected  domicile  those  who  are  in  a  good 
state  of  body  and  mind  will  not  contract  the  disease,  but  in  the  opposite  con- 
ditions it  is  not  improbable  that  the  poison  may  be  so  intensified,  and  the  sys- 
tem rendered  so  liable  to  receive  the  prevailing  malady  through  impairment 
of  the  general  health  and  diminished  resisting  power,  that  cerebro-spinal 
fever  may,  though  rarely,  be  communicated  either  by  the  breath  of  the  patient 
or  by  exhalations  from  his  surface  or  from  soiled  clothing. 

The  occurrence  of  cerebro-spinal  fever  in  certain  of  the  lower  animals  is 
a  very  interesting  fact,  especially  as  the  question  is  sometimes  asked  whether 
it  may  not  be  communicated  from  them  to  man.  In  the  epidemic  of  1811  in 
Vermont,  according  to  Dr.  G-allop,  even  the  foxes  seemed  to  be  afiected,  so 
that  they  were  killed  in  numbers  near  the  dwellings  of  the  inhabitants. 
Cerebro-spinal  fever,  previously  unknown  in  New  York  City,  began,  as  stated 
above,  in  1871,  among  the  horses  in  the  large  stables  of  the  city  car-  and 
stage-lines,  disabling  many  and  proving  very  fatal,  while  among  the  people 
the  epidemic  did  not  properly  commence  till  January,  1872,  although  a  few 
isolated  cases  occurred  in  December  of  1871.  No  evidence  exists,  so  far  as 
I  am  aware,  that  the  disease  was  in  any  instance  communicated  by  these 
animals  to  man.  Those  who  had  charge  of  the  infected  horses,  as  the  veter- 
inary surgeons,  and  stable-men,  did  not  contract  the  malady,  certainly  not 
more  frequently  than  others  who  were  not  so  exposed.  Although  we  may 
admit  slight  contagiousness,  there  has  probably  been  no  well-established 
example  of  the  transmission  of  cerebro-spinal  fever  from  animals  to  man. 
If  transmission  ever  does  occtir,  it  is  so  rare  that  practically  no  account  need 
be  made  of  it. 

In  some  instances  we  are  able  to  discover  an  exciting  cause.  An  indi- 
vidual whose  system  is  affected  by  the  epidemic  influence  may  perhaps  escape 
by  a  quiet  and  regular  mode  of  life,  but  if  there  be  any  unusual  excitement 
or  if  the  normal  functional  activity  of  the  system  be  seriously  disturbed,  an 
outbreak  of  the  malady  may  occur.  Among  the  exciting  causes  we  may 
mention  overwork  and  lack  of  sleep,  fatigue,  mental  excitement,  depressing 
emotions,  prolonged  abstinence  from  food  followed  by  over-eating,  and  the 
use  of  indigestible  and  improper  food.  Thus,  in  one  instance  among  my 
cases  a  delicate  young  woman,  at  the  head  of  one  of  the  departments  in  a 
well-known  Broadway  store,  was  anxious  and  excited  and  her  energies  over- 
taxed at  the  annual  reopening.     Within  a  day  or  two  subsequently  the  disease 


CEREBROSPINAL  FEVER.  427 

began.  Another  patient,  a  boy,  was  seized  after  a  day  of  unusual  excitement 
and  exposure,  having  in  the  mean  time  bathed  in  the  Hudson  when  the 
weather  was  quite  cool.  Those  children  have  seemed  to  me  especially  liable 
to  be  attacked  who  were  subjected  to  the  severe  discipline  of  the  public 
schools,  returning  home  fatigued  and  hungry,  and  eating  heartily  at  a  late 
hour.  In  one  instance  which  I  observed  a  school-girl  ten  years  of  age 
returned  from  school  excited  and  crying  because  she  had  failed  in  her  exam- 
ination and  had  not  been  promoted.  In  the  evening,  after  she  had  closely 
studied  her  lessons,  the  fever  began  with  violent  headache. 

Dr.  Frothingham  ^  writes  as  follows  of  the  brigade  in  which  cerebro-spinal 
fever  occurred  in  the  Army  of  the  Potomac :  "  Under  General  Butterfield,  a 
stern  disciplinarian,  ....  the  men  were  drilled  to  the  full  extent  of  their 
powers,  often  to  exhaustion.  I  did  not  at  the  time  recognize  this  as  the 
cause  of  the  disease  in  question,  but  I  learnt  that  in  the  present  epidemic  in 
Pennsylvania  the  attack  generally  follows  unusual  exertion  and  exposure  to 
cold." 

Many  observers  have  noticed  that  bodily  fatigue  and  mental  depression 
and  excitement  are  important  factors  in  causing  an  attack  of  cerebro-spinal 
fever  when  this  disease  is  epidemic.  Dr.  Gallop,  in  his  history  of  cerebro- 
spinal fever  as  it  occurred  during  the  war  of  1812,  directs  attention  to  the 
severity  of  the  cases  among  the  troops  under  General  Dearborn,  who  were 
fatigued  by  marches  and  greatly  dispirited  on  account  of  a  repulse  which 
they  had  sustained  from  the  British.  In  one  case  which  occurred  in  my 
practice  a  boy,  six  years  and  eleven  months  of  age,  was  punished  at  school 
and  came  home  with  cheeks  flushed  from  excitement,  the  excitement  con- 
tinuing during  the  ensuing  night.  On  the  following  day  cerebro-spinal  fever 
began  with  vomiting  and  chilliness,  the  attack  ending  fatally  on  the  seven- 
teenth day.  In  another  case,  which  was  related  to  me  by  the  mother  and 
the  physician,  the  patient,  a  bright  girl  twelve  years  of  age,  of  nervous  tem- 
perament and  forward  in  her  studies,  had  been  much  excited  in  competing 
for  a  prize  in  athletic  exercises.  In  the  evening  of  the  same  day  a  violent 
thunder-storm  occurred,  and  after  a  severe  clap  she  started  from  bed  pallid 
and  excited,  and  expressed  the  belief  that  she  had  been  struck  by  lightning. 
The  disease  began  immediately  after  this,  and  terminated  fatally  on  the  fifth 
day. 

Secondary  Cerebro- Spinal  Fever. 

Fagge^  says :  "  Several  observers  have  found  that  during  or  just  after  an 
epidemic  of  cerebro-spinal  fever,  meningitis  has  presented  itself  with  unusual 
frequency  as  a  complication  of  other  acute  diseases."  He  mentions  croupous 
pneumonia,  pleurisy,  acute  tonsillitis,  and  scarlatinal  nephritis  as  the  diseases 
upon  which  it  is  very  liable  thus  to  supervene.  In  this  respect  cerebro-spinal 
fever  resembles  diphtheria  and  erysipelas,  which  we  know  are  very  liable  to 
occur  in  those  who  are  suffering  from  other  diseases. 

A  striking  example  of  cerebro-spinal  fever  occurring  as  a  complication 
was  recently  seen  by  me  in  consultation.  A  child  of  about  ten  years  with 
typical  typhoid  fever  had  reached  about  the  twelfth  day  of  a  mild  form  of 
the  disease.  The  initial  headache  had  ceased,  there  was  no  delirium,  the 
temperature  was  but  moderately  elevated,  and  no  doubt  had  arisen  in  the 
mind  of  the  experienced  physician  in  attendance  that  the  disease,  which 
presented  the  characteristic  signs,  would  terminate  favoi'ably  after  the  usual 
time.  Suddenly  violent  headache  occurred,  the  temperature  rose  to  103°  or 
104°  F.,and  in  a  few  days  fatal  coma  terminated  the  case.     Another  disease 

^  American  Medical  Times,  April  30,  1864.  ^  Practice  of  Medicine,  vol.  i.  p.  614. 


428 


CONSTITUTIONAL  DISEASES. 


in  which  I  have  seen  cerebro-spinal  fever  occur  as  a  complication  is  gastro- 
intestinal catarrh. 

Sex. — It  is  stated  by  certain  writers  that  more  males  are  aflfected  than 
females.  The  statistics  of  hospitals  and  camps  show  this,  for  men  subject 
to  lives  of  hardship  are  especially  liable  to  be  attacked  ;  but  in  family  prac- 
tice, in  which  a  large  proportion  of  the  patients'  are  children,  the  number  of 
males  and  females  is  about  equal.  Thus,  in  105  cases  occurring  chiefly  in 
my  practice,  but  a  few  of  them  in  the  practice  of  two  other  physicians  of 
this  city,  I  find  that  59  were  males  and  46  females  ;  91  of  these  were  children. 
In  New  York  City,  during  the  epidemic  of  1872,  905  cases  of  cerebro-spinal 
fever  were  reported  to  the  Board  of  Health  between  January  1  and  Novem- 
ber 1,  and  of  these  484  were  males  and  421  females.  Dr.  Sanderson's 
statistics  of  the  epidemic  in  the  provinces  around  the  Vistula,  the  cases 
being  chiefly  children,  give  also  but  a  slight  excess  of  males.  Probably, 
therefore,  in  the  same  conditions  and  occupations  of  life  the  sexes  are  equally 
liable  to  contract  this  malady,  and  the  excess  of  males  in  the  above  statistics 
is  due  to  the  fact  that  they  lead  a  more  irregular  life  and  are  more  subject 
to  privations  and  exposures.  That  soldiers  on  duty  in  barracks  have  been 
attacked  while  families  in  the  vicinity  escape,  thus  increasing  the  proportion 
of  male  eases,  probably  occurs  in  consequence  of  irregularities,  hardships, 
and  perhaps  the  lack  of  sanitary  regulations  in  their  mode  of  life. 

Age. — My  observations  lead  me  to  think  that  the  younger  the  patient 
the  more  frequently  is  cerebro-spinal  fever  overlooked  and  some  other  disease 
diagnosticated.  Nevertheless,  all  published  statistics,  so  far  as  I  am  able  to 
ascertain,  show  that  a  large  proportion  of  cases  occur  under  the  age  of  five 
years,  and  that  a  larger  proportion  of  fatal  cases  are  in  the  first  year  of  life 
than  in  any  other  year.  Thus,  in  New  York  City  the  ages  of  those  who  died 
from  this  disease  in  1883  were  as  follows : 


Under    1   year 57 

From     1  to     2  years 31 

From     2  to     3     "       22 

From    3  to    4     "       ......  12 

From    4  to     5     "       9 

From    5  to  10     "       37 

From  10  to  15     "       18 

From  15  to  20     "      15 


From  20  to  25  vears 7 

From  25  to  30  ■  "       3 

From  30  to  35     "       4 

From  35  to  40     "       3 

From  40  to  45     "       1 

From  45  to  50     "       2 

From  50  to  60     "       1 

Over  60  years 1 


The  following  are  the  statistics  of  the  New  York  Health  Board  relating  to 
the  ages  of  the  cases  during  the  epidemic  of  1872  : 


Under  1  year 125 

From    1  to    5  vears 336 

From    5  to  10  ■'  " 204 

From  10  to  15    "       106 


From  15  to  20  vears 54 

From  20  to  30'  "       79 

Over  30  years 71 

Total 975 


In  the  cases  which  occurred  in  my  own  practice,  and  in  a  few  cases  in  the 
practice  of  other  physicians  added  to  mine,  I  find  that  the  ages  were  as 
follows : 


Under  1  year 16 

From  1  to    3  years 27 

From  3  to    5     "      25 

From  5  to  10     "      20 


From  10  to  15  years 10 

Over  15  years 15 

Total 113 


In  my  practice,  therefore,  three-fourths  of  the  cases  have  been  under  the 
age  of  ten  years ;  and  the  statistics  of  epidemics  in  other  localities  correspond 


CEREBROSPINAL  FEVER.  429 

with  mine  in  giving  a  large  excess  of  cases  in  childhood.  Thus,  Dr.  Sander- 
son, in  examining  the  records  of  deaths  in  one  epidemic,  ascertained  that  218 
had  perished  under  the  age  of  fourteen  years,  and  only  17  above  that  age ; 
and  although  this  does  not  show  the  exact  ratio  of  children  to  adults  in 
the  entire  number  of  cases,  it  is  evident  that  the  children  were  greatly  in 
excess. 

The  more  advanced  the  age  after  the  tenth  year,  the  less  the  liability  to 
this  malady,  so  that  very  few  who  have  passed  the  thirty-fifth  year  are 
attacked,  and  old  age  possesses  nearly  an  immunity.  In  New  York  City,  in 
which,  as  we  have  seen,  cerebro-spinal  fever  has  been  occurring  since  1871, 
only  two  cases  have  come  to  my  knowledge  which  had  passed  the  fortieth 
year.  The  age  of  one  was  forty-seven,  and  of  the  other  sixty-three  years. 
But  nearly  every  year  the  statistics  of  the  Health  Board  show  that  one  or 
two  old  persons  have  died  of  this  disease. 

Not  a  few  cases  occur  in  this  city  in  infants  of  the  age  of  three  or  four 
months.  An  infant  of  four  months  died  of  cerebro-spinal  fever  in  the  New 
York  Infant  Asylum,  the  nature  of  the  disease  not  being  known  until  it  was 
revealed  by  the  autopsy. 

Symptoms. — During  the  prevalence  of  cerebro-spinal  fever  cases  now  and 
then  occur  in  which  the  symptoms  are  mild  and  transient  and  the  health  is 
soon  fully  restored.  It  seems  proper  to  regard  some,  at  least,  of  these  as  gen- 
uine but  aborted  forms  of  the  disease.  The  following  cases  which  occurred 
in  my  practice  may  be  cited  as  examples : 

A  boy  eight  years  of  age,  previously  well,  was  taken  with  headache  and 
vomiting,  attended  by  moderate  fever,  on  April  2,  1872.  The  evacuations 
were  regular,  and  no  local  cause  of  the  attack  could  be  discovered.  On  the 
following  day  the  symptoms  continued,  except  the  vomiting,  but  he  seemed 
somewhat  better.  On  April  4th  the  fever  was  more  pronounced,  and  in  the 
afternoon  he  was  drowsy  and  had  a  slight  convulsion.  The  forward  move- 
ment of  the  head  was  apparently  somewhat  restrained.  On  the  6th  the 
symptoms  had  begun  to  abate,  and  in  about  one  week  from  the  commence- 
ment of  the  attack  his  health  was  fully  restored. 

A  boy  aged  six  was  well  till  the  second  week  in  May,  1872,  when  he 
became  feverish  and  complained  of  headache.  At  my  first  visit,  on  May 
14th,  he  still  had  headache,  with  a  pulse  of  112.  The  pupils  were  sensitive 
to  light,  but  the  right  pupil  was  larger  than  the  left.  The  bromide  and 
iodide  of  potassium  were  prescribed,  with  moderate  counter-irritation  behind 
the  ears.  The  headache  and  fever  in  a  few  days  abated,  the"  equality  of  the 
pupils  was  restored,  and  within  a  little  more  than  one  week  from  the  com- 
mencement of  the  disease  he  fully  recovered. 

These  cases  occurred  when  the  epidemic  of  1872  was  at  its  height  ;  but 
if  the  symptoms  are  so  mild  and  the  duration  of  the  disease  short  as  in  these 
two  cases,  the  diagnosis  must  sometimes  be  doubtful.  Observers  in  different 
epidemics  report  similar  cases,  and  as  the  symptoms,  so  far  as  they  appeared 
in  my  patients,  seemed  characteristic,  I  have  not  hesitated  to  regard  them  as 
genuine,  but  aborted  cases.  On  such  patients  the  epidemic  influence  acts  so 
feebly,  or  their  ability  to  resist  it  is  so  great,  that  they  escape  with  a  short 
and  trivial  ailment. 

Occasionally  also  during  the  progress  of  an  epidemic  we  meet  patients 
who  present  more  or  fewer  of  the  characteristic  symptoms,  but  in  so  mild  a 
form  that  they  are  never  seriously  sick  and  never  entirely  lose  their  appetite, 
but  the  disease,  instead  of  aborting,  continues  about  the  usual  time. 

Thus,  on  January  4,  1873,  I  was  called  to  a  girl  aged  thirteen  who  had 
been  seized  with  headache,  followed  by  vomiting,  in  the  last  week  in  Decem- 
ber.    During  a  period  of  six  to  eight  weeks,  or  till  nearly  March  1st,  she  had 


430  CONSTITUTIONAL  DISEASES. 

the  following  symptoms :  Daily  paroxysmal  headache,  often  most  severe  in 
the  forenoon  ;  neuralgic  pain  in  the  left  hypochondrium,  and  sometimes  in 
the  epigastric  region  ;  pulse  and  temperature  sometimes  nearly  normal,  and  at 
other  times  accelerated  and  elevated,  both  with  daily  variations  ;  inequality 
of  the  pupils,  the  right  being  larger  than  the  left  during  a  portion  of  the 
sickness.  The  patient  was  never  so  ill  as  to  keep  the  bed,  usually  sitting 
([uietly  during  the  day  in  a  chair  or  reclining  on  a  lounge,  and  she  never 
fully  lost  her  appetite.  Quinine  had  no  appreciable  effect  on  the  fever  or 
paroxysms  of  pain. 

There  can,  in  my  opinion,  be  little  doubt  that  this  girl  was  affected  by 
the  epidemic,  but  so  mildly  that  there  was,  for  a  considerable  time,  much 
uncertainty  in  the  diagnosis. 

Cases  like  these,  in  which  the  disease  is  so  feebly  developed  that  the 
patient  is  never  seriously  sick,  though  unimportant  pathologically,  must  be 
recognized  in  a  treatise  on  cerebro-spinal  fever. 

Mode  op  Commencement. — Cerebro-spinal  fever  rarely  begins  in  the  fore- 
noon after  a  night  of  quiet  and  sound  sleep.  In  the  cases  which  I  observed 
in  the  severe  and  fatal  epidemic  of  1872,  and  in  the  36  cases  of  which  I  have 
records  observed  since  1872,  the  commencement  was  almost  without  exception 
between  midday  and  midnight.  The  fact  that  this  disease  does  not  commence 
after  the  repose  of  night  till  several  hours  of  the  day  have  passed  shows  the 
propriety  and  need  of  enjoining  a  quiet  and  regular  mode  of  life,  free  from 
excitement  and  with  sufficient  hours  of  sleep,  during  the  time  in  which  the 
epidemic  is  prevailing. 

The  commencement  is  usually  without  premonitory  stage  and  sudden — 
unlike,  therefore,  the  beginning  of  other  forms  of  meningitis,  which  come  on 
gradually,  and  are  preceded  by  symptoms  which,  if  rightly  interpreted,  direct 
attention  to  the  cerebro-spinal  system.  Exceptionally  certain  premonitions 
occur  for  a  few  hours  or  days  before  the  advent  of  the  disease,  such  as  lan- 
guor, chilliness,  etc.  Mild  cases  usually  begin  more  gradually  than  cases 
of  a  severe  type.  The  ordinary  mode  of  commencement  is  as  follows : 
The  patient  is  seized  with  vomiting,  headache,  and  perhaps  a  chill  or  chilli- 
ness, so  that  there  is  a  sudden  change  from  perfect  health  to  a  state 
of  serious  sickness.  Rigor  or  chilliness  is  a  common  initial  symptom, 
especially  in  adult  patients.  One  patient,  an  adult  female,  had  three  or 
four  chills  of  considerable  severity  in  the  commencement  of  the  attack.  Chil- 
dren often  have  clonic  convulsions  in  place  of  the  chill,  or  immediately  after 
it,  partial  or  general,  slight  or  severe.  Stupor  more  or  less  profound,  or,  less 
frequently,  delirium,  succeeds.  In  the  gravest  cases  semi-coma  occurs  within 
the  first  few  hours,  in  which  patients  are  with  difficulty  aroused,  or  profound 
coma,  which,  in  spite  of  prompt  and  appropriate  treatment,  is  speedily  fatal. 
Those  thus  stricken  down  by  the  violent  onset  of  the  disease,  if  aroused  to 
consciousness,  complain  of  severe  headache,  with  or  without  or  alternating 
with  equally  severe  neuralgic  pains  in  some  part  of  the  trunk  or  in  one  of  the 
extremities.  The  pain  frequently  shifts  from  one  part  to  another.  Among 
the  early  symptoms  of  cerebro-spinal  fever  are  those  which  pertain  to  the  eye. 
The  pupils  are  dilated  or  less  frequently  contracted,  and  they  respond  feebly 
or  not  at  all  to  light  if  the  attack  be  severe  or  dangerous  ;  often  they  oscillate, 
and  occasionally  one  is  larger  than  the  other.  Vomiting  with  little  apparent 
nausea,  and  often  projectile,  is  common  in  the  commencement  of  cerebro-spinal 
fever.  It  occurred  as  an  early  symptom  in  51  of  56  cases  observed  by  Dr. 
Sanderson.  In  98  cases  occurring  in  New  York,  most  of  them  observed  by 
myself,  but  a  few  of  them  related  to  me  by  the  late  Dr.  John  G.  Sewall, 
vomiting  occurred  as  an  early  symptom  in  68  cases.  Its  absence  on  the  first 
day  was  recorded  in  only  3  cases,  while  in  the  remaining  27  patients  the 


CEREBROSPINAL  FEVER.  431 

records  of  tlie  first  day  make  no  mention  of  its  presence  or  absence.  It  was 
probably  present  in  most  of  these  27  cases  as  one  of  the  first  symptoms. 

Since  the  epidemic  of  1872,  in  examining  patients,  now  numbering  thirty- 
six,  as  has  been  ah'eady  stated,  I  have  made  careful  inquiry  in  regard  to  the 
mode  of  commencement,  and  with  only  two  or  three  exceptions  either  the 
previous  health  had  been  good,  or,  if  symptoms  of  ill-health  antedated  the 
cerebro-spinal  fever,  they  were  due  to  some  ailment  entirely  distinct  from 
this  disease.  In  a  boy  four  and  a  half  years  of  age,  living  in  Broadway,  it 
was  stated  to  me  that  the  cerebro-spinal  fever  came  on  gradually  with  pains 
in  the  head  and  elsewhere :  this  case  was  mild  throughout  and  the  patient 
was  never  in  imminent  danger.  In  nearly  all  the  cases,  if  the  patients  were 
at  home  and  under  observation,  the  exact  moment  of  the  beginning  of  the 
disease  could  be  stated.  Thus,  a  man  aged  twenty-eight  returned  from  his 
work  at  midday,  April  23,  1883,  in  good  health  and  cheerful,  ate  a  hearty 
meal  at  twelve  m.,  and  at  one  P.  M.  had  a  chill,  with  intense  headache  and 
severe  vomiting.  Minute  red  points  appeared  on  his  face  after  vomiting, 
from  capillary  extravasations.  In  this  case  the  interesting  fact  was  observed 
of  a  cessation  of  the  symptoms,  so  that  on  the  24th  and  25th,  being  free  from 
pain,  he  went  to  Brooklyn.  On  the  26th,  however,  the  symptoms  returned. 
He  had  pains  in  the  head,  back,  and  extremities,  and  was  seriously  sick. 
Occasional  remissions,  so  that  very  grave  symptoms  become  mild  for  a  time 
and  then  return  in  full  severity,  as  well  as  distinct  intermissions,  as  in  this 
case,  have  been  frequently  noticed  by  observers  in  different  epidemics.  A 
little  girl,  previously  entirely  well,  was  slightly  punished  on  June  11,  1882  ; 
immediately  she  vomited  and  seemed  quite  sick ;  by  kind  nursing  on  the  part 
of  the  mother  she  became  better,  so  that  on  the  12th  she  had  some  appetite 
and  went  out.  On  the  13th  cerebro-spinal  fever  began,  with  a  temperature 
of  103°  F.,  and  its  course  was  tedious.  A  robust  girl,  aged  thirteen,  vivacious 
and  cheerful,  went  as  usual  in  the  morning  to  one  of  the  public  schools  entirely 
well.  Before  the  school  was  dismissed  she  returned  home  crying  on  account 
of  dizziness  and  violent  pain  in  the  top  of  her  head,  in  her  knees,  and  in  the 
calves  of  the  legs.  The  case  was  attended  by  Prof.  Alonzo  Clark,  Prof.  Knapp, 
and  myself,  and  was  fatal  after  four  and  a  half  weeks.  A  boy  aged  ten  returned 
from  another  public  school  in  a  similar  manner,  having  gone  to  it  in  the  morn- 
ing in  apparently  perfect  health. 

We  may  therefore  summarize  as  follows  the  symptoms  which  commonly 
attend  the  commencement  of  cei'ebro-spinal  fever:  Violent  pain  in  some  part 
of  the  head,  and  sometimes  also  in  the  trunk  or  limbs,  vomiting,  a  chill  or 
chilliness,  clonic  convulsions,  dizziness,  dilated,  sluggish,  or  altered  pupils, 
fever  of  greater  or  less  intensity  according  to  the  severity  of  the  attack,  heat 
of  head,  and  in  most  patients  heat  of  the  surface  generally.  If  the  disease 
be  of  a  severe  and  dangerous  type,  these  symptoms  are  frequently  followed 
within  a  few  hours  by  delirium,  semi-coma,  or  coma. 

Nervous  System.  —  Since  in  cerebro-spinal  fever  extensive  and  severe 
inflammation  of  the  cerebral  and  spinal  meninges  occurs,  with  more  or  less 
congestion  of  the  brain  and  spinal  cord— lesions  which  we  will  consider  here- 
after— we  should  expect  that  this  disease  would  be  attended  by  severe  and 
dangerous  symptoms,  inasmuch  as  the  cerebro-spinal  axis  exerts  such  a  con- 
trolling influence  upon  the  functions  of  the  body.  Also  we  should  expect 
that  the  symptoms  would  vary  according  to  the  portion  of  the  meninges 
which  happens  to  be  most  severely  inflamed.  There  is,  indeed,  variation  in 
symptoms  according  to  the  extent  and  intensity  of  the  meningitis  and  the 
degree  in  which  the  cerebro-spinal  axis  is  congested  or  implicated,  but  cer- 
tain symptoms  occur  in  all  or  nearly  all  cases,  and  as  they  are  characteristic 
they  render  diagnosis  easy. 


432  CONSTITUTIONAL  DISEASES. 

Pain,  already  described  as  an  initial  symptom,  continues  during  tlie  acute 
period  of  the  malady.  It  is  ordinarily  severe,  eliciting  moans  from  the 
suiferer,  but  its  intensity  varies  in  different  patients.  Its  most  frequent  seat 
is  the  head,  and  the  location  of  the  cephalalgia  varies  in  different  patients 
and  in  the  same  patient  at  different  times.  One  refers  it  to  the  top  of  the 
head,  another  to  the  occiput,  and  another  to  the  frontal  region,  and  the  same 
patient  at  different  times  may  complain  of  all  these  parts.  The  pain  is 
described  as  sharp,  lancinating,  or  boring.  It  is  also  common  in  the  neck, 
especially  in  the  nucha,  the  epigastrium,  the  umbilical  and  lumbar  regions, 
along  the  spine  (rachialgia),  and  in  the  extremities,  where  it  shifts  from  one 
part  to  another.  It  is  more  common  and  persistent  in  the  head  and  along 
the  spine  than  elsewhere.  The  patient,  if  old  enough  to  speak  and  not 
delirious  or  too  stupid,  often  exclaims,  "  Oh  my  head ! "  from  the  intensity 
of  his  suffering,  but  after  some  moments  complains  equally  of  pain  in  some 
other  part,  while  perhaps  the  headache  has  ceased  or  is  milder.  In  a  few 
instances  the  headache  is  absent  or  is  slight  and  transient,  while  the  pain  is 
severe  elsewhere.  After  some  days  the  pain  begins  to  abate,  and  by  the  close 
of  the  second  week  is  much  less  pronounced  than  previously.  Vertigo  occurs 
with  the  headache,  so  that  the  patient  reels  in  attempting  to  stand  or  walk. 
I  have  stated  above  that  vertigo  may  be  a  prominent  initial  symptom,  as  in 
the  girl  of  thirteen  years  who  suddenly  became  sick  in  the  public  school 
which  she  was  attending,  and  reached  her  home  with  difficulty  on  account 
of  the  headache  and  dizziness.  Contributing  to  the  unsteadiness  of  the  mus- 
cular movements  is  a  notable  loss  of  flesh  and  strength,  which  occurs  early 
and  increases. 

The  state  of  the  patient's  mind  is  interesting.  It  is  well  expressed  in  oi'di- 
nary  cases  by  the  term  apathy  or  indifference,  and  between  this  mental  state 
and  coma  on  the  one  hand  and  acute  delirium  on  the  other  there  is  every 
grade  of  mental  disturbance.  Some  patients  seem  totally  unconscious  of  the 
words  or  presence  of  those  around  them,  when  it  subsequently  appears  that 
they  understood  what  was  said  or  done.  Delirium  is  not  infrequent,  especially 
in  the  older  children  and  in  adults.  Its  form  is  various,  most  frequently  quiet 
or  passive,  but  occasionally  maniacal,  so  that  forcible  restraint  is  required. 
It  sometimes  resembles  intoxication  or  hysteria,  or  it  may  appear  as  a  simple 
delusion  in  regard  to  certain  subjects.  Thus,  one  of  my  patients,  a  boy  of 
five  years,  appeared  for  the  most  part  rational,  protruding  his  tongue  when 
requ.ested.  and  ordinarily  answering  questions  correctly ;  but  he  constantly 
mistook  his  mother — who  was  always  at  his  bedside — for  another  person. 
Severe  active  delirium  is  commonly  preceded  by  intense  headache.  In  favor- 
able cases  the  delirium  is  usually  short,  but  in  the  unfavorable  it  often  con- 
tinues with  little  abatement  till  coma  supervenes. 

On  account  of  the  pain  and  the  disordered  state  of  the  mind  patients 
seldom  remain  quiet  in  bed,  unless  they  are  comatose  or  the  disease  be  mild 
or  so  far  advanced  that  muscular  movements  are  difficult  from  weakness.  In 
severe  cases  they  are  ordinarily  quiet  for  a  few  moments,  as  if  slumbering, 
and  then,  aroused  by  the  pain,  they  roll  or  toss  from  one  part  of  the  bed  to 
another.  One  of  my  patients,  a  boy  of  five  years,  repeatedly  made  the  entire 
circuit  of  the  bed  during  the  spells  of  restlessness.  In  mild  cases  or  cases 
attended  by  less  headache  or  mental  disturbance  patients  are  quiet,  usually 
with  their  eyes  closed  unless  when  disturbed. 

Hyperaesthesia  of  the  surface  is  another  common  symptom.  Few  patients, 
not  comatose,  are  free  from  it  during  the  first  weeks,  and  it  materially  increases 
the  suffering.  Friction  upon  the  surface,  and  even  slight  pressure  with  the 
fingers  upon  certain  parts,  extort  cries.  Gently  separating  the  eyelids  for  the 
purpose  of  inspecting  the  eyes,  and  moving  the  limbs  or  changing  the  position 


CEREBROSPINAL  FEVER.  433 

of  the  head,  evidently  increase  the  suiFering  and  are  resisted.  I  have  some- 
times heard  such  expressions  of  suifering  from  slowly  introducing  the  ther- 
mometer into  the  rectum  that  I  was  led  to  believe  that  the  anal  and  perhaps 
rectal  surfaces  were  hypersensitive.  The  hyperaesthesia  has  diagnostic  value, 
for  there  is  no  disease  with  which  cerebro-spinal  fever  is  likely  to  be  con- 
founded in  which  it  is  so  great.  It  is  due  to  the  spinal  meningitis,  and  is 
appreciable  even  in  a  state  of  semi-coma.  The  headache  and  hyperaesthesia 
fluctuate  greatly  in  the  course  of  the  disease,  and  the  former  sometimes  recurs 
at  times,  especially  from  mental  excitement  or  from  an  afiiux  of  blood  to  the 
brain  from  physical  exertion,  for  months  after  the  health  is  otherwise  fully 
restored. 

Some  contraction  of  certain  muscles  or  groups  of  muscles  is  present  in 
all  typical  cases.  In  a  small  proportion  of  patients  it  is  absent  or  is  not  a 
prominent  symptom — to  wit,  in  those  in  whom  the  encephalon  is  mainly 
involved,  the  spinal  cord  and  meninges  being  but  slightly  affected  or  not  at 
all.  This  contraction  is  most  marked  in  the  muscles  of  the  nucha,  causing 
retraction  of  the  head,  but  it  is  also  common  in  the  posterior  muscles  of  the 
trunk,  causing  opisthotonos,  and  in  less  degree  in  those  of  the  abdomen  and 
lower  extremities,  and  hence  the  flexed  position  of  the  thighs  and  legs,  in 
which  patients  obtain  most  relief.  The  muscular  contraction  in  not  an  initial 
symptom.  I  have  ordinarily  first  observed  it  about  the  close  of  the  second 
day,  but  sometimes  as  early  as  the  close  of  the  first  day,  and  in  other  instances 
not  till  the  close  of  the  third  day.  Attempts  to  overcome  the  rigidity,  as  by 
bringing  forward  the  head,  are  very  painful  and  cause  the  patient  to  resist. 
In  young  children  having  a  mild  form  of  the  fever,  with  little  retraction  of 
the  head,  the  rigidity  is  sometimes  not  easily  detected.  I  have  been  able  in 
such  cases  to  satisfy  myself  and  the  friends  of  its  presence  by  placing  the 
child  in  an  upright  position,  as  on  the  lap  of  the  mother,  and  observing  the 
difiiculty  with  which  the  head  is  brought  forward  on  presenting  to  the  patient 
a  tumblerful  of  cold  water,  which  is  craved  on  account  of  the  thirst.  The 
usual  position  of  the  patient  in  bed  in  a  typical  or  marked  case  is  with  the 
head  thrown  back,  the  thighs  and  legs  flexed,  with  or  without  forward  arch- 
ing of  the  spine.  The  muscular  contraction  and  rigidity  continue  from  three 
to  five  weeks,  more  or  less,  and  abate  gradually  ;  occasionally  they  continue 
much  longer.  Through  the  kindness  of  Dr.  Henry  Griswold  I  was  allowed 
to  see  an  infant  of  seven  months  in  the  tenth  week  of  the  disease.  It  was 
still  very  fretful,  and  exhibited  decided  prominence  of  the  anterior  fontanel, 
probably  from  intracranial  serous  efi"usion,  and  marked  rigidity  of  the  muscles 
of  the  nucha,  with  retraction  of  the  head. 

Paralysis  is  another  occasional  symptom,  but  complete  paralysis  of  any 
muscle  or  group  of  muscles  is  less  frequent  than  one  would  suppose  from 
the  nature  of  the  malady.  It  may  occur  early,  but  is  sometimes  a  late 
symptom.  It  may  be  limited  to  one  or  two  of  the  limbs,  as  the  legs  or  an 
arm  and  a  leg,  or  it  may  be  more  general.  In  a  case  occurring  in  Roosevelt 
Hospital  and  published  in  the  New  York  Medical  Record  for  October  10, 
1878,  the  patient,  a  boy  of  ten  years,  was  unable  to  move  his  legs  one  hour 
after  the  commencement  of  the  disease.  This  sudden  development  of  para- 
plegia in  the  commencement  of  cerebro-spinal  fever  resembled  that  of  infan- 
tile paralysis,  and  was  probably  due  to  the  same  cause — to  wit,  active  inflam- 
matory congestion  of  the  anterior  cornu  of  the  spinal  column.  The  sudden 
and  complete  loss  of  speech  which  occurs  in  certain  cases,  when  consciousness 
is  retained  and  the  vocal  organs  are  in  their  normal  state,  seems  to  be  due  to 
the  fact  that  the  portion  of  the  brain  which  controls  the  function  of  speech 
is  acutely  congested  or  is  the  seat  of  effusion.  Thus,  in  June,  1882,  a  girl 
of  three  years  whom  I  attended  lost  her  speech  on  the  second  day  of  cerebro- 
58 


434 


CONSTITUTIONAL  DISEASES. 


spinal  fever,  and  she  was  unable  to  articulate  even  the  simplest  word  for  two 
and  a  half  months.  Finally,  she  began  to  utter  slowly  and  with  difficulty 
the  easiest  monosyllables  ;  and  after  the  lapse  of  more  than  a  year  her  speech 
was  slow  and  lisping,  her  hands  were  tremulous  and  unsteady,  she  was  easily 
fatigued,  and  cried  often  from  oversensitiveness.  During  the  long  period  of 
speechlessness  she  daily  made  efforts  to  talk,  but  without  uttering  a  sound. 
Strabismus,  to  which  we  will  allude  hereafter  in  treating  of  the  eye,  is  a  com- 
mon symptom,  either  transient  or  protracted,  due  to  pai'alysis  of  certain  of 
the  motor  muscles  of  the  eye. 

Paralysis  of  more  or  fewer  muscles  has  been  noticed  and  recorded  by 
many  observers  in  this  country  and  in  Europe.  Dr.  Law  observed  a  patient 
in  the  epidemic  of  1865  in  Dublin  who  could  move  neither  arms  nor  legs, 
and  AVunderlich  saw  one  who  had  paralysis  of  both  lower  extremities  and 
of  a  considerable  part  of  the  trunk.  As  this  symptom  is  due  to  the  inflam- 
matory process  of  the  cerebro-spinal  axis,  it  usually  disappears  in  a  few  weeks 
as  the  inflammation  abates  and  absorption  of  the  inflammatory  products 
occurs ;  but  it  may  be  more  protracted.  In  Wunderlich's  case  there  was 
only  partial  recovery  from  the  paralysis  after  the  lapse  of  five  months. 

Clonic  convulsions  have  already  been  alluded  to  among  the  early  symp- 
toms of  the   attack.     They  indicate  a  grave  form  of  the  disease,  and  are 


Fig.  59. 


not  infrequent  in  young  children,  in  whom  they  appear  to  occur  in  place 
of  the  chill  which  is  common  in  those  of  a  more  advanced  age.  The 
eclamptic  attack  may  be  short  and  not  repeated,  or  it  may  be  protracted,  or 
return  again  and  again  when  the  medicines  which  control  it  are  suspended. 
Under  such  circumstances  it  is  likely  to  end  in  profound  coma,  and  is,  of 
coiirse,  a  symptom  of  great  gravity.  Thus,  an  infant  of  seven  months  had 
unilateral  eclamptic  attacks  daily  during  the  first  week  of  the  fever.  The 
mother  informed  me  that  the  convulsions  seldom  lasted  longer  than  three 
minutes,  and  that  the  intervals  between  them  were  short.  The  child  recov- 
ered with  loss  of  sight  from  the  cerebro-spinal  fever,  but  still  after  the  lapse 
of  a  year,  when  I  examined  him,  he  had  symptoms  which  were  apparently  due 
to  hydrocephalus.  Another  infant  of  eleven  months  had  clonic  convulsions 
nearly  constantly  during  the  first  twenty-four  hours,  but  with  occasional 
brief  intermissions.  On  the  following  day  he  was  in  profound  coma  and 
apparently  dying,  with  a  temperature  of  105°  F.  To  my  astonishment,  he 
gradually  emerged  from  the  state  of  unconsciousness,  and  after  a  week  was 
able  to  sit  in  his  cradle  long  enough  to  take  drinks. 


CEREBROSPINAL  FEVER.  435 

Occasionally  eclampsia  does  not  occur  in  the  first  days,  but  in  the  second 
or  third  week,  when  it  is  usually  accompanied  by  an  increase  of  other  symp- 
toms, due  to  a  recrudescence  of  the  disease.  A  female  infant  aged  eleven 
months,  treated  by  me  in  1882,  had  been  sick  one  week  when,  during  an 
increase  in  the  febrile  movement,  she  had  one  eclamptic  seizure.  Her  recov- 
ery, though  slow,  was  complete.  A  boy  aged  eleven  and  a  half  years,  whose 
attack  began  with  a  chill,  violent  headache,  and  fever,  and  whom  I  visited 
frequently,  died  on  the  fourth  day.  Clonic  convulsions  did  not  occur  in  his 
case  until  within  twenty-four  hours  of  his  death,  when  he  had  six  seizures, 
which  ended  in  coma. 

Though  adult  patients  are  much  less  liable  to  eclampsia  than  children, 
they  are  not  entirely  exempt.  A  male  patient  aged  twenty-eight  years, 
whom  I  saw  in  consultation,  had  a  single  clonic  convulsion  lasting  ten  to 
fifteen  minutes  on  the  third  day  of  his  illness.  In  five  weeks  he  had  fully 
recovered,  except  that  his  headache  returned  upon  any  excitement.  Even 
drinking  a  cup  of  beer  caused  it.  Clonic  convulsions  are,  however,  much 
less  common  than  the  tonic  muscular  contraction  and  rigidity  already  alluded 
to.  The  latter  occur  to  a  greater  or  less  extent  in  nearly  all  cases,  and  are 
symptoms  of  diagnostic  value,  the  rigidity  often  extending  to  the  muscles 
of  the  extremities.  Thus,  in  a  child  aged  three  years  who  had  no  eclampsia 
the  tonic  contraction  of  the  muscles  of  the  extremities  did  not  relax  till  after 
the  twelfth  day. 

Choreic  or  choreiform  movements  are  occasionally  observed.  I  do  not 
refer  to  the  tremulousness  which  sometimes  occurs  from  weakness  or  as  a 
premonition  of  eclampsia,  but  to  a  movement  which  has  the  character  of 
true  chorea.  An  infant  aged  ten  months  began  to  have  choreic  movements 
during  the  acute  stage  of  the  disease,  most  marked  in  the  upper  extremities 
and  ceasing  in  sleep.  They  continued  during  the  remainder  of  the  life  of  the 
child,  death  occurring  ten  months  subsequently  from  diphtheria.  Rarely  a 
choi'eiform  movement  of  the  eyes  is  also  observed — a  lateral  movement  from 
right  to  left  and  from  left  to  right,  designated  nystagmus.  I  recollect  two 
such  cases. 

Drowsiness,  already  spoken  of.  is  a  common  symptom,  and  it  exists  in  all 
grades  from  slight  stupor  to  profound  coma.  In  some  patients  it  is  present 
from  the  first  hour,  while  in  others  it  occurs  after  a  period  of  restlessness  or 
delirium  or  it  alternates  with  it.  Stupor  more  or  less  profound  is  common 
after  the  attack  of  eclampsia  or  the  chill.  That  it  is  a  frequent  symptom  in 
severe  cases  receives  ready  explanation  from  the  state  of  the  brain  and  its 
meninges,  for  the  exudation  which  occurs  upon  the  surface  of  the  brain  and 
the  serous  eifusion  within  the  ventricles  are  sufficient  to  cause  it  by  compress- 
ing the  cerebral  substance.  It  is  surprising  in  some  cases  how  profound  the 
stupor  may  be — a  state,  indeed,  of  coma,  and  yet  the  patient  gradually 
emerges  from  it  and  recovers.  In  the  epidemic  of  1872,  in  New  York 
City,  when  the  malady  was  new  with  us,  many  physicians  predicted  certain 
death,  and  employed  remedies  without  expectation  of  any  benefit  on  account 
of  the  apparently  hopeless  state  of  the  patients,  who  seemed  to  be  in  pro- 
found coma,  and  yet  not  a  few  of  them  gradually  and  fully  recovered. 

Digestive  System. — Vomiting,  which  is  the  most  prominent  symptom 
referable  to  the  digestive  system,  has  already  been  mentioned.  Occurring 
early  in  the  disease,  it  may  cease  in  a  few  hours  or  not  till  after  several  days, 
and  often  it  returns  during  the  periods  of  recrudescence  which  are  common 
in  the  progress  of  the  fever.  It  occurs  with  little  efi'ort  and  without  pre- 
vious nausea  or  with  little  nausea,  as  is  usual  when  it  has  a  cerebral  origin. 
It  does  not  difi"er  as  a  symptom  from  the  vomiting  which  is  so  common  in 
other  forms  of  mening-itis.     The  substance  vomited  consists  of  the  ingesta 


436  CONSTITUTIONAL  DISEASES. 

and  the  secretions,  as  mucus  and  bile.  Having  a  similar  origin  is  a  sensa- 
tion of  faintness  or  depression,  referred  to  the  epigastrium. 

The  appetite  is  usually  impaired  or  lost  during  the  active  period  of  the 
attack,  and  it  is  not  fully  restored  till  convalescence  is  well  advanced. 
Occasionally  considerable  nutriment  is  taken,  and  with  apparent  relish,  as 
by  one  of  my  patients,  twenty-eight  years  of  age,  who  always  had  some 
appetite.  Ordinarily,  on  account  of  repeated  vomitings,  constant  febrile 
movements,  impaired  appetite  and  digestion,  patients  progressively  lose 
flesh  and  strength,  so  that  in  protracted  cases  emaciation  is  always  a  promi- 
nent symptom,  and  is  often  extreme.  Much  emaciation  and  loss  of  strength, 
which  attend  many  cases  after  the  lapse  of  several  weeks,  greatly  diminish 
the  chances  of  a  favorable  termination.  Thirst,  already  referred  to,  and 
constipation  are  common  in  this  as  in  other  forms  of  meningitis,  but  retrac- 
tion of  the  abdomen  is  not  a  notable  symptom,  except  in  protracted  and 
greatly-wasted  cases.  The  diarrhoea  which  is  occasionally  present  in  cerebro- 
spinal fever  in  the  summer  months  must  be  regarded  as  a  distinct  disease 
and  a  complication.  The  tongue  and  the  buccal  and  faucial  surfaces  present 
nothing  unusual  in  their  appearance.  It  is  seldom,  even  in  the  most  pro- 
tracted and  emaciated  cases,  that  the  sordes  and  dry  and  brownish  fur  occur 
which  are  so  common  in  typhus  and  typhoid  fevers.  The  tongue  is  usually 
moist  and  but  slightly  furred. 

I  have  seen  in  consultation  two  patients  that  perished  early  with  inability 
to  swallow  as  the  prominent  symptom,  attended  in  both  by  an  abundant 
secretion  upon  the  faucial  surface,  without  any  redness,  swelling,  or  other 
evidence  of  inflammation.  The  early  death  of  these  young  children,  whose 
ages  were  ten  months  and  two  years,  rendered  the  diagnosis  less  certain  than 
in  most  other  patients,  but  the  attending  physician  as  well  as  myself  diag- 
nosticated cerebro-spinal  fever  with  suddenly  developed  paralysis  of  the 
muscles  of  deglutition,  so  that  no  nutriment  could  be  taken.  If  our  under- 
standing of  these  interesting  cases  is  correct,  the  paralysis  was  caused  by 
lesion  of  that  portion  of  the  medulla  oblongata  which  controls  the  function 
of  deglutition,  or  else  by  injury  of  the  intracranial  portions  of  the  nerves 
which  supply  the  muscles  concerned  in  this  act.  The  following  were  the 
cases  in  question : 

0 ,  male,  two  years  of  age,  became  feverish  and  dull,  but  without 

vomiting,  on  October  22,  1882 ;  axillary  temperature,  102°  F.  On  the  fol- 
lowing day  inability  to  swallow  occurred,  and  the  muscles  of  deglutition 
appeared  wholly  paralyzed.  Death  occurred  on  the  third  day,  suddenly  and 
apparently  without  suffering,  as  if  from  arrested  function  of  important  nerves, 
especially  the  pneumogastric.  The  abundant  secretion  of  thin  mucus  or 
transudation  of  sei'um  covering  the  faucial  surface,  and  reaecumulating  as 
soon  as  removed  without  any  notable  change  in  the  appearance  of  the  fauces, 
was  remarkable.  The  physician  in  attendance,  who  for  more  than  thirty  years 
had  had  a  large  city  practice,  had  seen  no  similar  case,  nor  had  I  at  the 
time. 

Soon  afterward  the  second  case  occurred.  An  infant  of  ten  months,  with- 
out cough  or  embarrassment  of  respiration  or  faucial  redness  or  swelling,  lost 
the  power  of  deglutition  soon  after  the  commencement  of  the  supposed  cere- 
bro-spinal fever,  so  that  in  the  attempts  to  swallow  the  drinks  entered  the 
larynx,  and  the  secretion  or  exudation  was  abundant,  as  in  the  other  case. 
Death  occurred  in  forty-eight  hours.  The  rectal  temperature  was  only 
101°  F. 

In  another  case,  which  was  ultimately  fatal  and  in  which  the  diagnosis  of 
cerebro-spinal  fever  was  certain,  a  robust  girl,  aged  twelve,  suddenly  lost  the 
power  of  deglutition   at  one  time    during  her  sickness,  although   she  was 


CEREBROSPINAL  FEVER.  437 

entirely  conscious  and  repeatedly  endeavored  to  swallow.  The  ability  to 
swallow  returned  in  a  few  days. 

Pulse. — This  is  usually  accelerated,  and  the  more  severe  and  dangerous 
the  attack  the  more  rapid  is  the  heart's  action,  except  occasionally  in  the 
comatose  state,  when,  probably  in  consequence  of  compression  of  the  brain 
from  an  abundant  exudation,  the  pulse  may  be  subnormal.  Thus,  in  one  of 
my  patients,  an  adult,  the  pulse  fell  to  -40  per  minute,  and  in  two  others  to 
between  60  and  70  per  minute.  With  the  exception  of  these  three,  the  pulse 
in  all  cases  which  I  have  observed,  so  far  as  I  recollect,  has  varied  from  the 
normal  number  of  beats  per  minute  to  such  frequency  that  it  was  difficult  to 
count  it.  As  death  draws  near  the  pulse  ordinarily  becomes  more  frequent 
and. feeble.  Intermissions  in  the  pulse  do  not  seem  to  be  as  common  as  in 
other  forms  of  meningitis,  but  marked  variations  in  its  frequency  during 
diflPerent  hours  of  the  day  and  on  consecutive  days  constitute  a  conspicuous 
symptom.  Thus,  in  a  case  which  was  fatal  in  the  fifth  week  consecutive 
enumerations  of  the  pulse  in  the  acute  stage  were  as  follows  :  128,  120,  88, 
130,  84,  112. 

Temperature. — Some  of  the  older  writers  before  the  days  of  clinical  ther- 
mometry stated  that  the  temperature  is  not  increased.  North  remarked  as 
follows  :  '•  Cases  occur,  it  is  true,  in  which  the  temperature  is  increased  above 
the  natural  standard,  but  these  are  rare  ;"  and  Foot  and  Gallop  make  similar 
statements.  Some  recent  writers  have  held  the  same  opinion.  Thus,  Lidell 
wrote  as  follows  in  a  treatise  bearing  the  date  of  1873  :  "Febrile  symptoms 
do  not  necessarily  belong  to  epidemic  cerebro-spinal  meningitis  as  a  substan- 
tive disease,  for  it  may,  and  not  unfrequently  does,  occur  without  exhibiting 
any  such  symptoms."  We  should  naturally  expect  that  meningitis,  accom- 
panied as  it  is  by  active  congestion  of  the  brain  and  spinal  cord,  would  pro- 
duce more  or  less  fever,  and  in  eighty-six  cases  which  I  examined  by  the 
thermometer  I  found  elevation  of  temperature  in  every  case  during  the  acute 
stage,  except  in  the  beginning  of  the  attack  in  two  instances.  In  a  young 
man  aged  twenty-eight  years  who  had  severe  headache  and  seemed  seriously 
sick  the  thermometer  under  the  tongue  showed  no  rise  of  temperature  on  the 
first  and  second  days,  but  on  the  third  day  it  was  at  100°  F.,and  it  remained 
elevated  till  his  death  on  the  thirteenth  day.  The  second  case  was  that  of  a 
young  woman  whom  I  saw  in  consultation,  and  who  at  the  time  of  my  visit 
had  fever,  but  had  none  previously,  according  to  the  statement  of  the 
attending  physician. 

In  the  87  cases  which  I  examined  the  heat  of  the  surface  occasionally 
did  not  seem  above  normal  to  the  touch,  and  now  and  then  the  thermometer, 
applied  in  the  axilla  or  groin,  did  not  indicate  fever,  but  the  rectal  temper- 
ature was  always  elevated  above  that  of  health  after  the  disease  was  fully 
established.  The  temperature  fluctuated  from  day  to  day  and  in  different 
hours  of  the  same  day,  but  there  was  no  exception  to  the  rule  that  it  was 
above  the  normal  during  the  active  stage  of  the  malady  after  the  first 
few  days.  Sometimes  the  elevation  of  temperature  was  slight,  as  in  a  female 
patient  forty-seven  years  of  age,  in  whom  the  thermometer  showed  no  eleva- 
tion of  temperature  when  it  was  placed  in  the  mouth  and  axilla,  but  on 
introducing  it  into  the  rectum  it  rose  to  99i^°  F.  In  the  case  of  a  young 
lady  attended  by  me  in  1890,  having  a  very  asthenic  and  fatal  form  of 
cerebro-spinal  fever,  accompanied  by  great  prostration,  a  brown  and  dry 
tongue,  and  delirium,  the  temperature  under  the  tongue  was  subnormal 
during  the  first  two  or  three  days,  but  was  afterward  above  normal. 

The  highest  temperature  which  I  have  thus  far  observed  was  lOTf  °  F., 
in  a  child  aged  two  years.  This  was  in  the  commencement  of  the  attack. 
Subsequently  it  fell  a  little,  but  rose  again  on  the  third  day  to  107°,  when 


438  CONSTITUTIONAL  DISEASES. 

she  died.  In  two  other  cases  the  temperature  was  106°  F.  on  the  first  day, 
and  it  did  not  afterward  reach  so  high  an  elevation.  One  of  these  died  on 
the  ninth  day,  and  the  other  in  the  ninth  week.  The  next  highest  temper- 
ature was  105|-  F.,  also  on  the  first  day,  in  an  infant  aged  eight  months,  who 
died  on  the  ninth  day.  The  first  and  last  of  these  cases  occurred  in  an  old 
wooden  tenement-house  in  the  suburbs  of  the  city  and  upon  an  elevated 
outcropping  of  rock.  The  highest  temperature  in  any  case  in  New  York 
City  which  has  come  to  my  notice  was  observed  in  a  male  patient  aged 
twenty-eight  years  who  had  active  delirium,  and  died  on  the  fifth  day  in 
Roosevelt  Hospital.  The  temperature  on  the  last  day,  taken  four  times,  was 
as  follows :  1022°,  1061°,  and,  when  the  pulse  had  become  imperceptible, 
109°  and  107f°  F.  Wunderlich  has  recorded  a  temperature  of  110°  F.  in 
one  or  two  cases,  but  so  great  an  elevation  must  be  very  rare,  and  is  of 
course  prognostic  of  an  unfavorable  ending. 

The  external  temperature  undergoes  still  greater  fluctuations  than  the 
internal,  rising  above  and  falling  below  the  normal  standard  several  times  in 
the  course  of  the  same  day.  Similar  fluctuations  occur  in  other  forms  of 
meningitis,  but  they  are,  according  to  my  experience,  less  pronounced  than 
in  cerebro-spinal  fever,  especially  as  I  observed  them  in  the  epidemic  of 
1872.  Perhaps  since  that  epidemic  they  have  been  less  marked  in  the  cases 
occurring  in  this  city.  The  more  grave  the  attack  in  those  not  comatose  the 
greater  these  variations.  The  following  is  a  common  example  of  these 
sudden  thermometric  changes,  occurring  in  a  child  of  two  years.  The  inter- 
nal temperature  varied  from  101°  to  104|-°  F.  as  the  extremes,  while  that  of 
the  fingers  and  hands  at  the  first  examination  was  902°,  at  the  second  90°, 
at  the  third  103°,  and  at  the  fourth  83°.  Hence  at  the  third  examination 
the  temperature  of  the  extremities  had  risen  13°,  so  as  nearly  to  equal  that 
of  the  blood,  and  at  the  fourth  examination  it  had  fallen  20°.  The  patient 
recovered.  These  great  and  sudden  variations  in  the  pulse  and  the  internal 
and  external  temperature  have  considerable  diagnostic  value  in  obscure  and 
doubtful  cases. 

Respiratory  System. — This  system  is  not  notably  involved  in  ordinary 
eases.  Intermittent,  sighing,  or  irregular  respiration  appears  to  be  less 
frequent  than  in  tubercular  meningitis,  but  it  does  occur.  In  most  patients 
the  respiration  is  quiet,  but  somewhat  accelerated,  and  without  any  marked 
disturbance  in  its  rhythm.  In  thirty-one  observations  in  children  who  had 
no  complication,  I  found  the  average  respirations  42  per  minute,  while  the 
average  pulse  was  137.  Therefore  the  respiration,  as  compared  with  the 
pulse,  was  proportionately  more  frequent  than  in  health,  due  perhaps  to  the 
fact  that  certain  muscles  concerned  in  respiration,  as  the  abdominal,  are  em- 
barrassed in  their  movements  by  tonic  contraction. 

Various  observers  in  different  epidemics  have  recorded  an  unusual  preva- 
lence of  croupous  pneumonia  occurring  simultaneously  with  cerebro-spinal 
fever.  Bascome  in  his  history  of  epidemics  stated  that  "  epidemic  encepha- 
litis and  malignant  pneumoiiias  prevailed  in  Germany  in  the  sixteenth  cen- 
tury" (Webber).  Webber  in  his  prize  essay  describes  a  variety  of  cerebro- 
spinal fever  which  he  designates  pneumonic,  in  which  the  cerebro-spinal  axis 
is  involved  but  slightly  or  not  at  all,  and  the  brunt  of  the  disease  falls  upon 
the  respiratory  organs.  According  to  him,  in  certain  epidemics  the  pneu- 
monic form  has  been  common  and  in  others  infrequent.  This  fact  is  interest- 
ing taken  in  connection  with  the  examination  of  the  microbes  of  croupous 
pneumonia  and  cerebro-spinal  fever,  as  detailed  in  our  remarks  under  the 
head  of  etiology. 

Cutaneous  Surface. — The  features  may  be  pallid,  of  normal  appearance, 
or  flushed  in  the  first  days  of  the  disease,  but  in  advanced  cases  they  are 


CEREBBO-SPINAL  FEVER.  439 

pallid,  as  is  tlie  skin  generally.  A  circumscribed  patcli  of  deep  congestion 
often  appears,  as  in  sporadic  meningitis,  upon  some  part  of  them,  as  the 
forehead,  cheek,  or  an  ear,  and  after  a  short  time  disappears.  The  hyper- 
aemic  streak,  the  tache  cerehrcde  of  Trousseau,  produced  by  drawing  the  fin- 
ger firmly  across  the  surface,  also  appears  as  in  other  forms  of  meningitis  if 
the  temperature  of  the  surface  be  not  too  much  reduced. 

The  following  are  the  abnormal  appearances  of  the  skin  most  frequently 
observed:  1.  Papilliform  elevations,  the  so-called  goose-skin,  due  to  contrac- 
tions of  the  muscular  fibres  of  the  corium.  This  is  not  uncommon  in  the 
first  weeks.  2.  A  dusky  mottling,  also  common  in  the  first  and  second 
weeks  in  grave  cases,  and  most  marked  when  the  temperature  is  I'educed. 

3.  Numerous  minute  red  points  over  a  large  part  of  the  surface,  bluish  spots 
a  few  lines  in  diameter,  due  to  extravasation  of  blood  under  the  cuticle, 
resembling  bruises  in  appearance,  and  large  patches  of  the  same  color  an 
inch  or  more  in  diameter,  less  common  than  the  others,  of  irregular  shape  as 
well  as  size,  and  usually  not  more  than  two  or  three  upon  a  patient.  These 
last  resemble  bruises,  and  they  may  sometimes  be  such,  received  during  the 
times  of  restlessness  ;  but  ordinarily  extravasations  of  this  kind  result 
entirely  from  the  altered  state  of  the  blood.  In  New  York  in  the  epidemic 
of  1872  they  were  common,  but  since  this  epidemic,  in  the  thirty-six  cases 
which  I  have  observed,  I  have  rarely  seen  either  the  reddish  points  or  the 
extravasations  of  blood.  They  were  probably  common  in  the  epidemics  in 
the  first  part  of  the  century  in  this  country,  since  the  disease  was  desig- 
nated by  the  name  "  spotted  fever  "  by  the  American  physicians  who  wrote 
upon  it  at  that  time.  That  they  are  unusual  in  the  European  epidemics  at 
the  present  time  we  infer  from  the  fact  that  Von  Ziemssen  expresses  surprise 
that  the  disease  should  ever  have  been  designated  in  America  by  such  a  title. 

4.  Herpes.  This  is  common.  It  sometimes  occurs  as  early  as  the  second  or 
third  day,  but  in  other  instances  not  till  toward  the  close  of  the  first  week  or 
in  the  second.  The  number  of  herpetic  eruptions  varies  from  six  or  eight  to 
clusters  as  large  as  or  larger  than  the  hand.  This  cutaneous  disease  evi- 
dently has  a  nervous  origin,  its  vesicles  occurring  in  most  instances  on  those 
parts  of  the  surface  which  are  supplied  by  branches  of  the  fifth  pair  of 
nerves.  Its  most  common  seat  is  upon  the  lips,  but  occasionally  it  appears 
upon  the  cheek,  upon  and  around  the  ears,  and  upon  the  scalp.  Erythema 
and  roseola,  both  transient  skin  eruptions,  occasionally  appear,  and  in  one 

■instance,  in  my  practice,  erysipelas  occurred.  During  the  first  days  the  skin 
is  frequently  dry  ;  afterward  perspirations  are  not  unusual,  and  free  per- 
spirations sometimes  occur,  especially  about  the  head,  face,  and  neck. 

Urinary  Organs. — In  other  forms  of  meningitis  it  is  well  known  that  the 
quantity  of  urine  excreted  is  usually  diminished,  but  in  this  disease  it  is 
normal,  and  it  may  be  more  than  normal.  Polyuria  has  been  noticed  in  dif- 
ferent cases  by  various  observers.  Mosler  observed  a  boy  aged  seven  years 
who  had  an  excessive  secretion  of  urine,  which  dated  back  to  an  attack  of 
cerebro-spinal  fever  in  his  third  year.  The  polyuria  is  probably  due  to 
injury  of  the  nervous  centre,  since  physiological  experiment  has  demon- 
strated that  irritation  of  the  central  end  of  the  vagus,  of  certain  parts  of  the 
cerebellum,  and  of  the  walls  of  the  fourth  ventricle  sometimes  produces  this 
effect.  The  urine  occasionally  contains  a  moderate  amount  of  albumen,  and 
in  exceptional  instances  cylindrical  casts  and  blood-corpuscles. 

Arthritic  inflammation,  apparently  of  a  rheumatic  character,  has  been 
occasionally  observed.  It  is  commonly  slight,  producing  merely  an  oedema- 
tous  appearance  around  one  or  more  joints.  Thus  in  one  case  which  came 
under  my  notice,  and  which  was  subsequently  fatal,  the  parents,  who  were 
poor,  and  were  therefore  without  medical  advice  till  the  case  was  somewhat 


440  CONSTITUTIONAL  DISEASES. 

advanced,  had  already  diagnosticated  rheumatism  on  account  of  the  pufl&ness 
which  they  had  noticed  around  one  of  the  wrists. 

The  Special  Senses.  —  Taste  and  smell  are  rarely  affected,  so  far  as  is 
known,  but  it  is  possible  that  they  are  sometimes  perverted,  or  even  tempo- 
rarily lost,  during  the  time  of  greatest  stupor.  In  one  case  which  T  saw  the 
sense  of  smell, was  entirely  lost  in  one  nostril,  and  I  do  not  know  whether  it 
was  ever  fully  restored. 

The  affections  of  the  eye  and  ear  are  important  and  of  frequent  occur- 
rence. Strabismus  is  common.  It  may  occur  at  any  period  of  the  fever, 
continuing  a  few  hours  or  several  days,  and  it  may  appear  and  disappear 
several  times  before  convalescence  is  established :  occasionally  it  continues 
several  weeks,  after  which  the  parallelism  of  the  eyes  is  gradually  and  fully 
restored.     In  other  instances  it  is  permanent. 

Changes  in  the  pupils  are  among  the  first  and  most  noticeable  of  the 
initial  symptoms,  as  I  have  already  stated  in  describing  the  mode  of  com- 
mencement. These  are  dilatation,  less  frequently  contraction,  oscillation, 
inequality  of  size,  feeble  response  to  light,  etc.  Most  patients  present  one 
or  more  of  these  abnormalities  of  the  pupils,  and  they  continue  during  the 
first  and  second  weeks,  and  gradually  abate  if  the  course  of  the  disease  be 
favorable.  Inflammatory  hyperaemia  of  the  conjunctiva  often  occurs.  It 
begins  early,  and  now  and  then  the  conjunctivitis  is  so  intense  that  con- 
siderable tumefaction  of  the  lids  results,  with  a  free  muco-purulent  secre- 
tion. The  false  diagnosis  has  indeed  been  made  of  purulent  ophthalmia  in 
cases  in  which  this  affection  of  the  lids  was  early  and  severe.  But  such 
intense  inflammation  is  quite  exceptional.  More  frequently  there  is  a  uni- 
form diff'used  redness  of  the  conjunctiva,  not  so  dusky  as  in  typhus,  and  the 
injected  vessels  cannot  be  so  readily  distinguished  as  in  that  disease. 

In  certain  cases  almost  the  whole  eye  (all,  indeed,  of  the  important  con- 
stituents) becomes  inflamed ;  the  media  grow  cloudy,  the  iris  discolored,  and 
the  pupils  uneven  and  filled  up  with  fibrinous  exudation.  The  deep  struc- 
tures of  the  eye  cannot,  therefore,  be  readily  explored  by  the  ophthalmo- 
scope, but  they  are  observed  to  be  adherent  to  each  other  and  covered  by 
inflammatory  exudation.  They  present  a  dusky-red  or  even  a  dark  color 
when  the  inflammation  is  recent.  Exceptionally  the  cornea  ulcerates  and 
the  eye  bursts,  with  the  loss  of  more  or  less  of  the  liquids  and  shrinking 
of  the  eye.  "  But  ordinarily  no  ulceration  occurs,  and  as  the  patient  con- 
valesces the  oedema  of  the  lids,  the  hypersemia  of  the  conjunctiva,  the  cloud- 
iness of  the  cornea  and  of  the  humors  gradually  abate  and  the  exudation  in 
the  pupils  is  absorbed.  The  iris  bulges  forward,  and  the  deep  tissues  of  the 
eye,  viewed  through  the  vitreous  humor,  which  before  had  a  dusky-red  color 
from  hyperasmia,  now  present  a  dull-white  color."  The  lens  itself,  at  first 
transparent,  after  a  while  becomes  cataractous.  Sight  is  lost  totally  and  for 
ever. 

If  the  patient  live,  the  volume  of  the  eye  diminishes,  as  the  inflammation 
abates,  to  less  than  the  normal  size,  even  when  there  has  been  no  rupture 
and  escape  of  the  fluids,  and  divergent  strabismus  is  likely  to  occur.  Prof. 
Knapp,  whose  description  of  the  eye  I  have  for  the  most  part  followed,  says : 
"  The  nature  of  the  eye  aff"ection  is  a  purulent  choroiditis,  probably  metastatic." 
Fortunately,  so  general  and  destructive  an  inflammation  of  the  eye  as  has  been 
described  above  is  comparatively  rare.  On  the  other  hand,  conjunctivitis  of 
greater  or  less  severity,  and  hypersemia  of  the  optic  disk,  consequent  upon 
the  brain  disease,  are  not  unusual,  but  they  subside,  leaving  the  function  of 
the  organ  unimpaired.  "  In  some  cases  incurable  blindness  is  noticed  under 
the  ophthalmoscope  picture  of  optic  nerve-atrophy,  probably  the  sequence  of 
choked  disk  "  (Knapp). 


CEREBROSPINAL  FEVER.  441 

Inflammation  of  ths  middle  ear,  of  a  mild  grade  and  subsiding  without 
impairment  of  hearing,  is  common.  The  membrana  tynipani  during  its  con- 
tinuance presents  a  dull-yellowish,  and  in  places  a  reddish,  hue.  Occasion- 
ally a  more  severe  otitis  media  occurs,  ending  in  suppuration,  perforation  of 
the  membrani  tympani,  and  otorrhoea,  which  ceases  after  a  variable  time. 
But  otitis  media  is  not  the  most  severe  of  the  affections  of  the  organs  of 
hearing.  Certain  patients  lose  their  hearing  entirely,  and  never  regain  it,  and 
that,  too,  with  little  otalgia,  otorrhoea,  or  other  local  symptoms  by  which  so 
grave  a  result  can  be  prognosticated.  This  loss  of  hearing  does  not  occur  at 
the  same  period  of  the  disease  in  all  cases.  Some  of  those  who  become  deaf 
are  able  to  hear  as  they  emerge  from  the  stupor  of  the  disease,  but  lose  this 
function  during  convalescence,  while  the  majority  are  observed  to  be  deaf  as 
soon  as  the  stupor  abates  and  full  consciousness  returns. 

Two  important  facts  have  been  observed  in  reference  to  the  loss  of  hearing 
in  these  patients — to  wit,  it  is  bilateral  and  complete.  When  first  observed  it 
is,  in  some,  as  stated  above,  complete,  but  in  others  partial,  and  when  partial  it 
gradually  increases  till  after  some  days  or  weeks,  when  it  becomes  complete. 
I  have  the  records  of  10  cases  of  this  loss  of  hearing,  most  of  them  occurring 
in  my  own  practice  in  the  epidemic  of  1872,  but  a  few  of  them  detailed  to 
me  by  the  physicians  who  observed  them  in  the  same  epidemic.  According 
to  these  statistics,  about  1  in  every  10  patients  became  deaf,  but  in  the  milder 
form  of  cerebro-spinal  meningitis,  which  has  prevailed  since  1872,  the  pro- 
portionate number  thus  affected  has  been  less  among  my  patients,  and 
the  same  may  be  said  in  reference  to  the  loss  of  sight:  1  of  the  10  cases 
was  a  young  lady,  but  the  rest  were  children  under  the  age  of  ten  years. 
Prof.  Knapp  has  examined  31  cases.  "  In  all,"  says  he,  "  the  deafness  was 
bilateral,  and,  with  2  exceptions  of  faint  perceptions  of  sound,  complete. 
Among  the  29  cases  of  total  deafness  there  is  only  1  who  seemed  to  give 
some  evidence  of  hearing  afterward."  The  same  author  has  recently  informed 
me  that  further  experience  has  confirmed  his  previous  statement,  that  while 
the  blindness  produced  by  cerebro-spinal  fever  is  in  the  majority  of  cases 
monolateral,  but  one  case  had  come  to  his  notice  in  which  the  deafness  was 
on  one  side  only. 

One  theory  attributes  the  loss  of  hearing  to  inflammatory  lesions,  either 
at  the  centre  of  audition  within  the  brain  or  in  the  course  of  the  auditory 
nerves  before  they  enter  the  auditory  foramina.  The  other  theory,  which  is 
the  better  established  of  the  two  and  must  be  accepted,  attributes  the  loss 
of  hearing  to  inflammatory  disease  of  the  ear,  and  especially  of  the  labyrinth. 

Symptoms  of  Endemic  or  Naturalized  Cerebro-spinal  Fever. — 
The  numerous  monographs  on  this  disease  which  have  appeared  during  the 
last  few  yeai's  relate  to  its  epidemic  form,  and  no  published  observations,  so 
far  as  I  am  awai'e,  describe  the  character  or  symptoms  which  it  presents  or 
the  changes  which  it  undergoes  when  it  occurs  as  an  endemic  or  naturalized 
disease.  The  endemic  disease  must,  of  course,  be  observed  in  the  cities  or 
populous  towns,  for  there  is  no  rural  locality,  so  far  as  I  am  aware,  in  which 
this  disease  is  permanently  established.  In  New  York  the  naturalized  disease 
appears  to  be  accompanied  by  a  less  profound  blood-change  than  occurs  in 
epidemic  cases.  Although  every  year  seeing  a  considerable  number  of  cases, 
I  have  not  in  the  last  ten  years  seen  one  with  the  livid  spots  upon  the  surface, 
due  to  subcutaneous  extravasation  of  blood,  which  were  so  common  in  the 
epidemic  of  1872,  and  which  have  been  so  common  in  epidemics  both  in  this 
country  and  in  Europe  that  the  term  "spotted  fever"  was  applied  to  the 
malady.  Occasionally  petechiae  occur  in  severe  cases  of  the  naturalized 
disease. 

Nature. — The  theory  that  cerebro-spinal  fever  is  a  local  disease,  occur- 


442 


CONSTITUTIONAL  DISEASES. 


ring  epidemically,  was  commonly  held  in  the  first  part  of  this  century,  but  is 
now  discarded.  Job  Wilson  in  1815  considered  it  a  form  of  influenza,  and 
could  see  no  utility  in  drawing  a  distinction  between  spotted  fever  and  influ- 
enza. We  at  the  present  time  can  see  no  resemblance  between  the  two,  ex- 
cept that  both  occur  as  epidemics.  The  theory  that  cerebro-spinal  fever  is  a 
peculiar  local  disease,  occurring  in  epidemics,  is  more  plausible  than  that  which 
holds  that  it  is  a  form  of  influenza.  Even  Niemeyer  says  that  it  presents  no 
symptoms  except  such  as  are  referable  to  the  local  afi'ection.  But  the  evi- 
dence is  strong  that  cerebro-spinal  fever  is  a  constitutional  malady  with  the 
meningitis  as  a  local  manifestation,  just  like  measles  with  its  bronchitis  or 
scarlet  fever  with  its  pharyngitis.  The  abrupt  and  severe  commencement, 
unlike  that  of  those  forms  of  meningitis  which  are  known  to  be  strictly  local, 
and  the  early  blood-change,  as  shown  in  certain  eases  by  the  appearance  of 
the  skin  and  extravasation  under  it,  indicate  a  general  disease.  Constitutional 
diseases  having  prominent  local  symptoms  and  lesions  are  usually  regarded  at 
first  as  local.  It  is  only  as  time  goes  on  and  they  are  more  thoroughly  studied 
and  understood,  and  clinical  observations  multiply,  that  their  constitutional 
nature  is  recognized. 

The  theory  that  cerebro-spinal  fever  is  a  form  of  typhus  once  had  advo- 
cates, but  it  is  now  so  generally  discarded  as  untenable  and  absurd  that  it 
would  be  a  waste  of  time  to  consider  the  facts  which  diff"erentiate  the  two 
maladies.  Cerebro-spinal  fever  should  therefore  be  considered  as  distinct 
from  all  other  diseases,  a  malady  sui  generis^  and  in  nosological  writings  it 
should  be  classified  with  those  constitutional  maladies  which  have  specific 
causes. 

Although  this  disease  ordinarily  occurs  in  an  epidemic  form  in  localities 
widely  separated  from  one  another,  and,  after  continuing  a  few  weeks  or 
months,  totally  disappears,  perhaps  never  to  return  or  not  till  after  the  lapse 
of  years,  nevertheless  in  localities  it  becomes  established,  so  that  it  is  proper 
to  describe  it  as  an  endemic — a  fact  to  which  we  have  already  referred  as 
regards  certain  American  cities.  I  do  not  know  that  it  is  endemic  in  any 
village  or  rural  locality  in  this  country.  The  large  cities,  with  their  promis- 
cuous population,  foreign  and  native,  their  crowded  tenement-houses,  and 
their  many  sources  of  insalubrity,  furnish  in  an  eminent  degree  the  condi- 
tions which  are  favorable  for  the  development  and  perpetuation  of  the  mi- 
crobic  diseases.  Those  diseases  which  in  the  present  state  of  our  knowledge 
we  have  reason  to  believe  are  caused  by  micro-organisms,  we  should  expect  to 
prevail  most  where  domiciles  are  crowded  and  filthy,  and  systems  are  enervated 
by  impure  air,  hardships,  and  privation.  Hence  in  New  York  City,  in  the 
crowded  quarters  of  the  poor,  cerebro-spinal  fever,  like  diphtheria,  is  seldom 
or  never  absent. 


Deaths  in  New  York  from  Cerehro- Spinal  Fever. 
Number. 


1872 
1873 
1874 
1875 
1876 
1877 
1878 
1879 


782 
290 
158 
146 
127 
116 
97 
108 


1880 

1881 
1882 
1883 
1884 
1885 
1886 
1887 


Number. 

.  170 

.  461 

.  238 

.  223 

.  210 

.  202 

.  223 

.  203 


It  is  seen  that  the  greatest  mortality  was  in  the  first  year  after  the  introduc- 
tion of  the  disease  into  the  city,  after  which  the  number  of  deaths  gradually 
diminished,  year  by  year,  till  1878,  when  the  lowest  mortality  was  reached. 


CEREBROSPINAL  FEVER.  443 

After  1878  the  mortality  gradually  increased  till  1881,  in  which  year  the 
number  of  deaths  was  double  that  of  any  other  year  except  1872. 

The  mortuary  reports  of  Philadelphia  likewise  show  that  cerebro-spinal 
fever  has  remained  in  that  city  since  its  introduction  in  1863,  a  period  of 
twenty-five  years,  the  annual  deaths  produced  by  it  varying  between  36,  the 
minimum,  in  1869  and  1870,  and  384,  the  maximum,  in  1864.  In  Providence 
also,  as  appears  from  Dr.  Snow's  reports,  cerebro-spinal  fever  has  caused  an- 
nually more  or  fewer  deaths  since  1871.  Therefore,  we  repeat,  this  fact  may 
be  added  to  the  sum  of  our  knowledge  of  this  disease,  that,  once  gaining  a 
lodgement  where  the  conditions  are  favorable  for  it,  as  in  a  large  city,  it  may 
become  established  and  remain  an  indefinite  time. 

Anatomical  Characters. — I  have  notes  of  the  post-mortem  appearances 
in  76  cases,  published  chiefly  in  British  and  American  journals  :  29  died  within 
the  first  three  days,  28  between  the  third  and  twenty-first  days,  and  the  dura- 
tion of  the  remaining  19  was  unknown.  These  records  furnish  the  data  for 
the  following  remarks : 

The  blood  undergoes  changes  which  are  due  in  part  to  the  inflammatory 
and  in  part  to  the  constitutional  and  asthenic  nature  of  the  disease.  The  pro- 
portion of  fibrin  is  increased  in  cases  that  are  not  speedily  fatal,  as  it  ordi- 
narily is  in  idiopathic  inflammation.  Analyses  of  the  blood  by  Ames, 
Tourdes,  and  Maillot  show  a  variable  proportion  of  fibrin  from  three  and 
four-tenths  to  more  than  six  parts  in  one  thousand.  In  sthenic  cases  accom- 
panied by  a  pretty  general  meningitis,  cerebral  and  spinal,  there  is,  after  the 
fever  has  continued  some  days,  the  maximum  amount  of  fibrin,  while  in  the 
asthenic  and  suddenly  fatal  eases,  with  inflammation  slight  or  in  its  com- 
mencement, the  fibrin  is  but  little  increased.  The  most  common  abnormal 
appearance  of  the  blood  observed  at  autopsies  is  a  dark  color,  with  unusual 
fluidity  and  the  presence  of  dark  soft  clots.  Exceptionally  bubbles  of  gas 
have  been  observed  in  the  large  vessels  and  the  cavities  of  the  heart.  An 
unusually  dark  color  of  the  blood,  small  and  soft  dark  clots,  and  the  presence 
of  gas-bubbles,  when  only  a  few  hours  have  elapsed  after  death,  indicate  a 
malignant  form  of  the  disease,  in  which  the  blood  is  early  and  profoundly 
altered.  In  certain  cases  this  fluid  is  not  so  changed  as  to  attract  attention 
from  its  appearance.  The  points  or  patches  of  extravasated  blood  which  are 
observed  in  and  under  the  skin  during  life  in  some  patients  usually  remain  in 
the  cadaver.  When  an  incision  is  made  through  them  the  blood  is  seen  to 
have  been  extravasated,  not  only  in  the  layers  of  the  skin,  but  also  in  the  sub- 
cutaneous connective  tissue.  Extravasations  of  small  extent  are  likewise 
sometimes   observed  upon  and   in  thoracic  and  abdominal  organs. 

In  those  who  die  after  a  sickness  of  a  few  hours  or  days— namely,  in 
the  stage  of  acute  inflammatory  congestion — the  cranial  sinuses  are  found 
engorged  with  blood  and  containing  soft  dark  clots.  The  meninges  envelop- 
ing the  brain  are  also  intensely  hyperfemic  in  their  entire  extent  in  most 
cadavers,  but  in  some  cases  the  hyperaemia  is  limited  to  a  portion  of  the 
meninges,  while  other  portions  appear  nearly  normal.  In  those  cases  which 
end  fatally  within  a  few  hours  this  hypersemia  is  ordinarily  the  only  lesion 
of  the  meninges  ;  but  if  the  case  be  more  protracted,  serum  and  fibrin  are 
soon  exuded  from  the  vessels  into  the  meshes  of  the  pia  mater,  and  under- 
neath this  membrane  over  the  surface  of  the  brain.  Pus-cells  also  occur 
mixed  with  the  fibrin,  sometimes  so  few  that  they  are  discovered  only  with 
the  microscope,  but  in  other  cases  in  such  quantity  as  to  be  much  in  excess 
of  the  fibrin  and  to  be  readily  detected  by  the  naked  eye.  Pus,  which  in 
these  cases  probably  consists  of  white  blood-corpuscles  which  have  escaped 
with  the  fibrin  from  the  meningeal  vessels,  often  appears  early  in  the  attack. 
The  arachnoid  soon  loses  its  transparency  and  polish,  and  presents  a  cloudy 


444  CONSTITUTIONAL  DISEASES. 

appearance  over  a  greater  or  less  extent  of  its  surface.  The  cloudiness  is 
usually  greatest  along  the  course  of  the  vessels  in  the  sulci  and  depressions, 
and  where  the  fibrinous  exudation  is  greatest,  but  it  occurs  also  in  places 
where  no  such  exudation  is  apparent  to  the  naked  eye. 

The  exudation — serous,  fibrinous,  and  purvilent — occurs,  as  in  other  forms 
of  meningitis,  within  the  meshes  of  the  pia  mater,  and  underneath  this  mem- 
brane over  the  surface  of  the  brain.  The  fibrin  is  raised  from  the  surface  of 
the  brain  with  the  meninges  in  making  the  autopsy.  It  is  most  abundant  in 
the  intergyral  spaces,  around  the  course  of  the  vessels,  over  and  around  the 
optic  commissure,  pons  Varolii,  cerebellum,  and  medulla  oblongata,  and  along 
the  Sylvian  fissures.  It  is  most  abundant  in  the  depressions,  where  it  some- 
times has  the  thickness  of  one-tenth  to  one-fourth  of  an  inch,  but  it  often 
extends  over  the  convolutions  so  as  to  conceal  them  from  view. 

Most  other  forms  of  meningitis  have  a  local  cause,  and  are  therefore 
limited  to  a  small  extent  of  the  meninges — as,  for  example,  meningitis  from 
tubercles  or  caries  of  the  petrous  portion  of  the  temporal  bone,  in  both  of 
which  it  is  commonly  limited  to  the  base  of  the  brain ;  or  from  accidents, 
when  the  meningitis  commonly  occurs  upon  the  side  or  summit  of  the  brain. 
The  meningitis  of  cerebro-spinal  fever,  on  the  other  hand,  having  a  general 
or  constitutional  cause,  occurs  with  nearly  equal  frequency  upon  all  parts  of 
the  meningeal  surface,  except  that  it  is  perhaps  most  severe  in  the  depres- 
sions, where  the  vascular  supply  is  greatest.  In  cases  of  great  severity  the 
inflammatory  exudation,  fibrinous  or  purulent,  or  both,  covers  nearly  or  quite 
the  entire  surface  of  the  brain. 

In  those  who  die  at  an  early  stage  of  the  attack  the  vessels  of  the  brain, 
like  those  of  the  meninges,  are  hyperaemic,  so  that  numerous  "  puncta  vas- 
culosa  '"  appear  upon  its  incised  surface.  At  a  later  period  this  hyperaemia, 
like  that  of  the  meninges,  may  disappear.  If  there  be  much  eifusion  of 
serum  within  the  ventricles  and  over  the  surface  of  the  brain,  the  convolu- 
tions are  liable  to  be  flattened,  and  the  pressure  may  be  so  great  that  the 
amount  of  blood  circulating  in  the  brain  is  reduced  below  the  normal  quan- 
tity. Thus,  in  the  case  of  a  child  of  three  years  who  lived  sixteen  days,  and 
was  examined  after  death  by  Burdon-Sanderson,  the  ventricles  contained  a 
large  amount  of  turbid  serum  and  the  brain-substance  was  everywhere  pale 
and  anaemic  from  compression. 

Cerebral  ramollissement  occurs  in  certain  cases.  At  one  of  the  examina- 
tions in  Charity  Hospital,  the  patient  having  been  only  three  days  sick,  the 
brain  was  found  much  softened.  The  dissection  was  made  seven  hours  after 
death,  so  that  the  softening  could  not  have  been  the  result  of  decomposition. 
At  one  of  the  post-mortem  examinations  in  Bellevue  Hospital,  softening 
of  the  fornix,  corpus  callosum,  and  septum  lucidum  was  observed,  and  in 
another  softening  in  the  neighborhood  of  the  subarachnoid  space.  In  a  case 
related  by  Dr.  Moorman'  it  is  stated  that  portions  of  the  brain,  medulla 
oblongata,  and  pons  Varolii  were  softened.  In  a  case  observed  by  Dr.  Upham 
softening  of  the  superior  portion  of  the  left  cerebral  hemisphere  had  occurred. 
Occasionally  the  whole  brain  is  somewhat  softened.  Burdon-Sanderson,  Rus- 
sell, and  Githens  each  relate  such  a  case.  Moreover,  the  walls  of  the  lateral 
ventricles  are  ordinarily  more  or  less  softened  in  fatal  cases  of  cerebro-spinal 
fever,  as  they  are  in  other  forms  of  meningitis.  In  rare  instances  the  brain 
is  oedematous,  as  in  a  ease  published  by  Dr.  Hutchinson.^  In  this  case  the 
patient  was  only  four  days  sick  and  the  whole  brain  was  oedematous,  serum 
escaping  from  its  incised  surface. 

The  ventricles  contain  liquid,  in  some  patients  transparent  serum,  in 
others  serum  turbid  and  containing  flocculi  of  fibrin  or  fibrin  with  pus.     The 

'  American  Journal  of  the  Medical  Sciences,  October,  1866.  '^  Ibid.,  July,  1866. 


CEREBROSPINAL  FEVER.  445 

liquids  in  the  different  ventricles,  since  they  intercommunicate,  are  the  same. 
The  choroid  plexus  is  either  injected  or  it  is  infiltrated  with  fibrin  and  pus. 
With  the  abatement  of  the  inflammation,  absorption  commences.  The  serum, 
from  its  nature,  is  readily  absorbed,  and  the  pus  and  fibrin  more  slowly  by 
fatty  degeneration  and  liquefaction.  Occasionally  the  serum  remains,  and 
chronic  hydrocephalus  results.  An  infant  who  contracted  the  disease  at  the 
age  of  five  months,  and  appeared  to  be  convalescent,  had,  two  months  sub- 
sequently, great  prominence  of  the  anterior  fontanel,  and  other  symptoms 
indicating  the  presence  of  a  considerable  amount  of  effusion  within  the 
cranium.  In  another  case,  one  year  afterward,  examination  showed  the 
enlargement  of  the  head  and  prominence  of  the  fontanel  which  characterize 
chronic  hydrocephalus.  A  boy  of  ten  years  treated  in  Roosevelt  Hospital  in 
1878  died  three  months  after  the  commencement  of  cerebro-spinal  fever. 
The  records  of  the  autopsy  state  :  "  Body  a  skeleton  ;  brain,  dura  mater,  and 
pia  mater  appear  normal,  except  a  little  thickening  of  latter  at  base  of  brain  ; 
ventricles  much  enlarged  and  full  of  clear  serum  ;  surface  of  walls  of  ven- 
tricles appears  normal,  but  is  soft ;  spinal  cord  and  membranes  apparently 
normal ;  heart,  lungs,  stomach,  and  intestines  normal ;  liver  congested ;  kid- 
neys pale."  In  this  case,  therefore,  all  the  other  lesions  of  the  cerebro-spinal 
axis,  except  the  serous  effusion,  had  nearly  disappeared.  No  post-mortem 
examinations,  so  far  as  I  am  aware,  have  yet  revealed  the  state  of  the  brain 
and  its  meninges  in  those  who  have  had  this  malady  at  some  former  time,  and 
have  fully  recovered.  Whether  there  may  not  be  some  traces  of  it  which  are 
permanent,  as  opacity  or  adhesions,  must  be  determined  by  future  observations. 

The  remarks  made  in  reference  to  the  cerebral  apply,  for  the  most  part, 
also  to  the  spinal  meninges.  There  is  at  first  intense  hypersemia  of  the 
membranes,  usually  over  the  entire  surface  of  the  cord,  soon  followed  by 
fibrinous,  purulent,  and  serous  exudation  in  the  meshes  of  the  pia  mater  and 
underneath  this  membrane.  This  exudation  is  sometimes  confined  to  a  por- 
tion of  the  meninges,  more  frequently  that  covering  the  posterior  than  the 
anterior  aspect  of  the  cord,  and  when  it  is  general  it  is  ordinarily  thicker 
posteriorly  than  anteriorly.  In  severe  cases  nearly  or  quite  the  entire  spinal 
pia  mater  may  be  infiltrated  by  inflammatory  products.  Thus,  in  the  case  of 
an  infant  that  died  of  cerebro-spinal  fever  at  the  age  of  ten  weeks,  in  the 
service  of  Dr.  H.  D.  Chapin  in  the  Out-door  Department  at  Bellevue,  the 
entire  spinal  cord  was  covered  by  a  fibrino-purulent  exudation,  except  a  space 
about  six  lines  in  extent  upon  the  anterior  surface. 

No  constant  or  uniform  lesions  occur  in  the  organs  of  the  trunk,  and 
those  observed  are  not  distinctive  of  this  disease.  Hypostatic  congestion 
of  the  lungs,  bronchitis,  atelectasis,  and  broncho-pneumonia  are  common. 
Pleuritic,  endocardial,  and  pericardial  inflammations  have  occasionally  been 
observed,  but  are  rare.  Effusion  of  serum,  sometimes  blood-stained,  occasion- 
ally occurs  in  the  pleural  and  other  serous  cavities.  The  auricles  and  ven- 
tricles of  the  heart,  as  already  stated,  contain  more  or  less  blood,  with  soft 
dark  clots  in  the  more  malignant  and  rapidly  fatal  cases,  but  larger  and  firmer 
in  those  which  have  been  more  protracted.  The  spleen  is  enlarged  in  less 
than  half  the  patients.  The  absence  of  uniformity  as  regards  the  state  of 
the  spleen,  the  fact  that  in  many  it  undergoes  no  appreciable  change,  is 
important,  since  this  organ  is  so  generally  enlarged  and  softened  in  the  infec- 
tious diseases.  The  stomach,  intestines,  and  liver  are  sometimes  more  or  less 
congested,  but  in  other  cases  their  appearance  is  normal.  The  agminate  and 
solitary  glands  of  the  intestines  have  ordinarily  been  overlooked,  but  in  cer- 
tain cases  they  have  been  found  prominent.  The  kidneys  are  normal,  or  they 
exhibit  the  lesions  of  nephritis.  In  1  of  8  autopsies  made  by  Prof  Welch 
acute  diffuse  nephritis  had  been  present,  as  shown  by  the  state  of  the  kidneys. 


446  CONSTITUTIONAL  DISEASES. 

In  the  case  of  a  child  of  nine  years  treated  by  Dr.  F.  A.  Burrall  in  the 
Presbyterian  Hospital  the  urine  was  very  albuminous  and  the  kidneys  pre- 
sented a  fatty  appearance.  Anatomical  changes  in  these  organs,  however,  are 
not  common,  unless  in  slight  degree,  so  that  in  most  patients  their  function 
is  fully  and  properly  performed. 

Prognosis. — Cerebro-spinal  fever  is  justly  regarded  as  one  of  the  most 
dangerous  maladies  of  childhood.  It  is  dreaded  not  only  on  account  of  the 
great  mortality  which  attends  it,  but  also  on  account  of  its  protracted  course, 
the  suffering  which  it  causes,  the  possible  permanent  injury  of  the  important 
organ  which  is  chiefly  involved,  and  the  irreparable  damage  which  the  eye 
and  ear  often  sustain. 

I  have  the  records  of  the  result  in  52  cases  which  I  attended  or  saw  in 
consultation  in  the  epidemic  of  1872.  Of  these  just  one-half  recovered.  16 
of  the  26  who  died  were  hopelessly  comatose  within  the  first  seven  days, 
most  of  them  dying  within  that  time,  and  some  even  on  the  first  and  second 
daj's,  while  others  of  the  16  lingered  into  the  second  week  and  died  without 
any  sign  of  returning  consciousness.  The  remaining  10,  who  subsequently 
died,  but  did  not  become  comatose  in  the  first  week,  were  nevertheless  seri- 
ously sick  from  the  first  day,  but  their  symptoms,  though  severe,  were  not 
such  as  necessarily  indicated  a  fatal  result,  so  that  there  was  some  expecta- 
tion of  a  favorable  ending  till  near  death,  which  occurred  for  the  most  part 
from  asthenia.  One  succumbed  to  purpura  haemorrhagica,  the  hemorrhages 
occurring  from  the  mucous  surfaces.  The  patient  died  after  a  sickness  of 
more  than  two  months,  in  a  state  of  extreme  emaciation  and  prostration.  The 
26  who  recovered  convalesced  slowly,  and  usually  after  many  fluctuations. 
Their  highest  temperature  and  most  severe  and  dangerous  symptoms  occurred 
in  the  first  week.  Most  of  them  were  several  weeks  under  observation  and 
treatment  before  they  sufiiciently  recovered  to  be  out  of  danger.  The  statis- 
tics of  this  epidemic  therefore  show — and  the  same  is  true  of  other  epidemics 
— that  the  first  week  is  the  time  of  greatest  danger,  and  if  no  fatal  symp- 
toms are  developed  during  this  week,  recovery  is  probable  with  proper  thera- 
peutic measures  and  kind,  intelligent,  and  efiicient  nursing,  which  is  very 
important. 

Since  1872  I  have  seen  a  larger  number,  and  have  preserved  records  of 
40  cases  which  I  was  able  to  follow  to  the  close.  Some  were  seen  in  consul- 
tation. Of  these  40,  21  recovered  and  19  died.  Of  the  19  fatal  cases,  9  died 
in  the  first  week,  5  in  the  second  week,  1  in  the  third  week,  1  on  the  twenty- 
fifth  day,  1  on  the  thirty-first  day,  and  1  in  the  sixteenth  week.  This  last 
patient,  a  boy  of  ten  years,  would,  in  my  opinion,  have  recovered  with  better 
nursing.  His  death  occurred  from  large  bed-sores  which  extended  to  the 
bones,  produced  by  lying  a  long  time  in  one  position  on  a  hard  bed  when  he 
was  too  weak  to  move,  and  often  with  soiled  bedclothes  underneath  him. 
The  remaining  case  of  the  19  died  after  a  prolonged  sickness. 

There  is  probably  no  disease  which  falsifies  the  predictions  of  the  phy- 
sician more  frequently  than  cerebro-spinal  fever.  This  is  due  partly  to  the 
severity  of  the  cerebral  symptoms  in  the  commencement,  which,  did  they 
occur  in  other  forms  of  meningitis  with  which  he  is  more  familiar,  would 
justify  an  unfavorable  prognosis,  and  partly  to  the  remissions  and  exacerba- 
tions, the  occurrence  alternately  of  symptoms  of  apparent  convalescence  and 
recrudescence  or  relapse,  which  characterize  the  course  of  this  malady.  Grave 
initial  symptoms,  which  may  appear  to  have  a  fatal  augury,  are  often  fol- 
lowed by  such  a  remission  that  all  danger  seems  past,  and  in  a  few  hours 
later  perhaps  the  symptoms  are  nearly  or  quite  as  grave  as  at  first. 

Under  the  age  of  five  years  and  over  that  of  thirty  the  prognosis  is  less 
favorable  than  between  these  ages.     An  abrupt  and  violent  commencement. 


CEREBROSPINAL  FEVER.  447 

profound  stupor,  convulsions,  active  delirium,  and  great  elevation  of  tempera- 
ture are  symptoms  which  should  excite  solicitude  and  render  the  prognosis 
guarded.  If  the  temperature  remain  above  105°  F.,  death  is  probable,  even 
with  moderate  stupor.  Numerous  and  large  petechial  eruptions  show  a  pro- 
foundly altered  state  of  the  blood,  and  are  therefore  a  bad  prognostic  ;  and  so 
is  continued  albuminuria,  since  it  shows  great  blood-change  or  nephritis,  while 
other  organs  than  the  kidneys  are  probably  so  involved.  In  one  case,  a  boy 
whom  I  examined  nearly  a  year  after  the  cerebro-spinal  fever,  the  kidneys 
were  still  affected.  He  had  anasarca  of  the  face  and  extremities,  with  albu- 
minuria. Chronic  Bright's  disease  had  occurred  from  the  acute  nephritis 
which  complicated  cerebro-spinal  fever.  Profound  stupor,  though  a  danger- 
ous symptom,  is  not  necessarily  fatal  so  long  as  the  patient  can  be  aroused  to 
partial  consciousness  and  the  pupils  are  responsive  to  light ;  so  long  as  it 
does  not  pass  into  actual  coma  it  is  less  dangerous  than  active  or  maniacal 
delirium,  which  is  likely  to  eventuate  in  this  coma. 

A  mild  commencement  with  general  mildness  of  symptoms,  as  the  ability 
to  comprehend  and  answer  questions,  moderate  pain  and  muscular  rigidity, 
some  appetite,  moderate  emaciation,  little  vomiting,  etc.,  justify  a  favorable 
prognosis,  but  even  in  such  cases  it  should  be  guarded  till  convalescence  is 
fully  established. 

We  may  repeat  and  emphasize  the  important  fact  shown  by  the  above 
statistics,  that  patients  who  live  till  the  close  of  the  second  week  without 
serious  complications  will  probably  recover.  The  danger  after  this  period 
is,  in  most  instances,  from  exhaustion  and  feeble  action  of  the  heart,  result- 
ing from  the  impaired  nutrition  and  the  protracted  course  of  the  disease. 

Complications  which  most  frequently  pertain  to  the  lungs  increase  greatly 
the  gravity  of  many  cases  and  contribute  to  the  fatal  ending.  The  fact  that 
Webber  in  his  prize  essay  describes  a  variety  of  cerebro-spinal  fever  which  he 
designates  pneumonic,  and  that  those  who  make  post-mortem  examinations 
find  that  "  oedema,  hypostatic  congestion  of  the  lungs,  bronchitis,  atelectasis, 
and  broncho-pneumonia  are  extremely  common  lesions  in  cerebro-spinal  men- 
ingitis "  (Welch),  indicate  a  source  of  danger  in  addition  to  that  located  in 
the  cerebro-spinal  system.  One  close  observer  of  an  epidemic  writes:  "In 
all  the  fatal  cases  which  came  under  my  notice  the  most  prominent  symptoms 
which  preceded  death  were  those  which  indicate  impairment  and  perversion 
of  the  respiratory  functions.  As  the  breathing  became  more  hurried  and 
difficult  the  general  depression  became  more  intense,  the  pulse  became  weaker 
and  quicker,  and  the  temperature  of  the  skin  more  elevated." 

Parenchymatous  degeneration  of  the  liver  and  kidneys  is  another  serious 
complication.  The  kidneys  are  probably  more  frequently,  and  to  a  greater 
extent,  diseased  than  the  liver.  We  have  already  .stated  that  nephritis  was 
present  in  1  of  the  8  cases  examined  by  Prof  Welch.  In  the  Revue  viedi- 
cale  for  June  3,  1882,  M.  Ernest  Gandier  published  the  case  of  a  female 
who  died  comatose  on  the  sixth  day  of  cerebro-spinal  fever.  Examination 
of  the  urine  had  revealed  the  presence  of  "  retractile  albumen  of  Prof. 
Bouchard,  attributable  to  renal  lesions,  and  non-retractile  albumen,  consid- 
ered as  an  indication  of  some  general  infection  of  the  system."  Microscopic 
examination  of  the  kidneys  "  showed  considerable  swelling  and  granular 
degeneration  of  the  renal  epithelial  cells,  with  effusion  of  granular  matter 
within  the  lumina  of  the  tubules."  We  have  seen  from  the  case  referred  to 
above  that  the  renal  complication  may  persist  and  become  chronic.  Those 
who  fully  recover  often  exhibit  symptoms,  usually  of  a  nervous  character,  as 
irritability  of  disposition,  headache,  etc.,  for  months  or  years  after  conva- 
lescence is  established. 

Diagnosis. — Cerebro-spinal  fever,  on  account  of  the  nature  and  severity 


448  CONSTITUTIONAL  DISEASES. 

of  its  symptoms  and  the  suddenness  of  its  onset,  may  be  mistaken  foi*  scarlet 
fever,  and  vice  versa.  In  one  instance,  to  my  knowledge,  this  mistake  was 
made.  High  febrile  movement,  vomiting,  convulsions,  and  stupor  are  common 
in  the  commencement  of  scarlet  fever,  and  the  same  symptoms  commonly  usher 
in  the  severer  forms  of  cerebro-spinal  fever.  It  will  aid  in  diagnosis  to  ascer- 
tain whether  there  be  redness  of  the  fauces,  for  this  is  present  in  the  commence- 
ment of  scarlet  fever,  and  a  few  hours  later  the  characteristic  efflorescence 
appears  on  the  skin. 

The  diagnosis  of  cerebro-spinal  fever  from  the  common  forms  of  menin- 
gitis is  ordinarily  not  difficult,  for  while  in  the  former  the  maximum  inten- 
sity of  symptoms  occurs  in  the  first  days,  in  the  latter  there  is  gradual  and 
progressive  increase  of  symptoms  from  a  comparatively  mild  commencement. 
Moreover,  cases  of  ordinary  or  sporadic  meningitis  occurring  at  the  age 
when  cerebro-spinal  fever  is  most  freqvient  are  commonly  secondary,  being 
due  to  tubercles,  caries  of  the  petrous  portion  of  the  temporal  bone,  or  other 
lesion,  and  are  therefore  preceded  and  accompanied  by  symptoms  which  are 
directly  referable  to  the  primary  disease.  We  have  seen  how  different  it  is 
in  cerebro-spinal  fever,  which  in  most  patients  begins  abruptly  in  a  state  of 
previous  good  health.  Again,  in  cerebro-spinal  fever  after  the  second  or 
third  day  hyperaesthesia,  retraction  of  the  head,  and  other  characteristic 
symptoms  occur,  which  are  either  not  present  or  are  much  less  pronounced 
in  ordinary  meningitis.  Some  of  the  milder  cases  of  cerebro-spinal  fever 
might  be  mistaken  for  hysteria,  but  the  pain  in  the  head  and  elsewhere,  the 
muscular  rigidity,  and  especially  the  occurrence  of  more  or  less  fever,  enable 
us  to  make  the  diagnosis.  Continued  fever,  typhus  or  typhoid,  resembles 
cerebro-spinal  fever  in  certain  particulars,  but  it  lacks  the  muscular  contrac- 
tion and  rigidity  which  characterize  the  latter.  It  does  not  usually  begin  so 
abruptly,  with  such  severe  symptoms,  especially  such  severe  headache,  has 
less  marked  fluctuations,  and  a  more  definite  duration.  These  facts  in  con- 
nection with  the  character  of  the  prevailing  epidemic  will  enable  us  to  make 
the  diagnosis.  In  one  instance  commencing  retro-pharyngeal  abscess,  prob- 
ably associated  with  vertebral  caries,  was  at  first  mistaken  by  me  for  cerebro- 
spinal fever.  The  patient  was  an  infant,  had  a  temperature  of  104°  F.,  stiff- 
ness of  the  neck,  with  some  retraction  of  the  head,  and  cried  from  pain 
when  the  head  was  brought  forward.  The  speedy  occurrence  of  two  large 
abscesses  in  other  parts  of  the  system,  difficult  deglutition,  and  noisy  respi- 
ration, led  to  a  digital  exploration  of  the  fauces,  when  the  abscess  was  found 
and  opened. 

Treatment. — Since,  in  epidemics  of  cerebro-spinal  fever  cases  are  more 
frequent  and  severe  where  antihygienic  conditions  exist,  it  is  evident  that 
measures  looking  to  the  removal  of  such  conditions,  measures  designed  to  pro- 
cure pure  air  in  the  domicile,  wholesome  diet,  and  a  quiet  and  regular  mode 
of  life — in  fine,  measures  designed  to  produce  the  highest  degree  of  health — 
are  of  the  first  importance  for  the  prevention  of  the  disease.  Cleanliness  of 
the  streets  and  areas,  as  well  as  of  the  apartments,  good  sewerage  and  drain- 
age, the  prompt  removal  of  all  refuse  matter,  avoidance  of  overcrowding — in 
a  word,  the  strict  observance  of  sanitary  requirements  in  every  particular — 
will,  there  can  be  little  doubt  from  what  we  know  of  the  causation  and  nature 
of  cerebro-spinal  fever,  diminish  the  number  and  severity  of  the  cases.  The 
avoidance  of  fatigue  and  overwork  and  of  mental  excitement,  the  use  of  plain 
and  wholesome  diet,  sufficient  sleep,  the  utmost  regularity  in  the  mode  of  life, 
with  the  least  possible  exposure  to  depressing  agencies,  are  the  important  pre- 
ventive measures  which  should  be  recommended  during  an  epidemic  of  cere- 
bro-spinal fever. 

The  enjoining  of  a  quiet  and  regular  mode  of  life  as  a  preventive  measure 


CEREBROSPINAL  FEVER.  449 

during  the  occurrence  of  an  epidemic  of  cerebro-spinal  fever  is  not  inconsist- 
ent with  the  theory  that  the  cause  is  a  micro-organism.  It  is  not  unreason- 
able to  suppose  that  the  system  may  be  more  or  less  under  the  influence  of 
the  specific  principle,  and  that  this  principle  may  obtain  lodgement  in  the  blood 
or  tissues  without  result  until  some  exciting  cause  occurs  which  depresses  the 
system  and  disturbs  the  functions,  when  the  resisting  power  fails  and  cerebro- 
spinal fever  appears  ;  just  as  those  exposed  to  Asiatic  cholera  may  remain  well 
until  some  imprudence  in  the  diet  or  the  mode  of  life  causes  an  outbreak  of 
the  malady. 

Curative  Treatment. — In  the  commencement  of  cerebro-spinal  fever  in- 
tense inflammatory  congestion  occurs  of  the  cerebral  and  spinal  meninges,  and 
also  to  a  certain  extent  of  the  brain  and  spinal  cord.  As  regards  treatment, 
the  obvious  indication  is  to  reduce  the  hyperaemia  of  the  vessels  as  quickly 
as  possible  and  subdue  or  diminish  the  inflammation.  For  this  purpose  bags 
or  bladders  of  ice  should  be  immediately  applied  over  the  head  and  to  the 
nucha,  and  constantly  retained  there  as  long  as  there  is  no  complaint  of  chil- 
liness, no  marked  diminution  of  temperature,  and  the  patient  experiences  some 
relief  from  the  intense  headache  and  other  symptoms.  Bran  mixed  with 
pounded  ice  produces  a  more  uniform  coldness  and  is  sometimes  more  agree- 
able to  the  patient  than  the  ice  alone.  The  bag  or  bags  should  be  about 
one-third  full,  so  as  to  fit  upon  the  head  like  a  cap,  and  the  nurse  should  be 
instructed  to  renew  the  ice  as  soon  as  it  melts.  In  severe  cases  with  marked 
elevation  of  temperature  it  is  proper  to  apply  cold  over  the  dorsal  and  lum- 
bar vertebrae,  as  well  as  upon  the  head  and  nucha.  A  hot  mustard  foot-bath 
or  a  general  warm  bath  in  those  cases  in  which  convulsions  are  present  or 
threatening,  or  in  which  there  is  delirium  or  great  agitation  or  severe 
peripheral  pains,  is  also  useful,  since  it  has  a  calmative  efi"ect  and  acts  as 
a  derivative  from  the  hyperaemic  nerve-centres.  One  writer  states  that  he 
obtained  marked  benefit  in  a  case  by  immersing  the  body  to  the  neck  in  hot 
water. 

The  abstraction  of  blood,  usually  by  leeches  applied  to  the  temples,  be- 
hind the  ears,  or  along  the  spine,  has  been  employed,  but  even  in  the  com- 
mencement of  the  present  century,  when  it  was  customary  to  bleed  generally 
and  locally  in  the  treatment  of  inflammatory  and  febrile  diseases,  a  majority 
of  the  American  physicians,  whose  writings  are  extant,  discountenanced  the 
abstraction  of  blood  in  the  treatment  of  this  disease.  Drs.  Strong,  Foot,  and 
Miner,  though  under  the  influence  of  the  Broussaisian  doctrine,  were  good 
observers,  and  they  soon  abandoned  the  use  of  the  lancet  and  leeches  in  the 
treatment  of  these  patients  for  more  sustaining  measures.  Strong^  states  that 
certain  physicians  employed  venesection  as  a  means  of  relieving  the  internal 
congestions,  but,  finding  that  the  pulse  became  more  frequent  after  a  mode- 
rate loss  of  blood,  they  soon  laid  aside  the  lancet.  Some  experienced  physi- 
cians of  that  period,  however,  continued  to  recommend  and  practise  deple- 
tion, general  as  well  as  local,  as  for  example.  Dr.  Gallop,  who  treated  many 
cases  in  Vermont  in  the  epidemic  of  1811. 

Venesection  in  the  treatment  of  cerebro-spinal  fever  is  universally  dis- 
carded at  the  present  time  in  this  country  and  Europe,  but  some  intelligent 
physicians,  as  Sanderson  and  Niemeyer,  approve  of  local  bleeding  in  certain 
cases.  It  is,  in  my  opinion,  after  examining  the  histories  of  many  cases,  uncer- 
tain whether  the  abstraction  of  blood  should  ever  be  recommended,  but  if  it 
be  prescribed  it  should  be  on  the  first  day,  when  the  hyperaemia  is  greatest, 
by  the  application  of  only  a  few  leeches  behind  the  ears,  and  never  except 
when  coma  or  convulsions  are  present  or  threatening  and  the  patient  is  robust. 
The  fact  should  not  be  forgotten  that  cerebro-spinal  fever  is  in  its  nature 
^  Medical  and  Physiological  Register,  1811. 
29 


450  CONSTITUTIONAL  DISEASES. 

asthenic  and  protracted,  and  that  the  intense  inflammatory  congestion  of  the 
nervous  centres  can  ordinarily  be  relieved,  if  relieved  at  all,  by  the  other 
measures  recommended,  which  do  not  reduce  the  strength.  The  alarming 
symptoms  which  usher  in  an  attack,  the  intense  headache,  restlessness,  delir- 
ium, sometimes  eclampsia  or  coma,  seem  to  demand  the  most  energetic  treat- 
ment, and  yet  it  is  surprising  to  one  who  has  his  first  experiences  with  this 
malady  how  patients  under  proper  treatment,  without  the  abstraction  of 
blood,  emerge  from  an  apparently  almost  hopeless  state  and  ultimately  recover. 
There  may  be  total  unconsciousness,  the  pupils  dilated  like  rings  and  insensible 
to  light,  the  head  intensely  hot,  tonic  convulsions  present  or  alternating  with 
frequent  clonic  convulsions,  and  yet  these  symptoms,  which  in  any  other 
disease  would  be  regarded  as  sufficient  to  justify  the  prognosis  of  certain 
death,  may  gradually  pass  off  toward  the  close  of  the  first  or  in  the  second 
week,  and  the  case  afterward  progress  favorably.  In  the  New  York  epidemic 
of  1872 — previous  to  which  physicians  of  this  city  had  no  personal  expe- 
rience with  cerebro-spinal  fever — many  cases  were  pronounced  hopeless  which 
ultimately  did  well  without  abstraction  of  blood.  In  a  case  occurring  in  the 
practice  of  Dr.  Griswold  the  patient  was  comatose  for  three  days,  with  pupils 
not  responding  or  but  very  feebly  responding  to  light,  but  he  recovered  with- 
out the  abstraction  of  blood  and  with  the  remedies  ordinarily  employed.  In 
a  case  which  we  will  presently  relate  in  speaking  of  another  local  treatment 
the  patient  was  still  unconscious  in  the  third  week,  with  pupils  greatly  dilated 
and  insensible  to  light,  and  yet  recovered  without  losing  blood.  Such  cases 
show  that  the  most  urgent  symptoms,  such  as  seem  to  indicate  the  prompt 
employment  of  leeches  in  order  to  reduce  the  meningeal  hyperaemia  and  the 
consecutive  congestion  of  the  nerve-centres,  may  be  relieved  and  the  patient 
recover  without  such  depletion,  and  with  the  preservation  of  the  blood,  which 
is  so  much  needed  in  the  subsequent  asthenic  course  of  the  malady. 

In  only  one  case  have  I  recommended  the  abstraction  of  blood,  and  this 
was  so  instructive  that  I  will  briefly  relate  it :  A  girl  four  years  of  age  was 
seized  on  March  7,  1873,  with  vomiting,  chilliness,  and  trembling,  followed 
by  severe  general  clonic  convulsions  lasting  about  fifteen  minutes  ;  was  semi- 
comatose ;  pulse  132,  and  a  few  hours  later  156;  temperature  101i°  F. ; 
respiration  44 ;  eyes  closed,  pupils  moderately  dilated  and  feebly  responsive 
to  light ;  dusky  mottling  of  skin,  constant  tremulousness  with  twitching  of 
limbs.  Bromide  of  potassium  was  administered  in  hourly  doses  of  four  grains, 
ice  applied  to  the  head  and  nucha,  and  a  hot  mustard  foot-bath  followed  by 
sinapisms  to  the  nucha.  On  the  following  day,  March  8th,  she  was  partly 
conscious  when  aroused,  but  immediately  relapsed  into  sleep  ;  head  retracted  ; 
bowels  constipated  ;  pulse  136  ;  temperature  102°  ;  vomited  occasionally.  It 
was  thought  proper,  on  account  of  the  extreme  stupor,  to  apply  one  leech  to 
each  temple,  and  the  bites  trickled  slowly  nearly  five  hours.  The  other  treat- 
ment was  continued.  On  the  9th  the  pulse  was  180 — so  feeble  that  it  was 
counted  with  difficulty  ;  temperature  101  J°.  The  patient  was  evidently  sink- 
ing. It  was  necessary  to  order  whiskey  in  teaspoonful  doses  every  two  hours, 
with  beef  tea  and  other  most  nutritious  drinks.  Evening,  pulse  172,  still 
feeble.  March  10th,  pulse  180,  barely  perceptible;  great  hyperaesthesia ; 
axillary  temperature  100°  ;  axis  of  eyes  directed  downward.  After  this  the 
patient  gradually  rallied  for  a  time,  the  pulse  becoming  stronger  and  less 
frequent,  but  death  finally  occurred  after  nine  weeks  in  a  state  of  extreme 
emaciation  and  exhaustion,     Slight  convulsions  occurred  in  the  last  hours. 

It  is  seen  that  in  the  above  case,  which  may  be  regarded  as  typical,  the 
patient  passed  into  a  state  of  extreme  prostration  after  the  application  of  the 
leeches,  so  that  for  three  days  I  did  not  believe  that  she  would  live  from 
hour  to  hour,  and  death  occurred  after  an  illness  of  nine  weeks,  apparently 


CEREBROSPINAL   FEVER.  451 

from  sheer  exhaustion.  Experience  like  this,  which  corresponds  with  that 
of  most  other  observers,  shows  the  necessity  of  preserving  the  blood,  and 
thereby  the  strength,  however  urgent  the  initial  symptoms,  inasmuch  as 
cerebro-spinal  fever  in  its  subsequent  course  is  attended  by  such  marked 
asthenia.  On  May  3,  1878,  a  boy  of  ten  years  was  admitted  into  one  of  the 
New  York  hospitals  in  the  service  of  a  prominent  physician.  It  was  stated 
that  he  had  been  four  days  sick  with  cerebro-spinal  fever,  and  among  other 
characteristic  symptoms  he  had  had  delirium  every  night,  and  on  May  2d 
delirium  in  the  day-time,  which  had  abated  considerably  after  free  epistaxis. 
In  the  hospital  the  application  of  ten  leeches  along  the  spine  was  ordered, 
but  it  does  not  appear  to  have  diminished  the  delirium  or  any  other  symp- 
tom, and  the  following  day  the  pulse  was  so  frequent  and  feeble  that  active 
stimulation  by  brandy  was  resorted  to.  He  had  three  strong  convulsions  on 
May  13th,  which  were  relieved  by  ice  to  the  head  and  nape  of  neck  and  by 
six  minims  of  Magendie's  solution.  Severe  pains  occurred  at  times  in  the 
back  and  limbs,  and  on  the  29th,  one  month  after  the  commencement  of  the 
disease,  the  same  pain  frequently  recurring,  twelve  leeches  were  ordered  to 
be  applied  to  the  spine.  On  June  2d  the  limbs  were  flexed  and  quite  stiff, 
and  the  effort  to  move  them  was  attended  by  great  pain.  The  pain  in  the 
back  was  also  more  constant,  and  in  consequence  sixteen  leeches  were  applied 
to  the  spine.  The  next  day  there  was  no  pain,  but  the  patient  was  very 
stupid.  On  June  6th  the  records  state  that  he  was  obviously  losing  strengh 
day  by  day— that  his  emaciation  was  extreme  and  his  anaemia  very  marked. 
But  he  had  very  great  vitality,  and,  although  he  had  strabismus,  bed-sores, 
incontinence  of  urine  and  feces,  and  extreme  prostration,  he  lingered  till 
August  1st.  At  the  autopsy  :  "  Body  a  skeleton  ;  brain,  dura  mater,  and  pia 
mater  appear  normal,  except  a  little  thickening  of  latter  at  base  of  brain ; 
ventricles  much  enlarged  and  full  of  clear  serum  ;  surface  of  walls  of  ven- 
tricles looks  normal,  but  is  soft ;  spinal  cord  and  membranes  appear  normal 
to  the  naked  eye."  No  disease  was  discovered  in  other  organs,  except  that 
the  liver  appeared  congested  and  the  kidneys  pale.  It  can  scarcely  be  doubted 
that  although  some  temporary  relief  from  the  pain  may  have  resulted  to  this 
patient  by  the  repeated  application  of  leeches,  which  diminished  the  menin- 
geal hyperaemia,  yet  his  chances  for  ultimate  recovery  would  have  been  far 
better  without  such  depletion.  Therefore  the  histories  of  cases  show  that 
the  result  of  abstraction  of  blood  has  been  unsatisfactory,  on  account  of  the 
asthenic  nature  and  protracted  course  of  cerebro-spinal  fever,  and  it  should 
never  be  recommended  as  a  remedial  agent. 

Some  benefit  is  apparently  derived  from  the  application  of  stimulating 
and  moderately  irritating  lotions  along  the  spine.  A  liniment  consisting  of 
equal  parts  of  camphorated  oil  and  turpentine  briskly  applied  by  friction 
with  flannel  up  and  down  the  spine  till  redness  is  produced,  appears  to  cause 
some  alleviation  of  the  suffering,  and  it  does  not  conflict  with  the  use  of  the 
ice-bag.  Dr.  William  H.  Sutton  of  Dallas,  Texas,  has  published  the  follow- 
ing interesting  case,  showing  the  benefit  from  stimulating  and  irritant  appli- 
cations over  the  spine  made  in  an  unusual  manner :  A  child  aged  three  and  a 
half  years  had  been  three  weeks  under  treatment,  through  error  of  diagnosis, 
for  supposed  continued  fever.  When  Dr.  Sutton  assumed  charge  of  the 
case,  November  20,  1877,  the  pupils  were  greatly  dilated  and  insensible  to 
light ;  features  pallid  and  pinched  ;  pulse  130  ;  temperature  103°  F. ;  patient 
totally  unconscious.  November  21st,  morning  temperature  105°,  pulse  140  ; 
evening  temperature  101  i°,  pulse  120.  November  22d,  morning  temperature 
IO65,  pulse  160;  restless;  evening  temperature  105^°,  pulse  120;  had  not 
slept,  except  for  moments,  for  nearly  two  weeks.  A  strip  of  flannel  saturated 
with  turpentine  was  placed  over  the  spine  from  the  neck  to  the  sacrum,  and 


452  CONSTITUTIONAL  DISEASES. 

a  hot  smoothing-iron  was  run  up  and  down  it,  and  eight  drops  of  the  fluid 
extract  of  ergot  were  given  every  three  hours.  Dr.  Sutton  adds :  '■  The 
father  stated  to  me  that  as  soon  as  the  application  was  finished  the  child  fell 
asleep,  and  slept  several  hours — the  first  for  two  weeks — and  the  fever  rapidly 
declined.  From  this  time  he  began  to  improve,  and  gradually  and  fully  recov- 
ered." The  use  of  irritants  and  derivatives  over  the  spine  in  the  treatment 
of  cerebro-spinal  fever  has  been  long  and  favorably  known,  but  the  mode 
of  producing  irritation  in  the  above  case  was  novel. 

Internal  Treatment. — It  will  aid  in  the  selection  of  the  proper  remedies  to 
recall  to  mind  the  pathological  state  which  we  know  to  be  present  from  the 
many  autopsies  which  have  been  recorded.  AVe  have  seen  that  the  largest 
mortality,  and  consequently  the  most  dangerous  period,  is  in  the  first  days, 
when  there  is  intense,  suddenly-developed  inflammatory  congestion  of  the 
meninges,  with  more  or  less  secondary  hyperaemia  of  the  underlying  brain 
and  spinal  cord,  producing  great  headache,  delirium,  or  somnolence,  with 
exaggerated  reflex  instability  of  the  spinal  cord,  so  that  eclampsia  is  a  com- 
mon and  fatal  complication. 

Fortunately,  a  remedy  has  been  discovered  in  modern  times  (the  bromide 
of  potassium)  which  acts  promptly  and  efficiently.  It  can  be  safely  admin- 
istered in  large  and  frequent  doses  to  the  youngest  child.  It  is  quickly  elim- 
inated from  the  system  through  the  kidneys  and  other  emunctories  in  chil- 
dren, so  as  to  prevent  the  occurrence  of  bromism,  at  least  to  the  extent  of 
causing  any  unpleasant  consequences.  It  causes  contraction  of  the  minute 
vessels  of  the  nervous  centres  so  as  to  diminish  the  hyperaemia,  as  shown  by 
the  experiments  and  observations  of  Dr.  Putnam-Jacobi  and  others,  and  at 
the  same  time  it  diminishes,  in  a  marked  degree  the  reflex  irritability  of  the 
spinal  cord — two  most  beneficial  and  important  efi'ects  of  its  use  in  this  dis- 
ease. Many  children  by  its  timely  employment  are  saved  from  the  dangers 
of  eclampsia,  and  by  its  sedative  eff'ect  on  the  nervous  system  and  contractile 
action  on  the  capillaries  it  probably  diminishes  the  intensity  of  the  inflam- 
mation and  the  amount  of  exudation.  I  usually  prescribe  it,  as  recommended 
by  Dr.  Squibb,  dissolved  in  simple  cold  water.  In  ordinary  cases,  not  attended 
by  eclampsia  or  marked  symptoms  which  show  that  eclampsia  is  threatening, 
I  generally  prescribe  at  my  first  visit  about  four  grains  every  two  hours  to  a 
child  of  two  years  who  has  the  usual  restlessness  and  apparent  headache, 
and  six  grains  to  a  child  of  five  years.  If  eclampsia  occur,  the  bromide 
should  be  given  more  frequently,  as  every  five  or  ten  minutes,  till  it  ceases. 
It  is  important  to  be  able  to  determine  when  the  quantity  of  the  bromide 
administered  should  be  diminished  and  when  its  use  should  be  discontinued. 
I  have  very  rarely  observed  bromism  in  children,  and  never  to  the  extent  of 
doing  any  serious  harm,  though  for  many  years  I  have  administered  it  in 
large  and  frequent  doses  whenever  the  occasion  seemed  to  require  it ;  but 
the  symptoms  of  bromism  cannot  readily  be  discriminated  from  those  which 
may  result  from  cerebro-spinal  fever,  such  as  muscular  weakness,  dilated 
pupils,  with  perhaps  impaired  vision,  unsteady  gait,  nausea  or  vomiting,  and 
abdominal  pains.  If  the  case  progress  favorably,  frequent  and  large  doses 
should,  in  my  opinion,  be  given  only  in  the  first  week,  after  which  this  agent 
should  be  given  at  longer  intervals  or  in  smaller  doses.  But  during  exacer- 
bations, which  are  liable  to  occur  from  time  to  time  till  the  patient  is  well  on 
the  way  to  recovery,  the  use  of  the  bromide  in  full  doses  is  again  indicated 
till  the  urgent  symptoms  begin  to  abate. 

Phenacetin  is  one  of  the  most  important,  perhaps  the  most  important,  of 
the  remedies  for  the  early  stages  of  the  disease.  I  know  no  remedy  which 
controls  the  headache  and  the  fever  more  efiectually  than  this,  and  without 
any  detriment.     Yet  I  prescribe  it  very  sparingly,  or  not  at  all,  after  the  first 


CEBEBRO-SPINAL  FEVER.  453 

week  or  ten  days,  through  fear  of  its  depressing  eflfect.  I  always  prescribe 
it  with  caiFeine,  which  being  a  cerebral  excitant,  counteracts  the  depressing 
effects  of  the  phenacetine.  The  following  is  the  formula  which  I  employ 
for  the  adult : 

R.   01.  cinuamomi,  gtt.  x  ; 

Phenacetinse,  Qiv  (gr.  80)  ; 

Sodii  bromidi,  ^iij  ; 

CafFeinse  alkaloid,  gr.  xx  ; 

Sacch.  lactis,  3J. — Misce. 

Divid.  in  chart  No.  x.  Give  to  an  adult  one  powder  every  four  to  six  hours 
according  to  the  headache  and  fever.  To  a  child  of  twelve  years,  half  a  pow- 
der ;  to  a  child  of  eight  years,  one-third  of  a  powder. 

Recently  the  pharmacists  of  New  York  City  have  in  stock  a  coated  pill  con- 
taining 3  grains  of  phenacetine  and  IJ  grains  of  citrate  of  caiFeine.  A  half 
of  one  of  these  pills  can  be  given  to  a  child  of  twelve  years,  and  one-fourth 
of  one  to  a  child  of  six  years. 

Ergot  is  another  remedy,  but  I  am  not  aware  that  I  have  observed  any 
benefit  from  its  use  in  this  disease.  Its  effect  is,  I  think,  mostly  on  the  lower 
part  of  the  spinal  system.  If  employed  it  should  be  given  during  the  first 
and  second  weeks,  when  the  congestion  of  the  nervous  centres  is  greatest. 
At  a  more  advanced  stage,  when  there  is  less  congestion  and  the  danger 
arises  from  the  inflammatory  products  and  structural  changes,  the  time  for 
the  use  of  ergot  is  past,  or  if  it  is  still  of  some  service  it  is  less  needed  than 
at  first  and  should  be  given  less  frequently. 

The  severe  headache  and  restlessness  which  attend  many  cases  require 
the  occasional  use  of  an  opiate  or  the  hydrate  of  chloral.  Chloral  in  proper 
dose  never  fails  to  give  quiet  sleep,  and  it  is  supposed  by  some  who  have 
'studied  its  therapeutic  action  that  it  diminishes  the  cerebral  circulation.  It 
is  therefore  a  useful  adjuvant  to  the  bromide.  Five  grains  usually  suffice 
for  a  child  of  six  to  eight  years.  Chloral  is  especially  useful  in  cases 
attended  by  eclampsia  or  by  symptoms  which  threaten  eclampsia,  since  it  acts 
promptly  and  decidedly  in  diminishing  reflex  irritability.  Formerly  it  was 
considered  injudicious  and  unsafe  to  prescribe  opiates  in  meningeal  inflamma- 
tion, since  it  was  supposed  that  they  increased  the  liability  to  coma,  but 
experience  shows  that  they  are  sometimes  very  useful  in  this  disease  when 
administered  in  small  or  moderate  doses,  and  without  the  risk  which  was  once 
supposed  to  be  incurred  by  their  use.  The  thirty-second  part  of  a  grain  of 
morphia  administered  at  intervals  of  some  hours  was  sufficient  to  relieve  the 
suffering  of  one  of  my  patients  at  the  age  of  six  years. 

Quinia  apparently  does  not  exert  any  marked  controlling  effect  on  the 
course  of  cerebro-spinal  fever  or  its  symptoms,  although  the  paroxysmal  cha- 
racter of  the  severe  pains  in  many  patients  suggests  the  use  of  this  agent  as 
an  antiperiodic.  It  was  frequently  prescribed  by  New  York  physicians  in 
the  epidemic  of  1872,  but  I  believe  that  the  opinion  was  unanimous  that  it 
was  not  the  proper  remedy.  I  have  prescribed  it  in  large  and  small  doses,  in 
one  instance  giving  fifteen  grains  to  a  child  of  thirteen  years,  but  do  not  know 
that  I  have  observed  any  benefit  from  its  use  in  this  malady.  It  may  increase 
the  hyperjemia  of  the  meninges  and  the  cerebro-spinal  axis. 

When  the  acute  stage  has  abated  measures  designed  to  remove  the  serum 
which  sometimes  remains,  constituting  a  hydrocephalus,  are  indicated.  For 
this  purpose  the  iodide  of  potassium  is  probably  more  useful  than  any  other 
agent.  It  is  administered  by  some  physicians  early  along  with  the  bromide, 
in  the  same  manner  in  which  they  have  been  in  the  habit  of  treating  other 
forms  of  meningitis.  I  have  prescribed  it  with  the  bromide  and  alone  when 
the  bromide  was  discontinued,  but  whether  it  produces  any  marked  sorbefa- 


454  CONSTITUTIONAL  DISEASES. 

cient  eiFeet  in  this  disease  apart  from  the  removal  of  serum  seems  to  me 
doubtful. 

The  result  depends  to  a  great  extent  on  the  nursing.  The  skill  of  the 
physician  may  be  thwarted  and  the  life  of  the  patient  lost  by  inefficient 
nursing.  No  other  disease  more  urgently  requires  kind,  intelligent,  and  con- 
stant attendance  night  and  day  on  the  part  of  the  nurse.  Not  only  should 
the  medicines  and  nutriment  be  given  punctually  and  regularly,  but  the 
great  restlessness  of  the  patient  in  the  first  days  requires  constant  readjusting 
of  the  ice-bags,  and  during  the  long  period  of  convalescence  the  utmost  care 
is  required  to  remove  at  once  the  excretions  in  order  to  prevent  bed-sores, 
and  to  give  the  proper  amount  and  kind  of  nutriment  to  prevent  the  emacia- 
tion and  weakness  from  which  many  perish. 

The  diet,  from  the  beginning  to  the  end  of  the  malady,  should  be  the 
most  nutritious  and  such  as  is  easily  digested.  It  is  necessary  to  give  it  in 
the  liquid  form,  imless  in  mild  cases  in  which  the  appetite  may  not  be  entirely 
lost.  It  is  proper  to  aid  the  digestion  by  pepsin  preparations.  Nutritive 
enemata,  consisting  of  beef  tea  or  one  of  the  extracts  of  beef,  milk,  and 
brandy,  aid  in  averting  the  fatal  prostration  in  protracted  cases.  After  the 
acute  stage  has  passed  and  the  meningeal  hyperaemia  has  abated  the  alcoholic 
compounds  in  moderate  doses,  which  in  the  beginning  might  be  injurious, 
may  now  be  useful,  administered  regularly  by  the  mouth.  The  room  should 
be  dark,  well  ventilated,  and  quiet.  All  sympathizing  friends  who  are  not 
required  in  the  nursing  should  be  excluded.  I  know  of  no  other  disease  in 
which  this  is  so  necessary,  for  mental  excitement  may  produce  dangerous 
aggravation  of  symptoms. 

We  will  close  our  remarks  on  this  interesting  disease  by  the  report  of  a 
case  from  the  pen  of  Dr.  Augustus  Caille,  professor  of  the  Post-Graduate 
Hospital,  and  one  of  the  best  clinical  observers  of  New  York: 

"  C.  v.,  a  girl  of  German  parentage,  four  years  of  age,  was  admitted  to 
the  Babies'  wards  January  29,  1894.  She  had  become  acutely  ill  four 
days  previously,  complaining  of  pain  in  the  head,  which  was  followed  by 
vomiting  and  restlessness.  When  admitted  to  the  hospital  she  was  in  a 
greatly  emaciated  state,  with  the  head  retracted.  A  diagnosis  of  cerebro- 
spinal meningitis  was  at  once  made,  and  the  administration  of  mercury, 
quinia,  and  salicylate  of  sodium  was  contemplated  in  the  order  named,  with 
the  hope  of  counteracting  with  a  few  "  specific  "  drugs  the  infection,  the 
nature  of  which  is  still  unknown.  Calomel  was  given  in  one-quarter  grain 
doses  every  three  hours  for  two  days.  On  the  third  and  fourth  days  several 
five-grain  doses  of  sulphate  of  quinine  were  administered  in  compound  elixir 
of  taraxacum  and  subsequently  sodium  salicylate,  five  grains  four  times  a 
day  in  a  watery  solution,  was  given  by  mouth.  An  ice-cap  was  placed  to 
the  head,  and  a  liquid  diet  was  ordered.  Constipation,  a  prominent  symp- 
tom throughout  the  case,  was  overcome  by  means  of  compound  licorice 
powder.  The  temperature  was,  as  usual,  very  irregular,  ranging  from  101° 
to  105°  F. 

"  On  February  8th  the  salicylate  was  discontinued  and  five  grains  of 
phenacetine  were  given  night  and  morning,  and  a  pepsin  and  hydrochloric- 
acid  mixture  was  given  several  times  during  the  day  to  aid  digestion.  From 
February  14th  to  18th  no  medicine  was  given  on  account  of  vomiting.  The 
child  about  this  time  remained  for  hours  in  complete  opisthotonos.  Hyper- 
sesthesia  was  a  prominent  feature  throughout  the  case,  and  contractures  of 
different  groups  of  muscles  were  noticed,  usually  with  an  elevation  of  tem- 
perature, but  no  eclamptic  attacks.  Oscillations  of  the  pupils  were  noticed. 
The  urine  was  free  from  abnormal  constituents. 

"  About  February  20th  a  slight  purulent  discharge   from   the   ear  was 


ACUTE  RHEUMATISM.  455 

observed,  and  a  few  days  later  divergent  squint.  In  the  later  stage  of  the 
disease  warm  baths  were  given  daily,  and  bromide  of  potassium  internally, 
together  with  a  nutritious  and  easily  digested  diet.  On  March  10th  the 
child  was  out  of  bed  and  able  to  move  about,  and  in  a  few  days  it  will  be 
sent  to  its  parents,  presenting  no  evidence  of  the  recent  severe  illness 
through  which  it  has  passed." 


CHAPTER  V. 

ACUTE  RHEUMATISM. 

Rheumatism  is  a  constitutional  disease  with  a  local  manifestation — to 
wit,  inflammation  of  the  fibrous  tissues,  chiefly  in  and  around  the  articula- 
tions, but  occasionally  in  other  parts,  as  the  heart  and  nervous  centres.  It 
was  formerl}^  supposed  to  be  rare  in  children,  but  more  accurate  observations 
show  that  it  is  scarcely  less  common  during  childhood  than  in  adult  life.  In 
young  patients,  especially  under  the  age  of  six  or  eight  years,  it  is  frequently 
overlooked,  for  the  articular  inflammations  in  such  patients  are  commonly 
slight.  In  the  last  twenty-five  years,  during  my  connection  with  the  chil- 
dren's class  in  the  Bureau  for  the  Relief  of  the  Out-door  Poor,  I  have  exam- 
ined many  children  with  rheumatism  or  the  cardiac  lesions  resulting  from 
rheumatism,  and  ordinaril}"  I  have  found  that  few  joints  had  been  affected, 
and  that  there  had  been  but  little  swelling  of  them  or  redness,  and  that  the 
patients  were  usually  not  confined  to  bed,  or  even  to  the  sitting  posture,  but 
had  been  able  to  walk  about,  though  with  restraint  and  complaint  of  pain  or 
soreness.  The  parents  in  many  instances  supposed  that  their  children  were 
suffering  from  '-growing  pains,"  as  they  designated  them.  At  the  same 
time,  with  this  mildness  of  symptoms  the  heart  was  becoming  seriously  and 
permanently  crippled  by  endocarditis.  Those  who  have  attended  my  clinics 
will  recollect  that  on  some  days  as  many  as  three  or  four  children  with 
cardiac  lesions  have  been  present  whose  histories  show  an  overlooked  rheu- 
matism of  this  mild  type.  Cases  like  the  following  are  very  common  among 
the  city  poor : 

In  January,  1871,  a  little  girl  three  years  old  was  presented,  having  dis- 
tinct aortic  direct  and  mitral  regurgitant  murmurs.  The  mother  was  not 
aware  that  she  had  had  rheumatism,  but  at  the  age  of  twenty  months  she 
had  for  several  days  pretty  active  febrile  symptoms,  which  the  physician 
attributed  to  some  other  ailment.  In  April,  1871,  another  girl,  of  the  same  age, 
was  brought  to  the  clinic,  having  a  distinct  mitral  regurgitant  murmur.  The 
mother  stated  that  she  had  been  well  till  a  month  previously,  when  she  was 
confined  to  her  bed  for  a  few  days,  having  a  high  fever.  She  was  attended  by 
a  homoeopathic  physician,  and  the  exact  character  of  her  sickness  the  mother 
was  not  able  to  state.  Further  medical  advice  was  sought,  as  the  child 
remained  delicate,  though  her  health  was  better  than  at  first.  There  can  be 
little  doubt  that  the  obscure  fever  in  this  case  was  rheumatic.  In  another 
child  treated  elsewhere,  not  old  enough  to  relate  the  subjective  symptoms, 
there  was,  in  addition  to  an  intense  fever,  evident  pain  in  one  foot  or  leg 
when  the  limb  was  moved.  Still,  the  nature  of  the  disease  was  not  diagnos- 
ticated till  some  time  after  recovery,  when  a  valvular  murmur  was  acci- 
dentally discovered.  Such  histories,  which  are  not  rare,  show  that  rheu- 
matism often  occurs  in  young  children,  even  infants,  and  they  inculcate  the 


456  CONSTITUTIONAL  DISEASES. 

important  practical  lesson  that  the  disease  at  this  age  may  be  so  obscure  or 
latent  as  to  be  overlooked  even  by  good  diagnosticians. 

Some  observers,  meeting  cases  of  valvular  disease  in  children  without  the 
history  of  rheumatism,  have  concluded  that  rheumatism  is  not  the  chief  cause 
of  endocarditis  at  this  age  ;  ^  but  the  explanation  which  I  have  given  seems 
to  me  more  in  consonance  with  the  facts.  Scarlet  fever  not  infrequently 
causes  endocarditis,  but  this  exanthem  seldom  occurs  without  detection,  and 
it  has  been  as  often  absent  as  has  rheumatism  from  the  histories  as  given  by 
the  parents  of  young  children  with  valvular  disease  whom  I  have  examined. 
Moreover,  the  endocarditis  of  scarlet  fever  is  in  many  cases  associated  with, 
if  it  do  not  result  from,  scarlatinous  rheumatism. 

Kheumatism  in  children  is  primary  or  secondary.  The  secondary  form 
occurs  chiefly  in  the  declining  stage  of  scarlet  fever  and  variola.  It  is  stated 
also  to  occur  occasionally  in  new-born  infants  during  epidemics  of  puerperal 
fever,  but  I  have  not  observed  such  cases. 

Causes. — An  inherited  rheumatic  diathesis  is  universally  recognized  as 
an  important  predisposing  cause  of  this  disease,  so  that  it  frequently  occurs 
in  difi"erent  members  of  the  same  family.  When  the  family  history  shows  a 
strong  predisposition  to  rheumatism,  it  occurs  in  the  child  from  a  slight 
exciting  cause ;  if  no  such  predisposition  exist,  it  only  occurs  through 
unusual  circumstances  of  exposure.  Investigations  have  been  made  in  order 
to  determine  whether  acute  rheumatism  is  a  microbic  disease.  Dr.  Alfred 
Mantle  of  England  made  cu.ltures  from  the  serum  of  V  and  from  the  blood 
of  16  patients  with  acute  rheumatism.  He  states  that  he  made  use  of  every 
precaution  to  prevent  contamination  by  germs  from  without.  The  organisms 
obtained  by  Mantle  in  the  cultures  were  a  micrococcus  and  a  small  bacillus. 
He  states  that  these  organisms  produced  lactic-acid  fermentation  in  sterilized 
milk.  He  believes  that  the  microbes  do  not  produce  the  symptoms  of  rheu- 
matism by  their  direct  action,  but  by  the  ptomaines  to  which  they  give  rise, 
and  he  raises  the  question  whether  lactic  acid  is  not  the  chief  ptomaine 
(Brit.  Med.  Jonr.,  1887).  Popow  states  that  the  micrococci  obtained  by  cul- 
tivation from  the  blood  of  rheumatic  patients  inoculated  in  rabbits  caused 
in  these  animals  the  characteristic  symptoms  of  rheumatism,  and  in  their  blood 
and  synovial  fluid  he  found  the  same  cocci  (  Wiener  med.  Presse,  Jan.  29, 1888). 
Cornil  and  Babes  have  also  related  a  fatal  case  of  rheumatism  in  which  mi- 
crococci and  bacilli  were  found  in  the  right  knee.  Wilson  found  bacilli  in  the 
pericardium  in  two  cases  of  rheumatic  pericarditis.  Petrone  examined  the 
serum  taken  from  the  knee-joint  in  three  cases  of  acute  rheumatism,  and 
in  all  the  specimens  examined  discovered  microbes  similar  to  those  detected 
by  Klebs  in  rheumatic  endocarditis.  Jaccoud  relates  the  histories  of  two 
newly-born  infants  whose  mothers  at  the  time  of  their  birth  had  acute  rheu- 
matism. One  of  them  twelve  hours  after  birth,  and  the  other  three  days 
after  birth,  '•  were  attacked  with  fever,  rapid  pulse,  and  well-marked  rheu- 
matic swelling  of  several  articulations."  Under  treatment  one  recovered 
in  eight  days  and  the  other  in  a  little  more  than  two  weeks.  The  above 
observations  lend  support  to  the  theory  that  acute  rheumatism  is  a  micro- 
bic disease,  and  perhaps  observations  indicate  that  it  is  to  a  certain  extent 
infectious. 

Children  who  have  had  one  attack  are  especially  liable  to  another,  and 
when  the  diathesis  is  acquired  slight  exposures  appear  to  be  sufi&cient  to  cause 
the  disease.  It  has  heretofore  been  the  common  belief  in  the  profeswsion — and 
this  opinion  is  also  held  by  the  laity — that  exposure  to  cold  is  the  usual  excit- 
ing cause  of  rheumatism  ;  but  if  the  disease  have  a  microbic  origin,  it  is  a 
question  whether  or  to  what  extent  this  theory  is  true.  It  is  stated  in  support 
^  Dr.  A.  StefFen,  Jahrhuehjur  Kinderh.,  1870. 


ACUTE  RHEUMATISM.  457 

of  it  that  rheumatism  is  most  common  in  cold  and  changeable  weather  and  in 
those  who  are  most  exposed  to  vicissitudes  of  temperature. 

Scarlatinous  rheumatism  has  been  alluded  to  above.  Frequently  daring 
the  course  of  scarlet  fever  inflammation  of  certain  joints  occurs  which  can- 
not be  distinguished  from  that  in  the  ordinary  form  of  rheumatism,  and  in 
some  of  these  instances  endocarditis  or  pericarditis  also  occurs.  Dr.  Ashby 
is  inclined  to  believe  that  scarlatinous  rheumatism  is  produced  by  septic 
poisoning,  but  it  sometimes  occurs  at  such  an  early  stage  or  in  cases  of  such 
mildness  that  the  conditions  giving  rise  to  ordinary  sepsis  do  not  seem  to  be 
present.  It  is  therefore  probable,  in  my  opinion,  that  in  some  instances  at  least 
this  articular  affection  occurring  in  scarlet  fever  is  due  to  the  direct  action  of 
the  scarlatinous  microbe  or  to  a  ptomaine  or  ptomaines  produced  by  this 
microbe. 

Symptoms. — The  commencement  of  acute  idiopathic  rheumatism  is  in 
most  cases  sudden  ;  occasionally  fever  and  a  degree  of  soreness  or  stiffness 
precede  the  articular  affection  for  a  few  hours  or  days.  The  inflammation, 
slight  at  first,  increases  gradually,  attaining  its  maximum  intensity  within  one 
or  two  days.  The  joint  is  painful,  red,  hot,  and  swollen.  The  swelling  is  due 
to  inflammatory  oedema  of  the  tissues  surrounding  the  joint  and  effusion  within 
the  joint.  As  in  all  inflammations,  the  vascularity  of  the  parts  involved  is 
increased,  the  synovial  membrane  loses,  more  or  less,  its  lustre,  and  the  effused 
fluid,  which  is  mainly  serum,  has  been  found,  in  most  of  the  cases  in  which 
an  opportunity  was  presented  for  examining  it,  to  contain  a  few  leucocytes. 
Rarely  fibrin  is  exuded,  producing  a  rubbing  sensation  when  the  joint  is  moved, 
and  perhaps  impairing  the  mobility  of  the  articular  surfaces.  Fortunately, 
however,  in  a  large  majority  of  cases  the  substance  exuded  both  without  and 
within  the  joint  is  mainly  serum,  and  hence  the  rapid  subsidence  of  the  swell- 
ing when  the  inflammation  ceases.  The  pain  is  commonly  not  severe  when 
the  child  is  quiet,  but  it  is  greatly  increased  if  the  joint  be  pressed  or  the 
limb  moved. 

The  joints  of  the  extremities  are  most  frequently  the  seat  of  rheumatic 
inflammation,  but  occasionally  those  of  the  trunk,  as  the  intervertebral,  the 
symphysis  pubis,  etc.,  are  involved.  As  the  inflammation  abates  in  the  artic- 
ulations first  affected  it  reappears  in  others,  unless  the  materies  morbi  have 
been  eliminated  from  the  system.  It  is  seldom  that  more  than  two  or  three 
of  the  joints  are  in  a  state  of  active  inflammation  at  the  same  time. 

The  temperature  in  acute  rheumatism  is  elevated  two  or  three  degrees 
above  that  of  health,  and  the  pulse  varies  from  120  to  140,  its  frequency  de- 
pending on  the  age  of  the  patient  as  well  as  the  gravity  of  the  disease.  Per- 
spiration is  a  common  symptom.  The  appetite  is  impaired,  the  tongue  slightly 
coated,  and  the  bowels  constipated.  The  watery  element  of  the  urine  is 
diminished,  as  in  most  febrile  diseases,  and  there  is  not  a  corresponding  reduc- 
tion in  the  solid  elements,  so  that  the  urine  is  rendered  more  dense  and  its 
specific  gravity  is  high.  The  amount  of  urea  and  coloring  matter  excreted 
from  the  kidneys  is  augmented  during  the  active  period  of  rheumatism,  and 
the  urine  when  it  cools  deposits  urates.  In  ordinary  cases  there  is  no  prom- 
inent symptom  referable  to  the  nervous  system,  with  the  exception  of  pain  in 
the  affected  joint. 

Acute  rheumatism,  if  only  the  articulations  were  involved,  would  be  a  dis- 
ease of  little  danger,  however  painful,  but  unfortunately  in  its  proneness  to 
produce  specific  inflammation  of  the  sero-fibrous  tissues  the  heart  frequently 
becomes  involved,  less  frequently  the  lungs  and  pleura,  and  in  rare  instances 
the  cerebral  or  spinal  meninges.  The  so-called  cerebral  rheumatism  is  attended 
by  high  fever,  restlessness,  headache,  and  sometimes  delirium  and  coma. 
Twitching  of  the  muscles  and  sometimes  tonic  or  clonic  spasms  occur.     Prof. 


458  CONSTITUTIONAL  DISEASES. 

Flint  says :  "  In  the  majority  of  cases  death  takes  place  during  coma.  In 
some  eases  recovery  sets  in  even  after  the  appearance  of  very  grave  symptoms. 
In  fatal  cases  no  lesions  of  the  brain  or  of  the  meninges  can  really  be  found. 
The  symptoms  seem  to  be  referable  to  some  profound  infection  or  intoxication 
which  acts  upon  the  thermic  and  other  nervous  centres."  This  form  of  rheu- 
matism is  certainly  rare  in  childhood.  Endocarditis  is  the  most  frequent  of 
the  heart  inflammations  occurring  in  rheumatism  ;  pericarditis,  though  less 
common,  is  not  infrequent ;  while  in  rare  instances  myocarditis  occurs,  usually 
associated  with  the  other  inflammations.  Endocarditis  is  limited  to  the  left 
side  of  the  heart,  and  seldom  continues  long  without  engaging  the  valves, 
aortic  or  mitral,  or  both,  causing  their  infiltration,  fibroid  degeneration,  with 
consequent  thickening,  and  sometimes  adhesion.  The  valvular  lesion  thus 
produced  is  in  most  instances  permanent,  so  impairing  the  action  of  the  valves 
as  to  obstruct  in  greater  or  less  degree  the  flow  of  blood  through  the  orifice 
and  allow  its  regurgitation. 

The  mitral  valve  is  more  frequently  afi"ected  than  the  aortic  ;  at  least  bruits 
produced  by  this  lesion  are  more  frequently  in  the  mitral  than  aortic  orifice, 
and  when  they  are  heard  in  both  orifices  they  are  commonly  loudest  in  the 
mitral.  This  fact,  noticed  by  difi"erent  observers,  I  have  repeatedly  verified 
by  observations  in  this  city. 

I  have  preserved  the  records  of  73  cases  of  valvular  disease  in  children, 
and  in  most  of  them  I  was  able  to  assign  rheumatism  as  the  cause,  but  it  wa& 
in  a  large  proportion  of  instances  very  slight,  so  as  not  to  confine  the  patients 
to  bed,  and  had  been  considered  by  the  parents  simply  "  growing  pains,"  so 
that  no  treatment  had  been  received.  The  statistics  of  difi"erent  observers 
show  that  endocarditis  in  acute  rheumatism  occurs  more  frequently  in  chil- 
dren than  in  adults.  The  first  sign  of  an  endocardial  inflammation  is  in 
most  instances  a  systolic  murmur  produced  in  the  mitral  orifice.  It  can  be 
heard  on  listening  over  the  heart,  and  also  over  the  left  scapula.  It  indi- 
cates insufficiency  of  the  mitral  orifice  and  regurgitation  of  blood  into  the 
left  auricle.  In  some  cases  the  aortic  valves  are  at  the  same  time  aff'ected, 
and  an  aortic  direct  murmur  occurs,  synchronous  with  the  mitral  regurgi- 
tant. In  rare  instances  the  endocarditis  extends  to  the  aortic  orifice,  causing 
thickening  of  its  valves  and  impairing  their  action,  so  that  an  aortic  bruit 
results,  while  the  mitral  orifice  is  not  affected,  and  therefore  no  mitral 
murmur  occurs. 

Another  cardiac  bruit  resulting  from  the  endocarditis  occasionally  observed 
is  a  reduplication  of  the  second  sound,  heard  most  distinctly  at  the  apex.  A 
diastolic  sound  sometimes  follows  this  reduplication,  and  when  it  is  well 
developed  it  constitutes  the  so-called  presystolic  murmur.  It  usually  results 
from  mitral  stenosis  caused  by  the  endocarditis. 

Pericarditis  is  not  so  common  in  rheumatism  as  endocarditis,  but  it  some- 
times occurs  in  children  as  well  as  in  adults.  It  occasionally  even  precedes 
the  affection  of  the  joints,  being  the  first  in  time  of  the  rheumatic  inflam- 
mations. It  cau.ses  an  increase  in  the  fever,  palpitation,  quick  and  irregular 
pulse,  restlessness,  cardiac  pain,  and  perhaps  dyspnoea.  At  first  a  pericardial 
friction-sound  may  be  detected,  and  subsequently,  when  sero-fibrinous  exuda- 
tion has  occurred,  the  area  of  dulness  may  be  increased,  with  a  mulfling  of 
the  sounds  of  the  heart.  If  the  effusion  of  serum  be  moderate,  the  peri- 
cardial surfaces  may  become  agglutinated  early  in  the  disease,  or  they  may 
become  agglutinated  after  the  serum  is  absorbed,  so  as  to  prevent  friction- 
sound.  An  adherent  pericardium  embarrasses  the  action  of  the  heart,  and 
is  likely  to  lead  eventually  to  hypertrophy.  Tonsillitis  occurs  so  frequently 
in  children  who  have  the  rheumatic  diathesis,  and  also  so  frequently  during 
rheumatism,  that   Trousseau   recognized  a  rheumatic  form   of  the  disease. 


ACUTE  RHEUMATISM. 


459 


Bronchitis,  pleurisy,  and  pneumonia  also  occasionally  occur  as  complications 
of  rheumatism. 

While  the  articular  affections  pertain  to  the  clinical  history  of  rheuma- 
tism, the  internal  inflammation,  whether  of  the  heart,  lungs,  pleura,  or 
meninges,  though  similar  as  regards  its  pathological  character,  is  properly 
considered  as  a  complication.  Acute  rheumatism  is  so  frequently  complicated 
by  one  or  the  other  of  these  affections  that  any  disproportionate  severity  in 
the  general  symptoms,  as  compared  with  the  inflammation  of  the  joints,  or 
any  sudden  and  unexpected  increase  in  the  symptoms,  should  always  lead 
the  physician  to  examine  thoroughly  the  condition  of  those  organs  which 
are  most  frequently  affected. 

Inflammatory  complications  occur,  as  a  rule,  during  the  active  period 
of  rheumatism,  when  the  inflammation  is  passing  from  joint  to  joint.  If  the 
general  symptoms  begin  to  improve  and  no  new  joints  are  involved,  the  lia- 
bility to  complications  is  greatly  diminished. 

Pathology. — The  joints  affected  by  rheumatism  present  various  grades 
of  inflammation,  but  in  all  typical  cases,  however  intense  the  inflammation, 
suppuration  does  not  occur.  In  a  paper  read  before  the  London  Medical 
Society.  April  9,  1888,  Dr.  Money  stated  that  when  suppuration  does  occur 
in  rheumatism  the  disease  is  complicated  with  septiccemia,  and  Sir  Wm. 
MacCormac  and  Dr.  Ord  expressed  a  similar  opinion. 

Acuteness  of  sensation  is  increased  over  the  inflamed  joint.  The  ana- 
tomical changes  in  the  joints  have  been  sufficiently  described  in  our  remarks 
relating  to  the  symptoms.  Recently  several  writers  have  called  attention 
to  the  fact  that  nodules  occasionally  occur  under  the  skin  in  rheumatism. 
Lindmann  relates  two  cases,  an  adult  and  a  child,  in  which  during  the  course 
of  rheumatism  numerous  nodules  appeared  rapidly  under  the  skin.  They 
were  about  the  size  of  a  pea,  hard,  movable,  and  painful,  but  without  red- 
ness. They  disappeared  during  convalescence.  Lindmann  collated  the  records 
of  59  rheumatic  cases  in  which  nodules  occurred.  A  majority  of  them  were 
females,  and  46  were  children.  These  bodies  usually  appeared  suddenly  in 
the  later  stages  of  rheumatism,  and  varied  from  the  size  of  a  pin's  head  to 
that  of  an  almond.  They  continued  from  a  few  days  to  a  month  or  longer 
(Deutsche  med.  Woch.,  p.  519,  1888). 

Examination     with     the     microscope  Fig.  60. 

shows  that  they  consist  of  newly- 
formed  connective  tissue,  such  as  re- 
sults from  inflammation  (Amer.  Journ. 
of  Med.  Sci,  Oct.,  1888).  Garrod  states 
that  these  nodules  and  muscular  atro- 
phy sometimes  occur  in  the  most  simple 
forms  of  hydrarthrosis,  and  are  usually 
attended  by  an  increase  in  the  reflexes, 
suggesting  an  excitability  in  the  spinal 
cord  (Lond.  Lane,  June  2,  1888).  It 
is  stated  that  Charcot  and  Parisot  also 
attribute  the  occurrence  of  these  nod- 
ules to  an  exaggerated  excitability 
of  the  spinal  cord.  On  the  other 
hand,  Mayer  and  Cuilleret  observed 
two  cases  of  nodules  and  atrophy  of 
certain  muscles  following  an  attack 
of  arthritis,  and  they  think  that  a  true 

myelitis   had   occurred   to   produce   such  a  result,  along  with   the   constant 
peripheral  irritation  (Lyon  medical,  Apr.  29,  1888).     Homan  relates  the  case 


460  CONSTITUTIONAL  DISEASES. 

of  a  patient  aged  eighteen  years  who  had  rheumatism  of  the  muscles  of  the 
left  leg  from  the  hip  to  the  ankle,  lasting  several  weeks.  In  the  latter  part  of 
his  sickness  the  calf  of  the  leg  became  unusually  tender,  and  a  hard  nodule 
occurred  in  the  muscular  substance,  and  was  accompanied  by  atrophy  of 
the  muscular  fibres.  The  nodule  gradually  subsided  and  disappeared  (<SV. 
Louis  Courier  of  Med..,  March,  1888).  The  above  observations,  to  which  more 
might  be  added,  show  that  the  anatomical  characters  of  acute  rheumatism 
are  not  restricted  to  the  joints  and  heart,  but  subcutaneous  nodules,  and  more 
or  less  muscular  atrophy,  occasionally  occur.  Cheadle  says  the  nodules  occur 
mostly  in  the  neighborhood  of  joints,  and  that  they  are  rare  in  adults,  but 
very  common  in  children.  They  develop  within  a  few  days,  and  sometimes 
in  successive  crops,  "  but  they  usually  take  many  weeks  to  subside."  The 
above  figure  represents  these  nodules  as  seen  by  Dr.  Cheadle  in  a  boy  of 
four  years. 

Fig.  61. 


V  V 


The  woodcut  (Fig.  61)  shows  the  microscopic  appearance  of  a  noduls  from  a 
child  of  seven  and  a  half  years,  as  observed  by  Dr.  Cheadle  ;  it  exhibits  the 
active  cell-infiltration  and  proliferation  of  fibrous  tissue. 

Duration  ;  Prognosis. — With  proper  treatment  and  without  complica- 
tion the  febrile  action  in  a  few  days  begins  to  abate,  and  the  disease  com- 
monly terminates  within  two  weeks.  Its  duration  is  ordinarily  shorter  than 
in  rheumatism  of  the  adult.  Fluctuations,  however,  are  liable  to  occur. 
The  disease  may  appear  to  be  abating  and  the  articular  inflammations  nearly 
cease  when  they  return  for  a  time,  often  without  new  exposure  and  without 
appreciable  cause.  The  prognosis,  even  when  cardiac  inflammation  has  super- 
vened, is  in  most  cases  favorable,  except  so  far  as  the  lesion  resulting  from 
this  inflammation  is  concerned,  which  being  permanent  may  entail  much  sub- 
sequent sufi"ering  and  occasion  death  after  months  or  years.  Indeed,  what  is 
most  to  be  dreaded  in  cases  of  acute  rheumatism  is  valvular  disease  or  peri- 
cardial adhesion  with  its  remoter  consequences — namely,  hypertrophy  of 
heart,  congestion  and  oedema  of  lungs,  dropsies,  etc. 

Secondary  rheumatism  occurring  in  scarlet  fever  is  sometimes  also  com- 
plicated with,  or  rather  coexists  with,  cardiac  inflammation,  pleuritis,  or  pneu- 
monitis, rendering  the  prognosis  more  unfavorable. 

In  rare  instances  the  acute  symptoms  of  rheumatism  abate,  but  the 
joints  remain  stifi"  and  more  or  less  swollen  and  painful  when  moved.     The 


ACUTE  RHEUMATISM. 


461 


acute  has  lapsed  into  a  subacute  or  chronic  rheumatism.     Such  a  case,  rep- 
resented in  the  accompanying  figure  (Fig.  62),  was  brought  to  the  children's 
class  in  the  Out-door  Department  at  Bellevue  Hos- 
pital in  February,  1871.    E.  H ,  a  female  three  Fig, 

and  a  half  years  old,  had  intermittent  fever  from 
the  age  of  nine  to  fifteen  months.  From  this  time 
she  remained  well  till  the  age  of  two  years,  when 
she  was  taken  with  acute  rheumatism,  commencing 
in  her  ankles  and  extending  to  other  joints.  The 
knee-  and  hip-joints  on  both  sides  have  only  par- 
tially recovered  their  mobility,  and  both  legs  and 
both  thighs  are  permanently  flexed,  so  that  the 
gait  is  slow  and  unsteady.  It  is  impossible  to 
straighten  either  limb  without  causing  great  pain, 
and  attempts  to  straighten  the  thigh  produce  the 
arch  in  the  back  very  similar  to  that  in  coxalgia. 

Diagnosis. — This  is  not  difficult  in  ordinary 
cases  if  a  proper  examination  be  made.  In  the 
commencement,  if  the  afi'ection  of  the  joints  be 
slight,  rheumatism  might  be  mistaken  for  remit- 
tent, typhoid,  one  of  the  eruptive  fevers,  or  men- 
ingitis ;  but  on  careful  examination  tenderness  of 
one  or  more  of  the  articulations  will  be  observed, 
and  probably  some  swelling.  This  tenderness  is 
readily  distinguished  from  the  hypergesthesia  which 
is  common  in  the  first  stage  of  the  essential  fevers, 
and  which  is  observed  when  pressure  is  made  upon 
the  chest  or  abdomen  as  well  as  upon  the  limbs, 
and  is  more  marked  between  the  joints  than  in 
them.  Any  doubt  which  may  at  first  exist  whether 
the  patient  may  not  have  one  of  those  diseases  is 
soon  dispelled,  since  their  clinical  history  presents  notable  differences  from 
that  of  rheumatism. 

I  have  known  scrofulous  arthritis  or  scrofulous  osteitis  near  the  joint 
present  so  close  a  resemblance  to  acute  rheumatism  as  to  be  at  first  mistaken 
for  it.  In  one  instance  this  inflammation  commenced  nearly  simultaneou.sly 
in  three  joints,  rendering  the  diagnosis  at  first  very  difficult.  But  scrofulous 
inflammation,  as  well  as  that  from  pyjemia,  can  be  diagnosticated  from  rheu- 
matic disease  of  the  joints  by  its  greater  persistence,  less  induration  and  sym- 
metry in  the  swelling,  and  by  the  history  of  the  case.  Chronic  rheumatism 
may  produce  deformity  similar  to  that  from  chronic  scrofulous  inflammation, 
as  in  the  case  mentioned  above,  but  the  rheumatic  history,  number  of  joints 
affected,  bilateral  character  of  the  inflammation,  good  general  health,  etc.  are 
sufficient  to  establish  a  clear  diagnosis  when  the  disease  has  been  observed  for 
some  days. 

Treatment. — The  treatment  of  acute  rheumatism  has  undergone  marked 
variations  in  the  last  thirty  years.  Its  speedy  cure  is  urgently  demanded,  on 
account  of  the  imminent  peril  to  the  heart.  From  1847  until  a  recent  period 
the  alkaline  treatment,  by  the  bicarbonate  of  potassium  and  bicarbonate  of 
sodium,  the  tartrate  of  potassium  and  sodium,  and  the  citrate  of  potassium, 
was  commonly  employed  to  the  extent  of  rendering  the  urine  alkaline  in 
twelve  or  twenty-four  hours.  Statistics  appeared  to  show  that  the  duration 
of  rheumatism  was  abridged  by  the  alkaline  treatment,  and  the  liabilitv  to 
cardiac  complications  was  diminished  as  soon  as  the  urine  became  alkaline. 
Garrod  reported  50  cases  in  which  the  average  duration  was  six  or  seven 


462  COXSTITUTIOXAL  DISEASES. 

days  under  the  alkaline  treatment.  Fuller  in  1862  stated  that  in  no  single 
instance  in  194:  cases  did  cardiac  complications  occur  %yhen  the  alkaline  treat- 
ment had  been  employed  twenty-four  hours.  Dickinsons  statistics  also  fur- 
nished strong  evidence  of  the  usefulness  of  alkalies  in  large  doses,  given  so  as 
to  render  the  urine  alkaline  in  twelve  to  twenty-four  hours.  He  also  stated 
that  the  alkaline  treatment  was  inadequate  unless  employed  so  as  to  render 
the  urine  alkaline.  More  recently,  the  late  Prof.  Austin  Flint  considered 
the  evidence  conclusive  in  regard  to  the  efficacy  of  the  alkaline  treatment  of 
rheumatism,  the  doses  employed  being  so  large  that  the  urine  becomes  alka- 
line in  twenty-four  hours. 

But  since  1875  a  new  and,  in  acute  cases  of  rheumatism,  a  very  efficient 
remedy  has  come  into  use — to  wit,  salicylic  acid,  or  its  compound,  salicylate 
of  sodium.  The  sodium  salicylate  is  most  frequently  employed.  It  may  be 
given  every  two  hours  to  adults  in  doses  of  ten  to  twenty  grains,  and  to 
children  in  proportionate  doses.  But,  although  salicylic  acid  or  salicylate 
of  sodium  acts  almost  as  a  specific  in  recent  cases  of  rheumatism,  relieving 
the  pain  and  fever  and  diminishing  the  articular  inflammation,  it  often  pro- 
duces certain  ill  efi'ects.  It  impairs  digestion,  causing  nausea,  and  sometimes 
vomiting.  It  produces  tinnitus  aurium,  and  sometimes  headache  or  vertigo, 
and  occasionally  albuminuria,  as  I  have  several  times  observed,  so  that  it 
should  not  be  employed  longer  than  is  required  to  control  the  rheumatism. 
The  employment  of  salicylic  acid  or  salicylate  of  sodium  does  not,  apparently, 
prevent  cardiac  or  other  complications,  and  it  is  probably  best  to  administer 
it  in  combination  with,  or  alternately  with,  an  alkali. 

The  following  formula  is  essentially  that  which  has  been  employed  in  the 
Out-door  Department  at  Bellevue  with  apparently  excellent  results : 

R.  Acidi  salicylic,  3ij-iij  ! 

Potas.  acetat.,  ,^ss  ; 

Glycerini,  ^j  ; 

Aquse,  q.  s.  ad  §v. — Misce. 

Give  one  teaspoonful  every  two  or  three  hours  to  a  child  of  six  years. 

An  eligible  vehicle  for  the  sodium  salicylate  is  the  syrup  of  raspberry, 
as  in  the  following  formula : 

R.  Sodii  salicylat.,  ^iij  ; 

Sodii  bicarbonat.,  .^ij  ; 

Syr.  rubi  ida?i,  31]  ; 

Aqufe,  5iij. — Misce. 

Give  one  teaspoonful  every  two  or  three  hours  to  a  child  of  six  years. 

Since  the  oil  of  wintergreen  contains  a  considerable  amount  of  salicylic 
acid,  it  has  been  sometimes  employed,  as  in  the  following  formula : 

R.  01.  gaultherise,  3J  ; 

Sodii  salicylat.,  .^iij  ; 

Syr.  simplic,  .^iij  ; 

Aquse,  ^vj. — Misce. 

Dose  :  A  dessertspoonful  to  a  child  of  five  years. 

During  the  declining  period  of  rheumatism  and  in  convalescence  quinine 
or  some  preparation  of  cinchona  should  be  employed  and  the  above  medicine 
given  less  often.  This  tonic  does  indeed  appear  to  exert  a  beneficial  efi'ect  on 
the  course  of  rheumatism,  and  is  employed  by  some  judicious  and  experienced 
physicians  from  the  commencement. 

If  there  be  a  high  temperature  and  a  quick  pulse,  quinine  administered  in 


ERYSIPELAS.  463 

an  occasional  large  dose  will  be  found  very  useful.  Three  to  five  grains  may 
be  given  to  a  cbild  of  five  years. 

Rheumatism  impoverishes  the  blood,  and  the  patient  often  begins  to  present 
an  anaemic  appearance,  when  he  requires  iron  in  addition  to  the  vegetable 
tonic.     The  citrate  of  iron  and  quinine  may  then  be  employed. 

Secondary  rheumatism  requires  sustaining  treatment  from  the  first.  Such 
cases  ordinarily  do  well  without  antirheumatic  treatment,  with  the  general 
supporting  measures  employed  for  the  primary  disease. 

Pneumonitis  complicating  rheumatism  is  best  treated  by  moderate  coun- 
ter-irritation and  emollient  poultices  and  the  internal  use  of  carbonate  of  am- 
monium or  quinine.  In  pericarditis  or  endocarditis  if,  as  is  commonly  the 
case,  the  movements  of  the  heart  be  accelerated,  aconite  or  the  tincture  or 
infusion  of  digitalis  is  demanded  to  the  extent  of  reducing  the  number  of 
pulsations  to  near  the  normal  frequency.  A  child  of  six  years  can  take  three 
drops  of  the  tincture  or  a  large  teaspoonful  of  the  infusion,  to  be  repeated, 
if  necessary,  in  three  hours  till  the  reduction  of  the  pulse  is  eiFected.  Pa- 
tients often  experience  relief  by  the  use  of  this  agent  from  the  palpitation 
and  dyspnoea  consequent  upon  the  embarrassed  movements  of  the  heart.  If 
the  heart  disease  be  severe  and  pnlse  feeble,  quinine  is  also  useful.  The  tinc- 
ture of  strophanthus  or  that  of  spartein  is  sometimes  prescribed  as  a  substi- 
tute for  the  digitalis. 

The  patient  should  be  kept  quiet  in  a  room  of  uniform  temperature,  and 
not  exposed  to  draughts  of  air.  By  such  precautions  the  danger  of  compli- 
cations is  greatly  diminished.  Repellant  applications,  as  cold  or  irritants, 
should  not  be  applied  to  the  joints  so  long  as  the  disease  is  acute,  for  they  also 
increase  the  danger  of  complications.  The  alfected  joints  should  be  envel- 
oped in  flannel  or  cotton,  and  the  pain,  if  intense,  may  be  diminished  by  apply- 
ing flannel  wrung  out  of  warm  water.  If  the  disease  become  subacute  or 
chronic,  if  the  urates  have  disappeared  from  the  urine,  and  the  inflammation 
cease  to  pass  from  joint  to  joint,  the  tincture  of  iodine  or  moderately  stimu- 
lating embrocations  applied  to  the  joints  involve  no  danger  and  are  useful. 


CHAPTERVI. 

EEYSIPELAS. 

The  term  "  erysipelas  "  is  applied  to  a  constitutional  or  blood  disease  which 
is  characterized  by  inflammation  of  the  skin  and  subcutaneous  connective 
tissue  and  a  tendency  to  spread.  It  is  accompanied  by  pungent  and  pricking 
heat,  swelling,  and  subcutaneous  infiltration. 

It  involves  especially  the  lymph  vessels  and  spaces.  The  skin  has  a  bright- 
red  color  and  is  swollen. 

Erysipelas  occasionally  occurs  in  childhood ;  the  cases  which  are  met  in 
this  period  present  nearly  the  same  features  and  pursue  nearly  the  same  course 
as  in  the  adult.  In  infancy  erysipelas  is  a  common  disease,  and  the  following 
remarks  relate  chiefly  to  erysipelas  occurring  in  this  period  of  life.  My  sta- 
tistics are  based  on  data  derived  mainly  from  the  records  of  cases  which  oc- 
curred in  this  city,  some  in  my  own  practice,  and  others  in  the  practice  of 
physicians  known  to  be  good  observers.  The  points  of  chief  interest  in  41 
cases  are  embraced  in  the  following  table.  In  addition  to  these  cases,  I  have 
records  of  some  which  are  designated  septicjemia  in  which  more  or  less 
erysipelas  occurred  at  and  extended  from  the  umbilicus. 


464 


CONSTITUTIONAL  DISEASES. 
Cases  of  Infantile  Erysipelas. 


o 

IZl 

k" 
^ 

Age. 

Point  of 
commencement. 

Parts  aflfected. 

Duration. 

Result. 

1 

M. 

5  months. 

Right  knee. 

Entire  surface,  except  face  and  scalp. 

5  weeks  and 

3  days. 
7  days. 

Recovered. 

2 

M. 

2  years. 

Left  knee. 

From  a  little  above  the  knee  to  the 

Recovered. 

ankle. 

3 

M. 

10  months 

Elbow. 

Whole  arm  and  forearm. 

Recovered. 

4 

F. 

20 

Below  right  knee. 

Entire  leg,  thigh,  and  trunk  to  the 
umbilicus. 

7  days.. 

Recovered. 

5 

F. 

9 

Vulva. 

Abdomen,  chest,  and   all   the  ex- 
treuiities. 

18    " 

Recovered. 

6 

M. 

9  days. 

Genitals. 

Both  lower  extremities,  abdomen  to 
the  umbilicus. 

6      " 

Died. 

7 

F. 

1  year. 

Vulva. 

Entire  surface,  except  face. 

6  weeks. 

Recovered. 

8 

F. 

6  weeks. 

At  or  near  the  ear. 

Forehead  and  side  efface. 

1  week. 

Died  in  tetanic 
spasms. 

9 

9  months. 

Epigastric  region. 

Trunk  and  lower  extremities. 

2  weeks. 

Died  in  tetanic 
spasms. 

10 

F. 

10 

At  angle  of  mouth. 

Entire  face  and  scalp. 

10  days. 

Recovered. 

11 

F. 

4  weeks. 

Vulva. 

Entire  surface,  except  face. 

3  weeks. 

Died. 

12 

F. 

3  months. 

Vulva. 

Surface  of  abdomen  to  umbilicus  and 
right  lower  extremity. 

2 

Recovered. 

13 

F. 

4  to  5  mos. 

Vulva. 

All  the  limbs  and  trunk,  except  the 
chest. 

3  to  4  weeks. 

Died. 

14 

F. 

5  months. 

From  syphilitic 
sores  around  anus. 

Trunk  and  both  lower  extremities. 

15 

F. 

3 

Vulva. 

Entire  trunk  and  both  upper  ex- 
tremities. 

3  weeks. 

Recovered. 

16 

M. 

8 

Face  near  nostrils. 

Entire  trunk  and  both  upper  ex- 
tremities. 

About  2 
weeks. 

Recovered. 

17 

F. 

4 

Vulva. 

Entire  trunk  and  all  the  extremities. 

1  week. 

Died. 

18 

F. 

7 

Knee. 

A  portion  of  trunk  and  both  lower 
extremities. 

o  weeks. 

Recovered. 

19 

F. 

6 

Near  the  ear. 

Entire  face  and  forehead. 

10  davs. 

Recovered. 

20 

M. 

7  days. 

Left  eyelid. 

Left  side  of  face. 

3      " 

Died. 

21 

M. 

14    " 

Genitals. 

Extended  to  knee,  over  abdomen  to 
the  chest. 

4      " 

Died. 

22 

M. 

3  months. 

Under  the  chin. 

Chin,  left  cheek,  neck,  left  side  of 
trunk,  left  thigh  and  leg. 

23 

F. 

28 

Right  shoulder. 

Arm  and  forearm. 

1  day. 

Died  in  con- 
vulsions. 

24 

F. 

3  or  4  days. 

Vulva. 

Body  and  all  the  limbs. 

12  davs. 

Died. 

25 

F. 

3}^  mos. 

Under  left  ear. 

Neck,  chest,  and  arms. 

About  2 

weeks. 

Died. 

26 

■   ■ 

7  months. 

Below  right  knee. 

Trunk,  neck,  and  head,  and  all  the 

limbs. 
Both  thighs  and  nearly  entire  trunk. 

2  weeks. 

Died  comatose. 

27 

F. 

6 

Vulva. 

3  days. 

Died  comatose. 

28 

M. 

19 

Near  point  of 
vaccination. 

Shoulder,  arm,  and  forearm. 

21    " 

Recovered. 

29 

M. 

4         ' 

Near  point  of 
vaccination. 

Chest  and  both  upper  limbs. 

2  weeks. 

Recovered. 

30 

M. 

2         " 

Near  vaccine 
vesicle. 

Trunk  and  all  the  limbs. 

10  days. 

Died. 

31 

3  to  4  mos. 

Near  vaccine 
vesicle. 

Arm,  forearm,  and  shoulder  on  one 
side. 

2  to  3  weeks. 

Died. 

32 

F. 

4  months. 

Near  vaccine 
vesicle. 

Arm,  forearm,  and  trunk. 

2  months. 

Died. 

33 

M. 

2 

Near  vaccine 
vesicle. 

Nearly  entire  surface. 

1  week. 

Died  with  per- 
itonitis. 

34 

M. 

sy^    " 

Near  point  of 
vaccination. 

Arm  and  forearm. 

Recovered. 

35 

M. 

2K     " 

Near  point  of 
vaccination. 

Arm. 

7  days. 

Died  probably 
of  peritonitis. 

36 

M. 

8 

Near  vaccine 
vesicle. 

Arm  and  forearm. 

17    " 

Died. 

37 

5 

Left  foot. 

Leg,  thigh,  and  lower  part  of  trunk. 

2  weeks. 

Died  with 

pneumonitis. 
Recovered. 

38 

5  weeks. 

At  one  ear. 

Entire  surface. 

2      " 

39 

; ; 

2  months 

Left  leg. 

Trunk  and  all  the  limbs. 

2      " 

Recovered. 

40 

4 

Near  point  of 

Trunk  and  all  the  limbs. 

2      " 

Died. 

vaccination. 

41 

M. 

14 

Face. 

Trunk  and  all  the  limbs.                     4      " 

Recovered. 

Age. — Of  the  above  cases,  27  were  under  the  age  of  six  months,  9  from 
six  months  to  twelve,  and  only  5  above  the  latter  age.  A  large  majority, 
therefore,  of  cases  of  infantile  erysipelas  occur  in  the  first  year  of  life. 

Point  of  Commencement. — In  58  cases  in  which  I  have  ascertained 
the  point  of  commencement  it  was  in  13  cases  the  vulva,  17  the  arm  after 


ERYSIPELAS.  465 

vaccination,  7  the  leg,  6  the  face,  3  the  male  genital  organs,  3  at  or  near  the 
ear,  1  the  elbow,  1  the  shoulder,  1  the  nates,  1  the  foot.  In  the  adult,  idio- 
pathic erysipelas  commonly  commences  upon  the  face  and  affects  only  the 
face,  ears,  forehead,  and  scalp.  On  the  other  hand,  in  infantile  erysipelas 
statistics  show  that  the  rash  commences  upon  the  face  only  in  a  small  pro- 
portion of  cases,  1  in  9,  and  that  it  rarely  extends  to  the  face  when  it  com- 
mences in  other  parts. 

Causes. — The  fact  that  erysipelas  is  infectious  has  led  to  many  micro- 
scopic examinations  in  order  to  discover  the  nature  of  the  microbe  which 
causes  it.  In  most  instances  some  injury  of  the  surface  has  occurred  through 
which  the  poison  is  received — a  scratch  or  abrasion  or  a  slight  cutaneous 
eruption.  Many  cases  have  been  cited  showing  infectiousness.  In  my 
practice  a  child  contracted  it  from  lying  in  bed  with  one  of  the  family  who 
had  facial  erysipelas.  The  following  cases  were  related  before  the  Paris 
Academy  in  1864  :  Dr.  Paintevin  contracted  erysipelas  from  two  cases  occur- 
ring m  a  hospital  ward,  and  was  visited  by  Dr.  Testart  of  Guise,  a  place  free 
from  erysipelas.  Three  days  after  returning  home  this  physician  sickened 
with  erysipelas.  His  servant,  who  waited  on  him,  and  a  relative  living 
twenty-four  miles  away,  who  called  on  him,  also  contracted  the  disease.  The 
relatives  wife  was  then  seized  with  it,  and  also  three  members  of  a  family 
who  had  called  upon  them.  These  last  patients  communicated  the  disease 
to  a  relative  and  two  Sisters  of  Mercy  who  nursed  them.  These  sisters, 
returning  to  the  convent,  infected  others,  among  whom  was  the  physician  of 
the  convent,  who  died.  The  physician's  daughter  also  contracted  it,  the 
inflammation  beginning  in  leech-bites  which  had  been  made  over  enlarged 
glands.  Infectiousness  has  been  shown  not  only  by  clinical  experience,  but 
also  by  experiments  ;  small  tumors  have  been  successfully  inoculated  with 
cultures  of  the  erysipelatous  cocci,  but  some  of  the  patients  thus  treated 
have  died.  The  attempt  to  remove  tumors  by  inoculating  them  with  the 
erysipelatous  virus  shows  the  highly  infectious  character  of  erysipelas,  and 
certain  small  tumors  have  been  removed  by  the  erysipelas,  while  in  other 
instances  the  result  has  been  disastrous,  death  occurring. 

Fehleisen  has  discovered  the  specific  microbe  of  erysipelas — to  wit,  a 
chain  coccus  designated  the  streptococcus  erysipelatis.  This  streptococcus 
has  been  designated  streptococcus  erysipelatis,  which  he  has  cultivated,  and 
by  inoculating  the  cultures  he  has  been  able  to  reproduce  erysipelas  in 
tumors.  More  recently  Meerovitch  made  microscopic  examinations  in 
thirty-one  cases  of  erysipelas,  and  invariably  found  a  large  number  of  these 
streptococci  in  the  affected  skin,  and  in  grave  cases  also  a  few  in  the  blood. 
He  detected  this  organism  in  abscesses  and  in  fatal  cases  likewise  in  internal 
organs.  The  cultures  made  in  meat  bouillon  preserved  their  vitality  four  or 
five  months.  It  is  now  known  that  this  organism  sometimes  passes  from 
the  maternal  organism  to  the  foetus  through  the  uterine  circulation.  Ziegler 
says  that  the  micrococcus  which  causes  erysipelas  enters  the  lymphatics  and 
spreads  chiefly  by  them.  They  are  found,  says  he,  in  immense  masses  or 
swarms  in  the  lymphatics,  and  from  them  they  spread  into  the  tissues,  where 
they  excite  inflammation  and  often  tissue-necrosis  (^Lond.  Med.  Recorder, 
Nov.  20,  1888). 

The  blood  may  undergo  certain  changes  which  predispose  to  erysipelas  or 
render  the  system  less  able  to  resist  the  micrococcus..  Among  the  causes 
which  produce  this  state  of  system,  uncleanliness,  residence  in  damp,  dark, 
and  crowded  apartments,  and  defective  alimentation  hold  a  principal  place. 
Hence  this  disease  is  more  common  in  the  poor  quarters  of  a  city  than  in 
the  country,  and  in  dispensary  and  hospital  than  in  family  practice. 

In  a  large  proportion  of  cases  there  is  an  irritation  or  inflammation  at 
30 


466  CONSTITUTIONAL  DISEASES. 

some  point,  generally  trivial,  through  which  the  streptococcus  enters  the 
system.  Erysipelas  therefore  commonly  begins  at  a  simple  ecthymatous  or 
impetiginous  eruption,  around  burns  or  suppurating  sores  or  syphilitic  erup- 
tions ;  it  frequently  commences,  as  is  seen  by  the  above  table,  near  the  point 
of  vaccination  immediately  after  vaccination  or  when  the  pock  is  developed, 
or  again  when  it  has  run  its  course  and  been  detached.  In  erysipelas  super- 
vening on  vaccinia  the  streptococcus  erysipelatis  has  probably  been  conveyed 
by  dirty  fingers  or  clothing.  I  might  relate  two  instances  in  the  practice  of 
two  physicians  in  which  the  old  way  of  vaccinating  with  the  scab  produced 
severe  erysipelas  in  children  on  whom  it  was  used.  The  scabs  probably  con- 
tained the  streptococcus  erysipelatis.  In  a  considerable  proportion  of  cases 
it  begins  at  the  point  where  the  skin  is  thin  and  delicate  or  where  it  unites 
with  a  mucous  surface.  Thus,  I  have  records  of  cases  in  which  it  commenced 
at  the  external  ear,  commissure  of  the  mouth,  and  at  the  vulva.  Indeed,  the 
frequency  with  which  it  commences  at  the  vulva  renders  female  infants  more 
liable  to  it  than  males.  In  some  instances  erysipelas  begins  without  any  local 
exciting  causes  upon  smooth  and  sound  skin,  even  when  there  are  sores  upon 
various  points  of  the  surface. 

Erysipelas  neonatorum  is  treated  of  in  our  remarks  on  Septicaemia  of  the 
New-born. 

Premonitory  Symptoms. — Infantile  erysipelas  in  certain  cases  has  no 
premonitory  stage,  or,  if  present,  it  escapes  notice.  In  other  instances  there 
are  well-marked  precursory  symptoms,  as  drowsiness  or  restlessness,  more  or 
less  fever,  oppressed  respiration,  with  perhaps  vomiting  and  sudden  twitch- 
ing of  the  limbs.  In  Cases  28  and  37  of  the  table,  which  occurred  in  my 
practice,  the  fever,  restlessness,  and  dyspnoea  were  so  great  for  thi'ee  days 
before  the  appearance  of  the  ertiption  as  to  cause  much  anxiety.  In  the 
adult  erysipelatous  patient  pharyngitis  often  precedes  the  occurrence  of  the 
rash  upon  the  skin.  The  same  inflammation  may  be  present  in  the  premon- 
itory period  of  infantile  erysipelas,  as  well  as  during  the  period  of  erysipe- 
latous eruption.  The  hurried  and  difficult  respiration  which  is  present  in  the 
commencement  of  some  cases  is  probably  due  to  an  erysipelatous  turgescence 
of  the  bronchial  mucous  membrane. 

Symptoms. — The  patient  with  this  disease  is  usually  restless  in  conse- 
quence of  the  burning  pain  which  accompanies  the  eruption.  In  severe  cases 
there  is  little  sleep,  night  or  day,  except  from  medicine.  The  sleep  is  short, 
and  is  often  interrupted  by  sudden  starting  or  twitching  of  the  limbs.  Con- 
vulsions may  occur,  but  are  not  common. 

Fever  is  constantly  present,  and  is  proportionate  to  the  extent  and  gravity 
of  the  erysipelas.  I  have  notes  of  cases  in  which  the  pulse  was  more  than 
200  per  minute,  although  other  symptoms  did  not  indicate  immediate  danger. 
The  skin  not  affected  by  erysipelas  is  dry  and  hot,  though  not  possessing  the 
pungent  heat  of  the  inflamed  portion  ;  face  often  flushed  ;  tongue  moist  and 
covered  with  a  light  fur ;  stomach  usually  retentive.  The  state  of  the  bowels 
varies  :  sometimes  they  are  regular,  sometimes  variable,  and  in  other  cases 
the  stools  are  green  and  more  frequent  than  natural.  I  have  records  relating 
to  the  state  of  the  bowels  in  20  cases,  as  follows :  In  7,  regular ;  in  9,  loose ; 
in  2,  constipated;  in  1,  constipated,  then  loose;  and  in  1,  constipated,  then 
regular.  Diarrhoea,  when  present,  is  usually  mild,  requiring  little  or  no  treat- 
ment. The  erysipelatous  redness  is  not  in  all  cases  so  pronounced  as  in  the 
adult,  but  otherwise  there  is  nothing  peculiar  in  its  appearance.  In  feeble 
infants  with  an  impoverished  state  of  the  blood  its  color  is  pink,  instead  of 
the  deep  red  which  characterizes  the  inflammation  in  the  robust.  Points 
of  vesication  may  occur  where  the  inflammation  is  most  severe,  as  in  the 
adult,  and  subsequently  the  same  desquamation  and  oedema. 


ERYSIPELAS.  467 

If  the  infant  be  debilitated,  there  is  great  danger  of  the  formation  of 
abscesses  around  which  the  inflammation  lingers  after  it  has  disappeared 
from  every  other  part  of  the  body.  Sometimes  also  in  very  young  infants 
gangrene  occurs,  especially  in  the  genital  organs  in  the  male.  Several  of 
these  cases  have  been  related  to  me,  all  under  the  age  of  a  month  or  six 
weeks,  and  all  fatal.  Occasionally  the  sloughing  is  so  great  as  to  denude  the 
testicle.  A  noteworthy  feature  of  erysipelas  in  infants  is  its  proneness  to 
return.  When  it  has  been  progressively  subsiding  and  hope  is  entertained 
of  its  speedy  disappearance,  it  not  infrequently  is  suddenly  relighted  from 
some  unknown  cause,  travelling  again  over  the  same  or  parts  of  the  same 
surface.  In  one  case  the  disease,  arising  from  vaccination,  extended  three 
times  over  the  arm  and  forearm  ;  and  in  another  case  a  second  time  over 
both  legs  and  a  considerable  part  of  the  trunk. 

The  internal  inflammations  which  most  frequently  complicate  erysipelas 
and  give  rise  to  symptoms  which  are  superadded  to  those  pertaining  to  the 
erysipelas  are  pharyngitis  and  peritonitis,  and  more  rarely  broncho-pneumonia 
or  enteritis.  In  a  case  which  I  examined  after  death  in  the  Nursery  and 
Child's  Hospital,  and  in  which,  the  erysipelatous  inflammation  having 
extended  over  the  abdomen,  the  lesions  of  peritonitis  were  present,  it 
appeared  from  the  thinness  of  the  abdominal  walls  that  the  inflammation 
had  extended  through  them  from  the  external  to  the  internal  surface  or  from 
the  skin  to  the  peritoneum. 

Prognosis. — Erysipelas  is  much  more  fatal  in  infancy  than  in  adult  life. 
In  the  death-statistics  of  this  city  for  three  years  I  find  80  deaths  from  ery- 
sipelas of  infants  under  the  age  of  one  year,  to  83  deaths  from  this  disease 
above  that  age.  Age  greatly  influences  the  prognosis.  Infants  under  the 
age  of  three  weeks  usually  die  ;  from  the  age  of  three  weeks  to  six  months  the 
result  is  doubtful ;  while  above  the  age  of  six  months  a  majority  recover  with 
correct  treatment.  It  will  be  seen  by  the  foregoing  table  that  7  infants  under 
the  age  of  six  weeks  had  erysipelas,  and  6  died  ;  from  the  age  of  six  weeks  to 
six  months,  6  recovered  and  9  died;  and  above  the  age  of  six  months,  9  recov- 
ered and  4:  died. 

With  the  exception  of  a  case  of  the  so-called  umbilical  erysipelas,  the 
youngest  child  who  recovered  of  whom  I  have  obtained  information  was  three 
weeks  old.  In  this  case  the  rash  extended  nearly  over  the  entire  surface,  be- 
ginning with  the  face.  Case  38  of  the  table,  treated  by  myself,  was  very 
similar  as  regards  the  extent  of  the  erysipelatous  eruption  and  the  result. 
This  infant  was  five  weeks  old. 

It  is  scarcely  necessary  to  state  that  erysipelas  is  more  favorable  when  it 
affects  the  limbs  than  when  it  invades  the  head,  neck,  or  body  ;  when  it  spreads 
slowly  than  rapidly ;  when  it  is  superficial  than  when  phlegmonous.  In  those 
cases  in  which  the  connective  tissue  is  much  involved  the  infant  is  not  always 
safe  after  the  disease  has  run  its  course;  he  sometimes  dies  exhausted  from 
the  discharge  of  abscesses ;  I  have  records  of  two  such  cases. 

Duration. — In  16  cases  that  recovered  the  erysipelas  terminated  within 
the  first  week  in  2,  the  second  week  in  6,  the  third  week  in  5,  fourth  week  in 
1,  and  in  2  cases  it  lasted  five  and  six  weeks.  The  average  duration  was  fifteen 
days.  In  19  fatal  cases,  10  died  within  the  first  week,  5  the  second  week,  3 
the  third  week,  and  1  in  the  fourth  week.  The  average  duration  of  fatal  cases 
was  about  ten  days. 

Modes  op  Death. — Death  occurs  in  diiFerent  ways :  in  chronic  or  tonic 
convulsions  followed  by  coma,  from  exhaustion,  and  from  internal  inflamma- 
tion, that  from  exhaustion  being  probably  the  most  common. 

Pathological  Anatomy. — The  blood  doubtless  in  this  disease  under- 
goes certain  pathological  alterations  previously  to  the  occurrence  of  the  erup- 


468  CONSTITUTIONAL  DISEASES. 

tion,  but  the  exact  changes  are  not  known.  Our  knowledge  of  the  morbid 
anatomy  of  erysipelas  relates  chiefly  to  the  local  affections,  which,  with  the 
excejition  of  the  inflammation  of  the  skin,  are  not  constant,  and  maj  there- 
fore be  regarded  as  complications.  The  cutaneous  inflammation  affects  all  the 
structures  of  the  skin,  and  in  greater  or  less  degree  also  the  subcutaneous  con- 
nective tissue.  The  inflammation  is  accompanied  by  more  or  less  serous  effusion 
or  oedema. 

The  not  infrequent  occurrence  of  peritonitis  in  connection  with  erysipelas 
has  long  been  known.  In  Heberden's  Epitome  Morhorum  Puerilium  the  ana- 
tomical character  of  erysipelas  is  expressed  in  one  sentence  :  "  When  the  body 
has  been  opened  after  death  the  intestines  have  been  found  glued  together  and 
covered  with  coagulable  lymph."  Since  Herberdeu's  time  nearly  all  who  have 
written  on  diseases  of  infancy  and  childhood  have  mentioned  peritonitis  as  one 
of  the  most  common  complications  of  erysipelas.  Underwood  says:  "Upon 
examining  several  bodies  after  death  the  contents  of  the  body  have  frequently 
been  found  glued  together  and  their  surface  covered  with  inflammatory  exu- 
dation exactly  similar  to  that  of  those  who  have  died  of  puerperal  fever." 
Similar  remarks  in  reference  to  the  frequency  of  peritonitis  in  this  disease  are 
made  by  recent  writers. 

The  statistics  in  reference  to  erysipelas  as  well  as  peritonitis  show  that  in 
infants  in  hospital  practice,  and  in  those  affected  by  erysipelas  during  epi- 
demics of  puerperal  fever,  peritonitis  is  a  not  infrequent  complication.  On  the 
other  hand,  as  we  commonly  meet  cases  of  infantile  erysipelas  occurring  spo- 
radically in  private  practice,  abdominal  distention  and  tenderness  are  not  suf- 
ficient to  indicate  peritonitis.  In  only  one  of  the  cases  embraced  in  the  fore- 
going table  was  a  post-mortem  examination  made,  and  in  that  there  had  been 
no  peritonitis.  The  occurrence  of  pharyngitis  in  connection  with  erysipelas  has 
been  already  mentioned. 

Enteritis  has  been  alluded  to  as  another  complication  in  infants.  Diar- 
rhoea has  been  stated  to  be  a  symptom  in  certain  cases,  and  it  has  been  found 
to  be  dependent  on  enteritis  of  a  mild  grade.  Billard  made  post-mortem  exam- 
inations of  16  infants  who  died  of  erysipelas,  and  "  found  in  2  gastro-enteritis, 
in  10  enteritis,  in  3  pneumonia  complicated  with  enteritis  and  cerebral  conges- 
tion, and  in  1  pleuro-pneumonia." 

Prophylaxis. — A  patient  with  erysipelas  should  be  isolated,  and  the  bed- 
ding and  linen  worn  by  him  should  be  placed  in  boiling  water  as  soon  as  re- 
moved. No  one  should  be  allowed  to  occupy  the  bed  or  room  when  vacated 
by  the  patient  until  it  has  been  thoroughly  disinfected. 

Treatment. — The  external  treatment  has  varied  greatly,  but  those  agents 
are  now  most  employed  which  have  soothing  or  antiseptic  properties.  Among 
them  we  may  mention  iodoform  in  collodion.  Scarification  and  leeching, 
formerly  employed,  have  been  abandoned  as  pernicious,  and  astringents,  as 
alum  and  sugar  of  lead,  are  now  known  to  be  inefficacious. 

I  have  obtained  the  best  results  by  applying  the  following  ointment  over 
the  inflamed  surface  every  three  or  four  hours : 

R.  Ichthyol,  gj  ; 

Ung.  aquse  rosse,  5J. — Misce. 

On  this  side  of  the  Atlantic  great  uniformity  prevails  as  regards  the  in- 
ternal treatment  of  erysipelas.  Sustaining  measures  are  prescribed,  and  the 
tincture  of  the  chloride  of  iron  is  the  tonic  generally  preferred.  Whatever 
the  intensity  of  the  febrile  reaction  and  the  stage  of  the  disease,  if  there  be 
no  intestinal  complication  ferruginous  or  other  tonics  should  be  administered. 


CRETINISM.  469 

The  largest  doses  of  the  tincture  of  the  chloride  of  iron  given  in  any  of  the 
cases  in  the  above  table  were  in  Case  No.  4 — namely,  ten  drops  every  two 
hours — and  this  patient  recovered  in  seven  days  from  a  pretty  severe  attack. 
Probably,  however,  nothing  is  gained  by  such  large  doses,  and  they  may 
irritate  the  intestinal  surface  and  increase  the  liability  to  enteritis,  which,  we 
have  seen,  complicates  a  certain  proportion  of  cases.  Four  drops  may  be  given 
every  three  hours  to  a  child  from  one  to  two  years  of  age.  Instead  of  the  iron, 
or  in  addition  to  it,  one  of  the  preparations  of  cinchona  may  be  prescribed. 

Erysipelas  being  an  asthenic  disease,  it  is  very  important  that  the  diet 
should  be  highly  nutritious  and  easily  digested.  Milk,  perhaps  peptonized, 
should  be  given  freely,  and  the  various  meat  peptones  are  also  useful. 
Brandy  or  wine  is  also  required.  If  vomiting  be  a  pronounced  symptom,  it 
may  be  necessary  to  employ  rectal  alimentation. 


CHAPTEE   VII. 

CRETINISM  (MYXCEDEMA). 

The  term  cretinism  has  long  been  employed  to  designate  a  remarkable 
disease  which  is  endemic  in  certain  localities  in  both  hemispheres,  and  also 
occurs  in  a  sporadic  form  in  places  widely  separated.  It  was  regarded  as  a 
disease  mainly  of  infancy  and  childhood  until  1873,  when  Sir  William  Gull 
published  his  observations  on  what  he  designated  "  a  cretinoid  state  super- 
vening in  adult  life  in  women,"  and  Ord  gave  it  the  name  myxoedema, 
which  is  still  retained  to  designate  cases  which  commence  in  adult  life. 

I  shall  apply  the  term  cretinism  to  cases  which  begin  in  infancy  or  child- 
hood or  come  under  observation  as  cretins  during  these  periods.  It  is 
known  that  a  large  proportion  of  cretins  manifest  symptoms  of  the  disease 
in  infancy,  or  at  so  early  an  age  that  their  cretinism  is  properly  regarded  as 
congenital.  Thus  in  his  instructive  paper  on  this  malady,  read  before  the 
New  York  Academy  of  Medicine,  Dr.  Crary  relates  the  case  of  a  female  in 
whom  the  symptoms  had  continued  during  the  entire  life  ;  and  at  the  age  of 
five  years,  when  the  child  was  not  larger  than  an  infant  of  ten  months, 
and  different  physicians  had  examined  her,  the  correct  diagnosis  was  first 
made.  The  cretinism  in  this  case,  as  in  many  others  having  a  late  diagnosis, 
was  evidently  congenital.  We  shall  see  hereafter  that  many  of  these  dwarfs 
suffering  from  cretinism  have  been  treated  for  months  by  prominent  physi- 
cians for  chronic  Bright's  disease. 

Cretinism  occurs  in  many  places  widely  separated  in  the  Alpine  chain, 
which  traverses  Switzerland,  Piedmont,  and  Lombardy ;  upon  the  northern 
slopes  of  the  Apennines  and  southern  slopes  of  the  Pyrenees  ;  in  Savoy ; 
along  the  banks  of  the  Danube  and  Traun  in  Wurtemberg ;  in  the  Black 
Forest :  in  the  valley  of  Ojat,  Russia  ;  Irkutsk,  Siberia  ;  on  both  slopes  of  the 
Himalaya  ;  and  in  parts  of  Cochin  China  and  Biirmah.  In  the  Western 
hemisphere  cretinism  occurs  along  the  valley  of  the  Magdalena  River ;  in 
certain  parts  of  New  England,  New  York,  Ohio,  California ;  but  in  no  part 
of  the  Western  hemisphere  have  cases  been  numei'ous,  so  far  as  I  can  learn. 

Although  cretinism  occurs  over  greater  and  smaller  areas  in  so  many 
localities,  sufficient  investigations  have  not  been  made  to  determine  the  influ- 
ence of  climate,  soil,  altitude,  or  the  habits  and  conditions  of  the  people 
bearing  upon  its  causation. 

I  have  not  been  able  to  ascertain  that  any  abnormal  state  of  either  parent 
or  in  their  mode  of  life  acts  as  a  predisposing  or  exciting  cause  of  cretinism 
in  their  children.     In  this  country  only  one  in  a  family  or  circle  of  relatives 


470  CONSTITUTIONAL  DISEASES. 

is,  as  a  rule,  aiFected.  But  the  fact  that  it  is  endemic  in  certain  localities  for 
a  long  series  of  years  encourages  the  belief  that  the  local  cause  or  causes, 
which  seem  to  act  by  destroying  the  thyroid  gland  or  antagonizing  its  func- 
tion, will  yet  be  discovered. 

No  other  disease  presents  to  our  consideration  more  anatomical  characters 
than  this.  Prudden  and  Delafield  say  :  "  The  most  marked  and  constant 
lesion  in  this  disease  is  an  atrophic  condition  of  the  thyroid  gland.  The 
parenchyma  is  more  or  less  completely  replaced  by  the  fibrillar  connective 
tissue  and  by  new-formed  reticular  tissue,  resembling  the  lymphatic  tissue  of 
the  lymph-nodes.  The  fat-tissues  may  be  atrophic,  and  the  subcutaneous 
tissue  has  been  shown  in  some,  but  not  in  all  the  cases,  to  contain  an  unusual 
amount  of  mucin.  In  certain  patients  the  fibres  of  the  upper  or  external 
part  of  the  corium  are  crowded  apart  by  fluid." 

Among  the  anatomical  characters  pertaining  to  the  circulatory  system 
may  be  mentioned  diminution  of  the  relative  number  of  red  corpuscles,  also 
of  the  hsemoglobin ;  white  corpuscles  normal;  hypertrophy  of  left  ventricle; 
intestinal  myocarditis,  endarteritis  ;  atheromatous  and  amyloid  degenerations. 
The  patient  is  liable  to  headaches,  anaphrodisia,  rheumatoid  pains,  low  tem- 
perature (95°  to  98°),  pulse  weak  and  slow,  respiration  17,  urine  of  low  spe- 
cific gravity,  1008-1014,  diminution  of  urea  ;  sometimes  the  presence  of 
albumen  in  small  amount,  with  a  few  hyaline  and  granular  casts ;  has 
variable  appetite  ;  constipation  ;  frequent  and  painful  micturition. 

The  body  of  the  cretin  is  always  short  and  thick.  When  fully  devel- 
oped its  height  is  from  'i^  to  42  feet ;  its  cutaneous  and  subcutaneous  circu- 
lation is  slow,  and  the  action  of  the  heart  is  generally  not  strong ;  sutures 
and  fontanelles  of  the  cranium  slow  in  closing ;  the  teeth  grow  slowly  and 
blacken  and  decay  early.  The  patient  has  atrophy  of  the  hair-follicles ; 
many  have  a  dry  and  scaly  scalp,  which  supports  a  coarse  growth  of  hair 
coming  down  low  on  the  forehead,  but  the  hair  is  absent  or  scanty  upon  the 
axillae  and  pubes ;  expression  of  face  dull ;  it  is  large  and  broad,  with  the 
usual  lines,  depressions,  and  prominences  wanting;  eyelids  cool,  smooth,  and 
dry,  appearing  thickened,  so  as  sometimes  to  nearly  obstruct  vision  by  their 
swelling  and  approximation  to  each  other  ;  nose  swollen,  short,  and  flattened  ; 
lips  large,  thick,  and  pendulous,  and  of  a  dark  violet  color ;  tongue  large, 
thick,  protruding,  and  only  partially  covered  by  the  lips ;  it  is  moved  with 
difficulty,  so  that  the  partaking  of  solid  food,  or  even  liquid  food  in  severe 
cases,  is  not  easy,  and  it  is  in  some  patients  regurgitated.  The  fact  that  there 
is  the  appearance  of  general  oedema,  and  yet  the  pitting  or  pressure  is  very 
slight,  has  been  alluded  to  by  various  writers.  The  explanation  of  this  given 
by  Delafield  and  Prudden  has  been,  I  believe,  generally  accei^ted  :  "  The  fat- 
tissues  may  be  atrophic,  and  the  subcutaneous  tissue  has  been  shown  in  some, 
though  not  all  of  the  cases,  to  contain  an  unusual  amount  of  mucin.  In 
some  cases  the  fibres  of  the  upper  layers  of  the  corium  are  crowded  apart  by 
fluid."  The  small  size  of  the  interspaces  in  the  superficial  part  of  the  corium 
and  the  viscidity  of  mucin  afford  explanation  of  the  fact  to  which  we  allude. 

Hectic  spots  occasionally  occur  over  the  malar  bones,  and  sometimes  parts 
of  the  surface,  especially  the  hands  and  face,  have  a  yellowish  or  mahogany 
color  or  that  like  Addison's  disease.  As  is  seen  in  all  the  illustrations,  the 
skin  of  the  abdomen  is  pendulous  and  flabby  and  the  swelling  of  the  breasts 
nearly  or  quite  conceals  the  nipples.  Breathing  thi-ough  the  nostrils  is  slow, 
and  if  for  any  reason  it  is  accelerated,  dyspnoea  results.  The  swelling  of  the 
Schneiderian  surface  embarrasses  respiration  through  the  nostrils,  and  snoring 
during  sleep  is  common.  A  muco-sanguinolent  or  reddish-brown  stain,  occur- 
ring during  sleep,  is  sometimes  observed  upon  the  pillow,  having  oozed  from 
the  nostrils  or  mouth. 


CRETINISM.  471 

Warm  weather  is  useful  to  these  cases,  and  during  the  heat  of  summer 
certain  cases  may  improve.  The  general  paresis  is  such  that  some  patients 
are  scarcely  able  to  stand  without  support,  even  at  the  age  of  four  or  five 
years.  Bramwell  says  that  the  walking,  or  waddling  as  he  expresses  it,  is 
like  that  of  the  hippopotamus. 

Cretinism  affects  equally  body  and  mind ;  it  arrests  bodily  and  mental 
growth  and  development.  While  at  the  age  of  four  or  five  years  the  cretin  can 
scarcely  stand  or  walk  without  support,  at  the  same  time  his  speech  lacks 
intelligence  and  sound  and  consecutive  thought,  and  is  likely  to  be  indistinct 
or  monosyllabic. 

Cretinism,  when  it  pursues  its  normal  course  uninfluenced  by  medicine,  is 
chronic.  It  may  continue  many  years,  with  occasional  amelioration  of  some 
of  the  symptoms,  but  only  for  a  brief  time.  Death  occurs  in  a  comatose 
state.  If  the  patient  reach  adult  life,  he  is  still  physically  and  mentally  de- 
generate till  the  close  of  life. 

Diagnosis. — Cretinism  has  such  pronounced  anatomical  and  physiological 
characters  that  the  diagnosis  is  easy  when  the  physician  has  once  observed  a 
case.  Yet  in  many  instances  a  mistaken  diagnosis  has  been  made  because  the 
physician  is  not  familiar  with  it  and  the  disease  is  in  its  early  stages.  It  has 
been  and  is  most  frequently  mistaken  for  chronic  Bright's  disease.  The  gen- 
eral oedema  in  the  one  from  mucin,  and  in  the  other  from  serum;  the  albumen 
and  occasional  casts  in  the  urine  and  the  general  weakness  which  occur  in 
both  diseases  have  led  to  cretinism  being  mistaken  for  Bright's  disease,  and 
vice  versa.  The  oedema  not  pitting,  not  affected  by  gravitation  or  but  slightly 
affected,  no  perspiration,  with  a  rough  and  dry  skin,  coarse,  "  wiry  "  and  scanty 
hair,  and  other  diagnostic  symptoms  which  are  related  in  this  paper  suf&ce  for 
the  exclusion  of  Bright's  disease. 

The  following  case  of  congenital  cretinism  was  presented  by  J.  P.  West, 
M.  D.,  of  Bellaire,  Ohio,  to  the  Eastern  Ohio  Medical  Society,  July  10, 189-1, 
and  January  8,  1895  : 

July  10,  1894 :  A  congenital  cretin,  now  seventeen  and  a  half  months  old,  was 
born  and  has  lived  about  a  mile  from  Bellaire,  on  a  hill  four  hundred  feet  above  the 
Ohio  River.  She  is  the  third  of  four  children  :  the  other  three  are  boys.  The  oldest 
died,  when  six  months  old,  of  cholera  infantum.  The  second  child  is  four  years  old, 
and  the  youngest  nine  weeks.  These  are  very  healthy  children.  The  father,  a  farmer, 
is  twenty-seven  and  the  mother  twenty-two  years  old,  both  being  healthy.  There  is 
no  history  of  any  hereditary  disease  nor  of  goitre,  nor  is  there  any  goitre  in  the 
vicinity. 

The  labor  was  normal,  the  child  small,  weighing  about  six  pounds.  For  the  first 
few  months  nothing  appeared  wrong  Avith  the  baby,  although  the  mother  saw  she  was 
slower  about  noticing  things  than  her  other  children  had  been,  and  would  lie  unnat- 
urally quiet  for  long  periods,  often  paying  no  attention  whatever  to  her  voice  or  to  any 
noise.  As  time  passed  she  showed  no  desire  to  sit  alone  and  seldom  a  desire  to  raise 
her  head.  Her  mouth  was  always  open,  her  tongue  protruding  ;  she  took  no  notice 
of  her  surroundings,  and  it  was  with  the  greatest  difficulty  that  her  attention  could 
be  attracted.  She" was  now  about  nine  months  old,  and  it  was  evident  to  the  pa- 
rents there  was  something  wrong,  but  it  was  believed  she  Avould  outgrow  it. 

When  seventeen  months  old  she  weighed  fourteen  and  a  half  pounds  and  Avas 
twenty-three  inches  in  height.  Her  skin  is  thick,  harsh,  dry,  and  yellowish.  Over 
her  shoulders  and  arms  there  is  some  roughness  and  peeling  of  the  skin  ;  this  often 
occurs  on  the  feet  also.  The  head  is  flat,  Avith  a  low  forehead  and  prominent  parietal 
eminences.  The  anterior  fontanel  widely  open  ;  at  times  flat,  at  others  full.  Her 
hair  coarse,  rough,  and  scanty;  eyes  dull;  the  lids  red  and  puffy,  and  cover  the 
lower  half  of  the  cornea  ;  nose  is  broad  and  flat ;  mouth  always  open  ;  lips  very  thick  ; 
neck  short  and  thick  ;  no  thyroid  gland  felt ;  chest  rather  narroAV  ;  a  small  swelling 
can  be  felt  where  each  rib  joins  its  cartilage  ;  abdomen  full,  prominent,  and  hard ; 
umbilicus  protruding  ;  abdominal  organs  normal :  the  hands  short  and  stubby  ;  legs 
short,  thick,  and  bowed;  joints  of  the  extremities  somcAvhat  enlarged;  some  lor- 


472  CONSTITUTIONAL  DISEASES. 

dosis ;  temperature  varies  from  97|°  to  99°  F.  in  the  rectum :  breathing  almost 
always  noisy,  as  if  there  were  naso-pharyngeal  obstruction  ;  respiration  24  :  pulse 
96.  I  have  never  heard  her  cry  but  once,  when  it  was  most  peculiar  and  distress- 
ing. When  crying  she  first  becomes  very  restless,  then  opens  her  mouth  wide, 
shuts  her  eyes  tight,  gets  very  red  in  the  face,  and  emits  a  sound  resembling  a 
grunting  cough.  This  sound  is  repeated  again  and  again,  from  twenty  to  forty 
seconds  apart;  the  face  in  the  interval  is  held  firmly  in  the  position  just  described. 
Her  laugh,  which  I  have  never  heard,  is  said  to  be  as  peculiar  as  her  cry. 

Is  good-natured ;  can  be  made  to  laugh,  and  seldom  cries ;  often  lies  perfectly 
still :  breathes  slowly  and  quietly,  and  cannot  be  aroused.  Occasionally,  when  laugh- 
ing or  crying,  or  even  when  still,  she  almost  strangles  ;  becomes  blue  in  the  face,  and 
it  is  only  with  difficulty  she  can  be  brought  to  her  normal  condition.  This  occurs 
without  recognizable  cause,  may  be  repeated  two  or  three  times  in  a  day,  or  may 
not  occur  for  a  week  at  a  time ;  seldom  sweats,  and  never  freely  ;  takes  but  little 
food,  and  that  milk  ;  is  very  costive. 

On  July  20,  1894,  she  was  put  on  Crary's  glycerin  extract  of  the  thyroid 
gland,  one  and  a  half  drops  three  times  a  day.  After  taking  this  two  weeks  she 
became  feverish  and  fretful,  and  the  dose  was  diminished,  and  stopped  entirely  from 
August  4th  to  7th,  then  was  begun  again  and  kept  up  until  August  23d.  From  this 
time  until  the  present  she  has  taken  almost  uninterruptedly  one  grain  of  the  pow- 
dered thyroid  twice  a  day.  In  the  latter  part  of  August  she  was  sweating  so  pro- 
fusely about  the  head,  particularly  when  asleep,  that  only  one  grain  daily  was  given 
during  the  first  ten  days  of  September,  but  as  this  had  no  effect  on  the  sweating, 
she  was  put  back  on  the  two  grains.  On  October  15th  and  again  on  December  10th 
three  one-grain  doses  were  tried,  but  she  could  not  tolerate  this  amount,  and  we 
continued  with  the  two  grains.  For  three  weeks  in  July  she  took  fluid  extract 
of  cascara  sagrada  for  the  constipation,  after  which  she  had  no  trouble  with  her 
bowels.  On  September  20th  she  was  ordered  five-  to  ten-drop  doses  of  cod-liver  oil 
and  a  small  teaspoonful  of  cream  three  times  a  day.  This  treatment  was  continued 
until  the  latter  part  of  November,  when  it  was  thought  best  to  discontinue  it,  as  the 
sweating  had  ceased  and  she  was  becoming  quite  fat. 

The  child  had  not  been  under  treatment  quite  four  weeks  before  some  improve- 
ment could  be  noticed.  Her  skin  was  not  quite  so  thick  and  yellowish,  her  lips  and 
tongue  not  so  large,  and  her  attention  more  easily  attracted.  During  August  there 
was  a  gradual  and  very  perceptible  change,  and  a  new  growth  of  hair  appeared. 
On  September  20th  I  noted  that  there  was  a  considerable  growth  of  new  hair, 
which  covered  most  of  the  scalp,  was  finer,  and  not  harsh  and  wiry  like  the  old ; 
on  the  sides  of  the  head  dark-brown,  much  darker  than  on  the  other  parts  of  the 
head.  She  plays  most  of  the  time  and  notices  everything  said  to  her  and  given 
her.  She  will  lie  on  the  floor  for  an  hour  playing  with  her  feet  and  trying  to  put 
them  in  her  mouth.  She  turns  her  head  quickly  when  spoken  to,  and  looks  at  one 
intelligently. 

October  1st :  Is  twenty -five  inches  in  height.  Weighs  sixteen  and  a  half  pounds. 
Her  abdomen  has  lost  two  and  a  half  inches  and  her  chest  gained  one  and  a  half. 
The  anterior  fontanel  is  one-third  smaller ;  skin  not  so  yellowish  nor  so  thick. 
There  is  a  little  peeling  over  the  knees  and  front  of  legs.  She  holds  the  head  up 
with  but  little  efibrt,  has  a  pleasant  expression,  smiles,  and  is  easily  made  to  laugh. 
The  cry  and  laugh  have  lost  their  former  peculiarities  and  are  now  perfectly  natural. 
The  eyelids  are  swollen  but  little,  her  lips  are  not  so  large,  and  the  tongue  is  very 
seldom  out  of  the  mouth.  A  few  hard  papules  are  scattered  over  her  face.  Her 
hands  are  not  quite  so  "  spade-like,"  but  she  retains  her  stumpy  look. 

November  1  st :  The  improvement  noted  above  has  continued,  and  she  has  gained 
in  every  way.  All  the  old  hair  is  gone.  The  head  is  not  so  flat  nor  square,  the 
fontanel  only  one-third  its  former  size.  The  tongue  no  longer  protrudes,  and  the 
mouth  is  assuming  a  much  better  shape.  The  skin  is  smooth,  soft,  and  clear.  She 
eats  and  sleeps  well,  and  plays  most  of  the  time,  knows  all  the  family,  and  exhibits 
considerable  jealousy  toward  her  younger  brother. 

January  8,  1895  :  Her  improvement  has  been  steady  and  rapid.  There  is  no 
evidence  now  that  would  indicate  that  this  child  was  a  cretin,  except  her  height. 
Sheis  several  inches  shorter  than  she  should  be  and  still  looks  somewhat  stumpy. 
Notice  that  her  skin  is  as  soft  and  clear  as  any  child's.  Her  hair  is  plentiful,  soft, 
and  silky,  while  before  it  was  scanty  and  wiry.  The  expression  of  her  face  is 
bright,  and  she  knows  all  that  goes  on  about  her.     She  will  try  to  cough  and 


CRETINISM. 


473 


sneeze,  and  do  many  other  things  when  told.  Her  eyelids  are  no  longer  swollen 
and  baggy.  Her  tongue  is  perfectly  normal,  and  her  mouth  anything  but  repul- 
sive. During  her  waking  hours  she  is  continually  on  the  move.  I  call  your  atten- 
tion, particularly,  to  her  abdomen  and  umbilicus,  and  the  changes  that  have  taken 
place  here.  The  abdomen  is  not  larger  than  it  should  be  and  the  umbilical  hernia, 
present  at  first,  is  gone.  On  October  1st  she  cut  her  two  lower  incisor  teeth,  the 
first  upper  incisor  on  November  27th  and  the  second  December  7th,  the  two  upper 


Fig.  63. 


Fig, 


Case  of  cretinism  described  above.  The  same  case  after  six  mouths'  treatment 

with  the  thyroid  extract. 

lateral  incisors  in  the  middle  of  December,  and  the  two  lower  the  latter  part  of  the 
month.     She  began  sitting  alone  the  middle  of  November,  and  now  can  stand  by 
holding  to  a  chair.     She  cannot  crawl,  but  you  would  be  surprised  to  see  how  fast 
she  can  go  across  a  room  by  rolling  over  and  over. 
This  table  will  afford  an  idea  of  her  improvement: 


Weight 

Height 

Neck 

Chest    ...... 

Abdomen 

Circumference  of  head 

Ear  to  ear 

Nose  to  occiput  .    .    . 


June  23, 1894. 


14*  lbs. 

23*  in. 

10 

15 

20 

16| 

10 

lU 


January 

8,  1895. 

22* 

lbs. 

27* 

m. 

19 

a 

21* 

u 

19 

u 

11 

n 

m 

" 

474  COXSTITUTIOyAL  DISEASES. 

Treatment. — The  remarkable  fact  has  been  established  by  many  obser- 
vations that  the  thyroid  gland  contains  some  substance  which,  administered 
to  cretins,  exerts  a  curative  eiFect.  Without  this  ductless  gland,  which  until 
recently  was  supposed  to  be  superfluous,  it  now  appears  that  man  would  be 
reduced  to  a  state  of  feebleness  and  imbecility.  There  is  no  branch  of  the 
human  race  which  does  not  have  more  mental  activity,  and  which  is  not  more 
competent  to  reduce  and  utilize  the  forces  of  nature,  than  the  ci'etin.  so  that 
if  we  all  lacked  this  substance  which  the  thyroid  gland  contributes  to  the 
system,  and  which  elevates  and  energizes  the  action  of  the  brain. — if.  in  other 
words,  all  human  beings  were  cretins,  the  condition  of  the  race  would  be 
deplorable. 

By  the  use  of  the  thyroid  gland  as  a  medicine  taken  by  the  mouth  or  by 
subcutaneous  injection  the  prominent  symptoms  of  cretinism  gradually  dis- 
appear, and  the  patient  approaches  more  and  more  the  normal  state  of  devel- 
opment and  growth.  The  temperature,  pulse,  and  respiration  become  more 
normal.  In  most  cases  gradual  improvement  occurs  under  correct  treatment 
in  the  many  particulars  in  which  the  disease  manifests  itself. 

Since  the  thyroid  gland  has  been  recognized  as  the  efficient  curative 
agent  of  cretinism,  it  has  been  employed  in  various  ways.  Murray's  original 
preparation  is  most  used.  It  contains  one  drachm  of  the  expressed  juice, 
one  drachm  of  glycerin,  and  one-half  of  1  per  cent,  of  the  aqueous  solu- 
tion of  carbolic  acid.  Five  to  fifteen  minims  are  injected  two  or  three  times 
daily  under  the  skin.  A  flushed  face,  pain  when  the  remedy  is  inserted, 
which  is  by  preference  in  the  lumbar  region,  indicate  that  the  remedy  should 
be  discontinued.  In  all  cases  of  the  use  of  the  glycerin  extract  the  glands 
are  carefully  cleaned,  minced,  and  24  grains  are  added  to  1  drachm  of  gly- 
cerin, and  after  maceration  with  the  glycerin  the  mixture  is  allowed  to 
stand,  after  which  it  is  filtered  by  compression.  Full  antiseptic  precautions 
are  used  in  the  process  of  preparing  the  gland,  and  the  glycerin  is  sterilized 
previously,  and  diseased  glands  are  rejected.  The  medicine  when  prepared 
should  be  kept  from  heat  and  light.  At  the  beginning  of  treatment  the 
dose  of  this  preparation  should  be  for  an  adult  5  drops  three  times  daily, 
with  a  gradual  increase  to  15  drops.  In  the  treatment  of  infants  1  drop  of 
the  above,  three  times  daily,  is  suflacient  at  first,  and  the  maximum  amount 
attained  by  gradual  increase  should  be  perhaps  4  drops  four  times  daily. 

In  the  opinion  of  Dr.  Crary  this  medicine  prepared  from  the  thyroid 
glands  of  lambs  is  more  efi'ectual  than  that  from  older  sheep. 

Case. — Related  by  Dr.  G.  W.  Crary,  D.  D.  :  Female,  aged  five  years,  born  in 
Boston  of  New  England  parentage ;  an  only  child.  The  mother  has  had  an  irri- 
table and  rapid  heart,  and  is  aneemic.  During  the  period  of  her  gestation,  ending 
with  the  birth  of  the  child,  she  was  constantly  nauseated.  She  had  also  tonsillitis 
for  five  weeks,  and  a  broken  rib  by  an  accident  in  the  third  month  of  gestation. 
The  birth  was  instrumental  and  the  cord  was  around  the  neck.  The  child  at  birth 
was  apparently  normal,  weighing  eight  pounds.  The  first  symptoms  of  cretinism 
were  noticed  at  the  age  of  three  months.  The  tongue  was  apparently  thick  and 
she  was  pronounced  tongue-tied.  She  weighs  at  five  years  fifteen  pounds  ;  has 
chronic  constipation.  At  the  age  of  four  months  she  cried  much,  and  had  attacks 
of  dyspnoea :  at  six  months  ceased  to  grow  and  lost  weight ;  at  eight  months  the 
abnormal  development  in  diff'erent  ways  was  first  noticed :  the  swollen  and  pro- 
truding tongue,  swelling  of  the  cheek,  lack  of  bodily  and  mental  development, 
were  apparent,  but  the  disease  was  not  diagnosticated  until  after  the  age  of  five 
years.     At  this  time  the  child  was  of  the  size  of  a  ten  months'  infant. 

The  following  symptoms  indicated  clearly  the  nature  of  the  disease  :  Slight 
mental  perception  -.  a  lighted  match  did  not  attract  attention  :  loud  noises  caused 
her  to  turn,  but  she  could  not  locate  them ;  no  response  to  the  call  of  her  name  -, 
disposition  good ;  when  placed  upon  her  back  turned  with  difficulty  upon  her  face 


CRETINISM.  475 

and  abdomen :  ^vhen  sitting  upon  the  floor  usually  fell  prostrate  without  efifort  to 
prevent  falling :  hair  of  scalp  thin  and  coarse,  but  present  upon  forehead  and  sides 
of  face  ;  temperature  97°-9S°  ;  ansemic. 

We  will  now  relate  the  mode  of  treatment :  "  I  have  used  the  glycerin 
extract  in  all  cases,  and  make  it  of  a  strength  of  24  grams  of  the  thyroid 
gland  of  the  lamb  to  1  drachm  of  glycerin.  The  glands  are  carefully 
cleaned,  minced,  and  after  maceration  with  the  glycerin  the  mixture  is 
allowed  to  stand  for  three  or  four  days,  after  which  it  is  filtered  under  pres- 
sure as  required  for  use." 

One  drop,  three  times  daily,  of  the  above  medicine  was  at  first  adminis- 
tered. This  was  gradually  increased  until  4  drops  were  given,  and  the  tem- 
perature arose  to  99°.  On  September  19th  the  appearance  was  better,  with 
more  notice  of  objects.  On  September  27th,  5  drops  were  taken  and  the 
temperature  was  normal ;  swelling  of  body,  face,  and  lips  much  reduced ; 
tongue  swells  and  more  movable,  and  could  be  kept  within  the  lips,  but  not 
within  the  closed  jaws  ;  skin  soft  and  more  moist ;  bowels  normal ;  is  brighter, 
and  turns  her  head  in  the  direction  of  the  voice.  On  October  5th  and  6th 
the  quantity  administered  of  the  extract  was  15  to  16  drops  daily,  and  her 
temperature  was  101°.  The  dose  was  therefore  reduced  to  3  drops  three 
times  daily,  but  she  was  far  advanced  toward  recovery. 

October  16th,  improvement  of  body  and  mind  continues.  The  circumfer- 
ences of  the  head,  face,  upper  extremities,  and  upper  part  of  the  trunk  have 
diminished. 

Dr.  Crary  states  that  the  eff"eets  of  the  thyroid  administration  may  be 
summed  up  as  follows :  Increased  metabolism,  shown  by — 

1.  Elevation  of  temperature  : 

2.  Increased  appetite,  with  more  complete  absorption  of  nitrogenous  food; 

3.  Loss  of  weight,  with  nitrogen  excreted  in  excess  of  that  taken  in  the 
food  ; 

4.  Growth  of  skeleton  in  the  very  young  ; 

5.  Marked  improvement  in  body-nutrition  generally  ; 

6.  Increased  activity  of  mucous  membrane,  skin,  and  kidneys. 

If  the  patient  has  recovered  or  is  well  on  the  way  to  recovery,  still  the 
medicine  should  not  be  omitted  entirely,  but  may  be  given  in  less  frequent 
doses. 


SECTIOISr  IT. 
MALFORMATIONS   AND   DEFORMITIES. 


CHAPTER    I. 

THE  DIGESTIVE  ORGANS. 

Lips  and  Palate. 

Atresia  Oris,  Microstoma,  small  mouth,  congenital  or  acquired,  requires 
treatment  either  by  dilatation  or  operation.  Dilatation  is  a  slow  and  tedious 
process,  and  must  be  persevered  in  for  a  long  period  to  eifect  satisfactory 
results.  The  tendency  to  contraction  is  very  great.  In  general  it  is  better 
to  enlarge  the  mouth  laterally,  and  draw  the  mucous  membrane  over  the 


Fig.  65. 


Fig 


Cicatricial  contraction  of  mouth. 


Large  mouth ;  pendulous  growths  near  ear. 


wound  and  attach  it  to  the  margin  of  the  skin.    If  union  is  secured,  the  result 
will  be  satisfactory.     If  it  fail  at  any  point,  the  operation  may  be  repeated. 

Macrostoma,  or  congenital  enlargement  of  the  mouth,  is  due  to  a  failure 
of  union  of  the  superior  maxillary  and  the  frontal,  nasal,  and  external  nasal 
processes.  It  is  usually  unilateral  and  can  readily  be  remedied  by  carefully 
paring  the  edges  and  uniting  them  by  suture. 


Fig.  67. 


Fig. 


Fig.  69. 


Showing  the  development  of  the 
intermaxillarv. 


Harelip,  congenital 
cicatrix. 


Harelip  as  slight 
notch. 


Harelip  is  a  congenital  non-union  of  the  central,  or  of  the  central  with 

476 


THE  DIGESTIVE  ORGANS. 


477 


Fig.  70. 


Fig.  71. 


Uncomplicated  double 
harelip. 


the  lateral  portion  of  the  upper  lip,  cleft  corresponding  with  the  junction 
of  the  intermasillary  or  of  the  maxillary  and  intermaxillary  bones  (Fig.  67)  ; 
it  is  most  common  in  males  and  is  frequently  hereditary  ;  it  may  be  "sino-le, 
double,  or  complicated. 

The  fissure  may  be  a  slight  cicatrix,  the  first  indication  of  harelip  (Fig.  68),  or 
a  short  notch  (Fig.  69) ;  but  in  general  it  extends  to  within  a  little  of  the  nostril, 
and   is    often    continuous   with    it 
(Fig.  70) :  when  double  it  may  be  of 
the  same  size  on  each  side  (Fig.  71), 
or  there  may  be  a  short  notch  on  one 
side  and  an  extensive  one    on  the 
other ;  the  substance  of  the  lip  al- 
ways varies  much  in  such  cases,  be- 
ing thick  and  fleshy  in  some  and  in 
others  thin  and  defective  in  all  re- 
spects, and  the  breadth  of  the  gap  Harelip  as  deep  fissure  on 
usually  varies  in   accordance  with  right  side. 

these  characters.  There  is  always, 
even  in  the  worst  cases  of  double  cleft,  an  intermediate  portion  of  lip  which  may 
be  broad  or  narrow,  long  or  short,  thin  or  of  the  natural  thickness  of  the  lip, 
but  generally  it  is  deficient. 

The  general  rules  of  treatment  are :  (1)  If  the  infant  is  feeble,  delay 
operation  until  after  the  third  month ;  (2)  if  healthy  and  the  cleft  single, 
operate,  if  it  is  desired,  immediately  ;  (3)  if  there  is  no 
special  urgency,  delay  till  from  the  third  to  the  sixth 
month  (the  comparative  mortality  in  the  different  periods 
favors  the  latter  course)  ;  (4)  when  there  is  inability  to 
take  food  operate  at  the  earliest  moment ;  (5)  defer  the 
operation  if  diarrhoea  or  eruptive  diseases  are  present ; 
(6)  the  midsummer  months  are  very  unfavorable ;  (7) 
if  the  harelip  is  double,  wait  until  the  child  is  two  or 
three  yeai's  old,  unless  the  conditions  render  an  earlier 
operation  necessary ;  (8)  chloroform  is  not  necessary  in 
infants :  (9)  cleanse  the  mouth,  gums,  lips,  and  nose  with 
boric-acid  solution.  The  stages  of  the  operation  are :  (1) 
The  infant,  having  a  sheet  wrapped  around  its  body  so  as 
to  enclose  its  arms,  should  be  held  upright  in  the  arms  of 
an  experienced  assistant,  and  its  head  firmly  grasped  by  a 


Fig.  72. 


Operation  for  hare- 
lip: position  for  a 
young  patient. 


72)  ;  the  older  child  should  recline 


second  assistant  (Fi 

with  its  head  raised ;  (2)  separate  thoroughly  all  adhe 
sions  to  the  gums,  so  that  the  two  flaps  move  freely  ;  (3) 
make  section  of  the  edges  of  the  cleft  with  strong  scissors 
or  with  the  knife,  and  in  such  form  as  will  most  completely  obliterate  deform- 
ity when  the  flaps  are  placed  in  perfect  apposition  ;  (4)  close  the  wound  with 
harelip  pins  if  the  tension  is  great,  and  with  silver-wire  suture  if  it  is  but 
slight ;  introduce  the  suture  or  pins  so  deeply  as  to  reach,  but  not  to  pene- 
trate, the  mucous  membrane.  Thomas  of  Birmingham  restores  the  cleft  into 
the  nostril  several  days  before  completing  the  operation.  The  flaps  rarely 
require  any  other  support  until  the  sutures  or  pins  are  removed. 

Partial  fissure  of  the  lip  is  best  treated  by  two  incisions  which  meet  at  a 
point  above  the  tip  of  the  fissure,  and  extend  into  each  flap  without  dividing 
the  margins  (Figs.  73,  74)  ;  the  double  flap  thus  formed  is  depressed,  the 
apex  presenting  downward,  and  the  wound  then  becomes  diamond-shaped. 
On  closing  the  wound  there  is  a  pouting  of  the  lip  which  gradually  disap- 
pears, leaving  no  deformity. 

Single  harelip  may  occur  on  either  side,  and  may  vary  in  extent  from  a 


478 


3IALF0RMATI0NS  AND  DEFORMITIES. 


slight  indentation  to  a  complete  division  into  the  nostril.  The  two  sides  of 
the  cleft  differ  in  their  regularity,  being  on  different  levels  and  variously 
bevelled  at  the  angles.     If  the  knife  is  used,  enter  it  at  the  angle  and  cut 


Fig.  73. 


Fig.  74. 


P'iG.  75. 


N^laton's  operation  for  partial  harelip. 


Operation  for  single  harelip. 


away  a  sufficient  portion  to  make  the  margin  straight  and  secure  easy  and 
perfect  adjustment  ;  at  the  free  border  (Fig.  75)  turn  the  edge  inward  to  the 
cleft,  to  avoid  the  notch  in  the  lip  and  save  a  portion  of  the  mucous  mem- 
brane. If  the  scissors  are  preferred,  the  same  section  can  be  made.  If  the 
free  borders  are  irregular  and  round,  the  method  of  saving  the  parings  should 
be  adopted — namely,  make  an  incision  from  A  B  (Fig.  76)  through  the  thick- 
ness of  the  lip  down  to  the  mucous  membrane,  but  not  through  it,  and  turn 
the  flap  back  ;  on  the  other  side  transfix  the  lip  at  C  and  separate  a  flap  as  far 
as  D,  dividing  it  at  E ;  bring  the  two  sides  together  and  attach  the  flap,  E,  C, 


Fig.  76. 


Fig.  77. 


Fig.  78. 


Collis's  operation  for  harelip. 


Malgaigne's  operation  for  harelip. 


to  J-  by  a  suture,  and  the  flap,  E,  7),  to  B  ;  apply  two  intermediate  sutures, 
and  the  result  will  be  a  lip  nearly  double  the  depth  (Fig.  77)  of  that  obtained 
by  the  ordinary  method  ;  the  same  result  follows  if  the  two  portions,  pared 
off  the  sides  of  the  cleft,  remain  attached  to  each  other  (Fig.  78),  as  well  as 
to  the  free  edge  of  the  lip,  and  are  turned  downward  and  the  two  sides  are 
united  as  before.     This  method  is  peculiarly  appropriate  to  clefts  which  do 


Fig.  79. 


Fig. 


^/*====. 


Harelip :  Giraldes's  method. 


not  extend  through  the  whole  depth  of  the  lip,  but  terminate  at  some  dis- 
tance from  the  nostril. 

In  cases  of  very  extensive  cleft,  or  with   a  projection  of  one  portion  of 


THE   DIGESTIVE   ORGANS.  479 

the  jaw,  the  following  operation  is  advised :  Cut  flaps  on  either  side  (Fig. 
79)  and  leave  them  attached,  one,  C,  by  the  lower,  and  the  other.  A,  by  the 
upper  end,  the  incision  being  carried  around  the  nose  as  far  as  may  be  deemed 
necessary,  E;  the  flap  attached  by  its  lower  end,  C,  is  then  turned  downward 
so  that  its  red  edge  forms  the  border  of  the  lip,  while  the  other,  A,  is  drawn 
upward  toward  the  nostril,  and  they  are  thus  dovetailed  together  (Fig.  80) 
with  interrupted  suture. 

In  some  cases  the  continuity  of  the  lip  border  may  best  be  preserved  by 
the  following  method :  Remove  the  edge  of  one  of  the  borders  clearly 
throughout ;  on  the  other  cut  a  flap  with  its  pedicle  below  ;  bring  the  edges 
together  so  that  the  flap  is  applied  from  below  upward  upon  the  notch.  If 
the  flaps  in  any  case  do  not  promptly  unite  and  the  edges  continue  to  granu- 
late, they  should  be  maintained  in  apposition  for  the  purpose  of  securing  union 
by  granulation. 

Double  harelip  may  exist  with  or  without  defect  in  the  bone.  When 
•complicated  with  fissure  of  the  hard  palate,  the  best-conducted  operations  are 
very  liable  to  fail.  If  the  clefts  are  limited  to  the  lips  (Fig.  81),  and  there 
is  not  severe  tension,  operate  upon  both  sides  at  the  same  time  (Fig.  82)  ;  but 

Fig.  81.  Fig.  82. 


Double  harelip. 

if  the  traction  upon  the  parts  is  great,  operate  upon  one  side  at  a  time,  mak- 
ing a  central  flap,  which  can  be  attached  at  the  sides  and  to  the  angles  of  the 
flaps  (Fig.  82)  ;  first  make  the  incisions,  B  and  A  ;  then  pare  the  edges  of  the 
projecting  mass  C;  turn  the  flaps,  A  and  i>,  downward  and  unite  them.  The 
result  is  good  (Fig.  82). 

If  the  intermaxillary  bone  has  not  formed  ossific  union,  it  projects  more 
or  less,  according  to  its  attachments  to  the  septum  nasi.  Except  when  it  is 
a  mere  pendulous  mass  from  the  tip  of  the  nose,  efi'orts  should  be  made  to 
save  it,  both  because  it  contains  the  sacs  of  the  incisor  teeth,  and  its  presence 
is  necessary  to  maintain  the  form  of  the  upper  jaw  and  lip.  In  the  slighter 
cases  of  projection  of  the  intermaxillary  bone  it  is  merely  necessary  to  frac- 
ture its  attachment  to  the  septum  and  press  the  mass  back  into  position,  or, 
if  it  be  too  large  to  flll  the  gap,  the  exuberant  parts  must  be  pared  away  at 
the  sides,  the  adjacent  sides  of  the  superior  maxillary  bones  refreshed,  and  any 
teeth  projecting  across  the  cleft  removed. 

A  wedge-shaped  piece  maybe  cut  from  the  septum,  which  allows  the  mass 
to  recede  more  readily  into  the  cleft  (Fig.  83) ;  a  suture  may  be  applied  to 
the  sides  of  this  notch  to  retain  the  depressed  bone  in  place.  The  bone  has 
been  retained  in  position  by  silver  sutures  passed  through  it  and  the  adjoin- 
ing hard  palate,  but  three  teeth  were  destroyed  by  the  penetration  of  their 
sacs.  The  bone  has  been  successfully  held  in  position  by  at  once  uniting  the 
clefts  in  the  soft  tissues.  When  the  flaps  are  insufiicient  to  close  the  cleft, 
they  may  be  dissected  away  from  the  cheek  to  such  an  extent  as  to  admit  of 
their  easy  approximation.     If  the  process  is  tedious,  it  should  be  divided  into 


480 


MALFORMATIONS  AND  DEFORMITIES. 


stages,  dealing  first  with  the  projecting  intermaxillary  bone,  and  then  with  the 
soft  parts.     When  the  mass  is  merely  suspended  from  the  tip  of  the  nose, 


Fig.  S3. 


Fig.  84. 


Fig.  85. 


Before  operation. 


Front  view. 


Side  view :  after  operation. 


it  must  be  removed  by  careful  dissection  with  strong  scissors,  the  soft  parts 
being  retained  and  so  placed  as  to  form  a  columna  nasi  or  to  fill  the  gap  in 
the  lip  (Fig.  84).     The  result  is  very  favorable  (Fig.  85). 

The  use  of  an  (esophageal  tube  to  feed  the  child  after  operation  may  be  employed  to 
prevent  the  contact  of  food  with  the  wound. 

Hypertrophy  of  the  mucous  glands  is  characterized  by  two  elevated  pen- 
dulous portions  of  tissue  appearing  on  either  side  of  the  middle  line  (Fig. 
86),  and  is  due  to  an  increase  of  the  glands  of  the  part  and  not  of  the  mucous 
membrane.  Make  a  straight  or  elliptical  incision  in  the  line  of  the  lip  :  excise 
the  submucous  tissue  ;  close  the  incision  with  fine  sutures. 

Hypertrophy  of  the  lip  generally  occurs  in  scrofulous  subjects  and  con- 
sists in  chronic  thickening  of  the  deep  structures.     It  may  result  from  a  con- 


FlG. 


Fig.  87. 


Hypertrophy  of  mucous  glands  of  lips  (Bryant ). 


Hypertrophy  of  lip  (Buck). 


genital  enlargement  of  capillaries  constituting  a  n^evus  (Fig.  87).  and  then  has 
a  raspberry  discoloration,  is  flabby,  pendulous,  and  contains  hard  knots  in  its 
substance.  Operate  as  follows :  Remove  a  V-shaped  patch,  equidistant  from 
the  angles  of  the  mouth,  and  having  its  apex  low  down  in  the  median  line 
under  the  chin  ;  divide  the  mucous  membrane  along  the  line  of  its  reflection 
from  the  jaw  on  either  side  of  the  wound ;  bring  the  opposite  edges  of  the 
wound  together  and  secure  them  in  exact  coaptation  by  pin-sutures  inserted 
at  equal  distances  from  each  other  below  the  lip-border ;  between  every  two 
pin-sutures  add  a  silver  wire,  and  on  the  vermilion  border  fine  thread  sutures, 
one  being  on  its  buccal  surface ;  when  union  is  complete,  a  second  operation 
is  required  to  reduce  the  thickness  of  the  lip.  This  is  efi"ected  by  two  parallel 
incisions,  including  one-third  of  the  thickness  of  the  lip  and  penetrating  deeply 
into  its  substance.  The  raspberry  color  must  be  destroyed  by  the  galvano- 
cautery. 


THE  DIGESTIVE  ORGANS. 


481 


The  Tongue. 

Tongue-tie  is  a  eougenitai  malformation  in  which  the  frgenum  linguae 
extends  too  far  forward  toward  the  point  of  the  tongue,  and  remains  rather 
below  its  natural  height,  measured  from  the  floor  of  the  mouth  :  protrusion 
is  hindered,  and  where  the  defect  is  great  the  tongue  cannot  be  applied 
against  the  roof  of  the  mouth  ;  the  slight  form  is  harmless,  but  the  severe 
form  presents  a  great  obstacle  to  sucking ;  in  the  latter  case  it  is  advisable 
to  operate.  Division  has  been  followed  by  fatal  hemorrhage  from  the  ranine 
arteries,  but  carefully  performed  it  is  without  danger  and  painless  ;  pass  the 
first  and  second  fingers  of  the  left  hand,  palm  downward,  under  the  tip  of 
the  tongue  on  either  side  of  the  fraenum,  and  put  it  well  on  the  stretch  ; 
snip  the  edge  of  the  frgenum  with  blunt-pointed  scissors  below  the  fingers, 
thus  escaping  the  ranine  arteries,  which  run  along  the  lower  surface  of  the 
tongue  ;  push  the  tongue  upward  against  the  roof  of  the  mouth,  and  divide 
further,  if  necessary  ;  this  method  is  preferable  .:■  the  use  of  the  cleft  in  the 
handle  of  the  ordinary  director. 

Hypertropliy  of  the  tongue  is  usually   congenital,   and  may  be  noticed 
immediately  after  birth,  or  may  appear  later,  being  uncertain  in  its  rate  of 
growth ;  when    fully    developed  the    tongue    protrudes, 
with  constant  dribbling  of  saliva,  and  causes  deformity  Tir   ss 

(Fig.  88)  of  the  jaw.  The  treatment  by  pressure  and 
astringents  may  first  be  attempted,  as  follows :  Apply 
daily  cupri  sulph.  9j  to  aq.  §j  on  lint,  and  compress 
with  a  bandage.  If  these  means  fail,  removal  is  the 
only  alternative.  Excision  is  very  dangerous  when  the 
organ  is  large,  owing  to  hemorrhage ;  the  knife,  ligature, 
ecraseur,  or  galvano-cautery  may  be  employed ;  when 
the  knife  is  used  the  flaps  may  be  made  by  transfixing 
the  tongue  laterally  or  vertically  ;  the  former  method 
is,  in  general,  preferable,  as  the  thickness  of  the  tongue 
is  thereby  much  more  reduced. 

The  head  being  supported  against  the  breast  of  an  assist-       Hypertrophy  of  the 
ant,  who  retracts  the  angles  of  the  mouth,  seize  the  tongue  "tongue  (Buck;, 

with   forceps  on  its  edges,  and  draw  it  well  forward :  pass  a 

strong  ligature  transversely  through  the  back  part  of  the  tongue  with  which  to 
draw  the  organ  forward  :  transfix  the  tongue  from  side  to  side  at  the  point  where 
excision  is  to  be  completed,  and  cut  forward  and  downward  through  its  under  sur- 
face, making  the  lower  flap  ;  form  the  upper  flap  by  cutting  in  a  reverse  direction, 
backward  and  downward,  to  the  point  where  the  first  section  had  commenced ; 
ligate  the  arteries  and  secure  the  flaps  in  contact  with  sutures  ;  recovery  with  a 
flattened  tongue  and  good  speech  results. 

A  vertical  incision  may  be  required,  in  order  to  remove  a  V-shaped  portion  of 
sufiicient  size,  and  bring  together  the  lateral  flaps  so  as  to  form  a  new  tip,  which 
shall  fall  within  the  teeth  ;  the  patient,  angesthetized,  being  placed  with  the  head 
elevated  and  held  by  an  assistant,  pass  the  knife  through  the  substance  of  the 
tongue  external  to  the  middle  line,  to  avoid  the  ranine  artery  :  cut  out  a  flap,  and 
tie  all  the  bleeding  vessels  :  pass  a  strong  ligature  through  this  flap  to  prevent  the 
tongue  falling  back  ;  enter  the  knife  at  the  same  point :  carry  it  across  the  middle 
lines,  dividing  the  ranine  arteries,  which  must  be  tied  before  the  flap  is  finally 
separated  :  close  the  wound  with  strong  sutures  thus:  Introduce  these  sutures  ihto 
the  lateral  flaps,  and  on  tying  them  the  tip  of  the  tongue  assumes  a  natural  appear- 
ance. Removal  by  the  ecraseur  involves  less  immediate  risk  from  hemorrhage,  but 
is  liable  to  be  followed  by  dangerous  inflammatory  swelling.  If  employed,  proceed 
thus :  Pass  the  chain  of  a  very  stout  instrument  through  the  substance  of  the 
tongue  at  the  same  point  as  in  excision  by  the  knife,  and  when  it  has  worked  its 
way  outward  a  little,  pass  a  second  chain  and  work  it  at  the  same  time  toward  the 
opposite  side. 
31 


482 


MALFORMATIONS  AND  DEFORMITIES. 


Angeioma,  vascular  tumor,  may  be  venous  or  ai'terial  ;  the  former  is 
common,  the  latter  rare.  Venous  angeiomas  are  generally  congenital,  may 
be  single  or  multiple ;  usually  appear  on  the  anterior  part  of  the  dorsum, 
projecting  slightly  above  the  surface,  thinning  the  mucous  membrane  over 
them,  and  showing  a  dull  blue  or  livid  color ;  in  some  the  contents  may  be 
pressed  out,  and  in  others  the  mass  feels  tense  and  elastic  like  a  thin  cyst 
filled  with  fluid  ;  they  are  usually  quite  painless,  seldom  very  large,  and  not 
inconvenient  except  from  their  bulk  and  occasional  liability  to  bleed.  They 
may  diminish  and  disappear,  or  increase,  or  undergo  warty  degeneration. 
They  are  composed  of  numerous  anastomosing  vessels,  or  are  cavernous. 
The  treatment  is  destruction  by  the  actual  or  galvano-cautery,  the  latter 
being  preferable.  The  point  of  one  of  the  platinum  instruments,  at  a  dull- 
red  heat,  should  be  made  to  penetrate  deeply  into  the  substance  of  the 
growth,  and  moved  in  all  directions  through  it  until  it  has  been  completely 
broken  up  ;  repeat  the  operation  if  necessary. 

Papillomata,  warty  tumors,  occur,  usually,  on  the  dorsum  within  the 
papillary  area,  and  are  then  due  to  hypertrophy  of  the  natural  papillae ;  they 
may  grow  on  the  under  surface.  They  may  be  mistaken  for  condylomata  or 
warty  carcinomata ;  the  history  of  the  case  is  the  guide  to  a  correct  diag- 
nosis in  the  first  class,  and  the  age  of  the  patient  and  the  induration  of  the 
base  determine  the  latter.  In  children  the  hypertrophied  papillas  may  be 
destroyed  by  the  solid  nitrate  of  silver  ;  the  larger  pedunculated  growth  may 
be  removed  with  scissors  or  the  ligature  ;  the  larger  papillomata  should  be 
removed  with  the  knife  or  scissors. 


The  Palate. 

Congenital  Defects  of  the  Palate, — Fissure  or  cleft  of  the  palate,  as  a 
congenital  defect,  may  involve :  (1)  only  the  ovula,  1  (Fig.  90) ;  (2)  the  soft 

Fig.  89. 


Mouth-gag. 


palate,  2  (Fig.  90) ;  (3)  the  hard  palate  as  far  forward  as  the  middle  of  the 
palate  process  of  the  superior  maxillae  or  through  the  palate  bones  only  (Fig. 
91)  ;  (4)  the  alveolar  ridge  entire  with  the  cleft  of  the  palate  (Fig.  92)  ;  (5) 
cleft  or  notch  of  the  alveolar  ridge  with  entire  cleft  of  palate  ;  (6)  double 
cleft  of  the  alveolar  ridge,  with  fissure  from  each  running  backward  and  in- 
ward and  joining  behind  the  intermaxillary  bones,  becoming  continuous  with 
a  median  fissure. 

There  are  also  many  o;rades  of  separation  of  the  fissure.     Usually  the  cleft  in 
the  palate  is  narrower  in  front  and  widens  toward  the  velum,  but  in  some  the  gap 


THE  DIGESTIVE  ORGANS. 


483 


will  be  very  wide  and  in  others  very  narrow,  though  complete  from  alveolus  to 
uvula.  In  partial  clefts  the  breadth  is  often  much  greater  than  is  apparent  from 
its  extent,  in  some  instances  giving  the  greatest  breadth  met  with. 

Fig.  90.  Fig.  91.  Fig.  92. 


Slight  Assure. 


Large  fissure. 


Fissure  of  soft  and  iiard  palate. 


The  operations  undertaken  for  the  relief  of  fissured  palate  are  staphylor- 
rhaphy and  uranoplasty,  the  former  being  an  operation  on  the  soft,  and  the 
latter  on  the  hard  palate. 

If  the  uvula  alone  is  bifid  and  the  voice  unaffected,  it  is  better  not  to  in- 
terfere with  the  fissure.  As  the  articulation,  however,  is  generally  affected, 
closure  by  suture  is  the  rule  of  treatment ;  the  operation  may  be  performed 
at  any  age,  but  when  circumstances  are  unfavorable  to  an  early  operation,  it 
is  better  to  defer  it  until  the  child  is  at  least  three  or  four  years  old,  or  even 
until  adult  life.  If  the  patient  is  a  child,  chloroform  should  be  given  and 
the  gag  inserted  (Fig.  93). 

Staphylorrhaphy,  suture  of  the  soft  palate,  is  an  operation  which  the 
surgeon  need  have  no  hesitation  of  undertaking  when  the  cleft  is  limited. 

The  child  being  properly  supported  by  an  assistant,  clean  the  mouth  with  boric 
acid.     First  seize  one  point  of  the  cleft  with  long  spring  forceps,  draw  it  for- 
ward, transfix  it  near  its  inner  border  with  a  narrow,  sharp  knife  on  a  long  handle, 
and  freely  cut  upward  or  down- 
ward   and    remove    the     mucous  Fig.  93. 
membrane  along  the  whole  of  its 
inner  margin  (Fig.  94)  ;  make  the 
same  section  on  the  opposite  side 
and  divide  the  angle  of  union  last. 

When  the  cleft  extends  for- 
ward through  the  whole  of  the 
velum,  or  even  to  a  slight  extent 
into  palate  bones,  the  operation  is 
more  complicated,  for  every  at- 
tempt to  bring  the  edges  of  the 
fissure  together  is  opposed  by  the 
combined  actions  of  the  levator 
and  tensor  palati  muscles  on 
either  side,  drawing  directly  away 
from  the  median  line  at  which  the 
edges  of  the  fissure  should  meet ; 
the  muscles  must  therefore  be 
divided  to  ensure  success.  The 
relaxation  of  the  tissues  of  the 
fissured  velum  may  generally 
be  sufiiciently  secured  by  means 
of  incisions  made  with  strong 
curved  scissors,  so  as  to  divide  the 
posterior  pillar  of  the  palate  just  where  it  begins  to  spread  out  into  the  velum  ;  in 
some  cases  an  additional  stroke  or  two  of  the  scissors  is  necessary  to  divide  a  band 


Wliitehead's  gag  and  tongue-depressor. 


484 


MALFORMATIONS  AND  DEFORMITIES. 


Fig.  94. 


of  firm   tissue   extending  above  and  behind  the  soft  palate.     The  division  of  the 

muscles  is  also  effected  as  follow^s  :  Pass  a  suture 
through  one  section  of  the  soft  palate  at  the  root  of 
the  uvula,  secure  the  ends  by  a  knot,  and  have  it 
held  outside  the  mouth  ;  repeat  a  similar  suture  on 
the  opposite  side  ;  draw  one  of  the  sutures  firmly, 
holding  one-half  of  the  soft  palate  to  its  opposite 
side,  so  as  to  stretch  this  section  of  the  palate  toward 
the  median  line  ;  recognize  the  hamular  j^rocess  in 
the  substance  of  the  soft  palate  internal  and  a 
very  little  posterior  to  the  last  molar  tooth ;  intro- 
duce the  point  of  a  thin,  narrow  knife  fixed  in  a 
long  handle,  the  blade  down,  a  little  in  front  and 
to  the  inner  side  of  this  process,  and  carry  it  up- 
ward, backward,  and  somewhat  inward,  until  the 
point  is  seen  in  the  gap,  having  passed  through 
the  entire  thickness  of  the  soft  palate,  and  cut  par- 
tially, if  not  wholly,  the  tendon  of  the  tensor 
palati ;  raise  the  handle  of  the  knife,  depressing 
its  point,  and  as  the  blade  is  drawn  forward  make 
it  cut  downward,  so  as  to  pass  through  a  consider- 
able section  of  a  circle  on  the  posterior  surface  of 
the  palate,  by  which  the  division  of  the  greater  portion  of  the  levator  palati  is 
effected ;  complete  its  section  as  the  knife  is  withdrawn  (Fig.  96). 

If  the  muscle  is  properly  divided,  all  movements  of  the  palate  cease,  and  it 
becomes  pendulous  and  flaccid  :  if  there  be  any  further  resistance,  reintroduce  the 
knife  and  divide  the  fibres  more  freely.  The  divisions  of  the  muscles  may  be  made 
a  day  or  two  before  the  operation  for  closing  the  fissure,  and  thus  avoid  the  bleed- 
ing ;  or  the  muscles  may  be  divided  after  paring  the  edges,  and  inserting  the 
sutures,  the  palate  being  put  on  the  stretch  by  means  of  the  threads  held  in  the 
hand ;  lateral  incisions  through  the  soft  parts  comjjletely  dividing  the  soft  palate 
from  its  lateral  attachments  will  allow  the  two  halves  to  fall  together. 

The  edges  of  the  fissures  should  now  be  thoroughly  denuded  of  mucous  mem- 
brane. The  suture  selected  should  be  silkworm-gut  or  Chinese  silk,  made  antiseptic. 
First  decide  how  many  sutures  will  be  required,  and  observe  the  points  at  which 
they  should  be  inserted  to  correspond  on  each  side ;  the  sutures  in  each  needle 
should  be  at  least  one  yard  in  length,  and  each  suture  should  be  doubled  for  its 
whole  length  before  being  passed  :  with  the  needle  in  the  right  hand  and  a  pair  of 
long  spring  forceps  in  the  left,  push  the  point  of  the  needle  through  the  soft  palate 


Showiug  the  paring  of  the  edges 
of  fissures  after  the  introduction 
of  the  sutures. 


Fig.  95. 


Fig.  96. 


Fig.  97. 


Passing  the  suture. 


S^dillot's  operation  for 
staphylorrhaphy. 


Incisions  to  relieve  tension. 


on  the  patient's  left  side,  as  near  to  its  anterior  margin  as  practicable  ;  seize  one 
thread  of  the  suture  and  draw  it  forward  ;  pass  the  needle  on  the  opposite  side 
with  a  double  thread,  the  loop  of  which  should  be  drawn  out ;  the  needles  being 
removed,  the  single  thread  of  the  one  side  is  passed  through  the  loop  of  the  other, 
the  looped  thread  withdrawn  from  the  palate  carrying  the  single  suture  through 


THE  DIGESTIVE   ORGANS.  485 

the  opposite  side  (Fig.  95) ;  repeat  until  the  requisite  number,  three  or  four,  is 
inserted  ;  tie  each  separately,  and  not  too  tightly,  to  allow  for  swelling ;  a  slip- 
knot (Fig.  95)  to  bring  the  edges  together,  and  a  second  knot  over  that,  are  suffi- 
cient (Fig.  96)  ;  the  ends  should  not  be  cut  off  very  close.  A  perforated  shot  may 
be  passed  over  the  suture,  and  compressed  to  prevent  slipping.  If  wire  is  used,  it 
must  be  applied  with  the  wire  adjuster,  be  nicely  twisted,  and  cut  closely.  The 
after-treatment  must  be  carefully  attended  to ;  the  diet  should  be  liquid ;  no  con- 
versation should  be  allowed  ;  the  sutures  may  be  removed  after  about  eight  days. 

To  relieve  tension,  the  soft  palate  may  be  incised  (Fig.  96),  or  by  the  side  cuts, 
B  (Fig.  97),  subsequently  gaping  so  as  to  appear  as  arches. 

Uranoplasty,  closure  of  fissure  of  the  hard  palate,  may  be  undertaken  at 
any  age,  yet  as  the  real  object  of  the  operation  is  to  enable  the  patient  to 
articulate  plainly  and  intelligibly,  and  as  a  child  does  not  commence  to  articu- 
late, as  a  rule,  before  twelve  months  old,  nor  to  pronounce  many  words  before 
two  years  of  age,  the  reasons  are  strong  against  its  performance  prior  to  this 
latter  period  of  life,  for  the  child  is  now  in  a  much  more  favorable  condition 
to  undergo  the  operation,  and  less  liable  to  succumb  to  the  effects  of  the  loss 
of  blood.  The  early  treatment,  therefore,  is  the  proper  nourishment  of  the 
infant  until  it  reaches  the  requisite  age,  and  the  mother's  milk  is  the  only 
food  that  should  be  given  for  the  first  six  or  eight  weeks ;  if  the  child  cannot 
nurse,  owing  to  the  extent  of  the  cleft,  it  must  be  hand-fed  with  her  milk. 
The  operation,  whatever  may  be  the  extent  of  the  fissure,  consists  in  dissect- 
ing up  the  membrane  covering  the  hard  palate,  quite  back  to  the  alveolar 
processes,  including  the  periosteum,  so  as  to  form  muco-periosteal  flaps.  The 
result  will  be  successful  in  any  case  where  the  patient  is  fairly  healthy  and 
the  parts  can  be  brought  together  without  undue  tension.  The  closure  is 
eff'ected  not  only  by  these  soft  tissues,  but  also  by  bone  subsequently  repro- 
duced in  the  periosteal  layer.  As  the  success  of  the  operation  depends  upon 
immediate  union  of  the  edges  of  the  flaps,  examine  the  patient  carefully  to 
ascertain  if  he  is  in  a  condition  of  health  to  justify  the  expectation  of  union 
by  first  intention  ;  if  there  are  any  signs  of  disordered  health  or  defective 
power,  as  pustules,  herpes,  excoriated  lips  or  nostrils,  the  operation  should  be 
postponed.  The  operation  may  be  completed  at  one  or  at  several  sittings ; 
unless  there  are  circumstances  of  peculiar  difficulty  in  the  case,  which  will 
make  the  operation  either  unusually  tedious  or  will  necessitate  such  an  exten- 
sive division  of  the  soft  parts  as  would  endanger  the  flaps,  the  whole  cleft 
should  be  closed  at  one  operation.  In  an  ordinary  case  of  cleft  of  the  hard 
and  soft  palate  proceed  as  follows  : 

Place  the  patient,  etherized,  in  a  good  light ;  introduce  the  gag  previously  fitted 
to  the  mouth  (Fig.  93) ;  or,  if  the  cleft  is  through  the  alveolar  process  also,  select 
a  gag  which  has  no  central  roof  portion.  Operate  first  on  the  soft  palate  ;  pare  the 
edges  of  the  cleft  from  below  upward,  the  point  of  the  uvula  being  held  with  for- 
ceps, b  (Fig.  88),  to  render  it  tense  ;  apply  the  sutures  from  below  upward,  passing 
them,  if  possible,  completely  through  both  sides  to  avoid  the  loops  described,  and 
fastening  each  after  the  next  is  passed  ;  relieve  the  undue  tension  by  longitudinal 
incisions  on  either  side  parallel  with  the  cleft  and  just  internal  to  the  hamular 
process,  avoiding  the  post-palatine  foramen,  or  cut  the  muscles,  seizing  with  the 
forceps,  b  (Fig.  88),  the  palato-pharyngeus  muscles  and  dividing  them  with  the  scis- 
sors, f  (Fig.  88),  low  down,  and  also  the  levator  palati  of  both  sides.  When  the 
soft  palate  has  been  closed  and  the  point  in  the  velum  has  been  reached  where  the 
sutures  can  no  longer  be  fastened,  from  the  amount  of  tension,  proceed  to  operate 
on  the  hard  palate  if  the  condition  of  the  patient  do  not  forbid  it.  Separate  the 
soft  tissues  from  the  bone,  commencing  at  the  edge  of  the  cleft  and  dissecting  out- 
ward to  the  alveolar  process,  or,  which  may  be  preferable,  from  the  alveolar  border 
toward  the  fissure,  as  follows  :  Make  an  inscision  close  to  and  parallel  with  the 
alveolar  ridge,  from  a  point  opposite  the  last  molar  tooth  forward  to  the  canine, 
and  separate  the  flaps  from  the  bone  by  means  of  the  periosteotome,  /i,  i  (Fig.  88), 
commencing  at  the  incisors  and  proceeding  inward  to  the  edge  of  the  gap,  avoid- 


486 


MALFORMATIONS  AND  DEFORMITIES. 


ing  bruisine;  the  flaps ;  these  flaps  should  now  fall  inward  and  downward  and 
meet  in  the  median  line  without  the  slightest  traction  ;  if  the  edges  do  not  readily 
meet,  the  flaps  have  not  been  sufficiently  detached,  and  search  m-ust  be  made  for  the 
point  preventing  descent,  which  should  be  freely  liberated  ;  pare  the  edges  with  a 
sharp  knife  so  that  two  entire  and  fresh  raw  surftices  are  brought  accurately  in  con- 
tact ;  pass  the  sutures  as  in  closure  of  the  soft  palate. 

No  special  treatment  is  required,  except  to  avoid  giving  warm  food  until 
Fig.  98.  Fig,  99. 


j1,  preliminary  puncture  with  awl  to  give  line  for  chisel;  B,  incision  through  bone  completed 
by  chisel ;  C,  holes  bored  through  hard  and  soft  palates  for  sutures  :  D,  junction  of  hard  and 
soft  palates ;  E,  E,  lateral  openings  subsequently  filled  up  by  granulation. 

the  day  after  the  operation,  and  to  abstain  from  looking  at  the  palate ;  give 
first  iced  milk,  and  afterward,  for  a  fortnight,  such  food  as  eggs,  milk,  rice 
milk,  cream  custard,  stewed  fruit,  arrow-root,  soup,  beef-tea,  pounded  meat 
with  wine,  brandy,  or  malt  liquors  ;  children  and  delicate  young  persons  should 
be  kept  in  bed  for  a  week,  when  practicable  ;  the  sutures  should  remain  three 
weeks  or  a  month  in  children,  and  be  removed  under  an  anaesthetic. 

The  following  method  of  operating  has  given  excellent  results :  Holes  are 
drilled  with  a  cui-ved  brad-awl  through  the  margin  of  the  hard  palate  (Fig.  98) 
for  the  passage  of  the  threads,  while  the  palate  itself  is  then  cut  through  with  a 
chisel  in  a  line  parallel  to  and  about  half  an  inch  from  the  cleft,  B  ;  such  step  being 
facilitated  by  previously  drilling  the  bone,  A  ;  this  loosening  of  the  margins  of  the 
hard  palate  allows  the  borders  of  the  cleft  to  be  brought  together  along  its  whole 
length  after  the  margins  have  been  pared  and  the  stitches  twisted  (Fig.  99). 

It  frequently  happens  that  under  the  most  favorable  circumstances  a  small  aper- 
ture will  remain  ;  these  openings  are  not  unlike  those  slight  congenital  defects 
which  appear  in  the  palate  as  orifices,  or  which  result  from  syphilitic  caries ;  they 
may  be  closed  by  subsequent  operations  or  with  a  metal  plate  or  with  a  hard-rubber 
obturator. 

Contracted  soft  palate  frequently  results  from  successful  closure  of  the 
cleft,  and  leads  to  imperfect  speech.  With  a  view  to  lengthen  the  curtain  or 
relieve  the  tension  upon  it,  several  operations  have 
been  performed :  (1)  The  inner  borders  of  the  palato- 
pharyngeus  muscles  have  been  pared  and  united,  but 
the  operation  had  the  effect  of  compelling  the  patient 
to  breathe  entirely  through  the  mouth,  without  im- 
proving speech.  (2)  The  attachments  of  the  palate 
to  the  sides  of  the  fauces,  together  with  the  anterior 
and  posterior  pillars,  may  be  divided  as  follows  :  Pass 
a  spatula  behind  the  soft  palate,  1,  2  (Fig.  100),  both 
to  steady  and  draw  it  forward  ;  then  transfix  the 
soft  palate  by  a  sharp-pointed  bistoury  by  the  side 
of  the  spatula  and  at  the  inner  edge  of  the  hamu- 
lar  process,  1,  4,  and  cut  through  the  free  margin  of 
100),  dividing   the   tensor  palati,  palato-glossus,  and 


Fig.  100. 


Contraction  of  soft  palate. 


the   palate   to   2  (Fi§ 


THE  DIGESTIVE  ORGANS.  487 

palato-pharyngeus  muscles  ;  retraction  follows,  3 ;  sutures  are  now  passed 
through  the  sides  of  the  flap  from  before  backward,  thus  hemming  the 
mucous  membrane,  5  ;  this  operation  is  extremely  simple,  comparatively  pain- 
less, and  has  always  resulted  in  some,  and  in  many  instances  marked,  im- 
provements of  the  voice.  (3)  Dissection  of  the  palato-pharyngeus  muscles 
to  form  flaps  in  connection  with  a  raised  portion  of  the  mucous  membrane  of 
the  prevertebral  region  was  attempted,  but  not  completed.  Careful  anti- 
sepsis must  be  practised. 

The  Rectum. 

Imperforate  rectum  is  caused  by  a  membranous  partition  which  may  be 
just  within  the  anus  or  an  inch  or  more  above ;  it  varies  in  thickness,  but  is 
usually  thin  ;  the  symptoms  are  retention  of  the  meconium  and  vomiting. 
Examination  with  the  finger  or  probe  or  a  small  elastic  catheter  or  bougie 
determines  its  nature  ;  if  the  membrane  is  thick,  it  may  not  be  possible  to 
decide  whether  the  intestine  is  continuous  above  till  an  incision  is  made,  but 
if  it  is  thin  it  will  bulge  down  upon  the  finger,  especially  when  the  child 
cries.  Delay  the  operation  a  day  or  two,  until  the  meconium  dilates  the  lower 
part  of  the  intestine  ;  if  the  septum  is  thin,  break  it  down  with  the  end  of 
the  little  finger ;  if  thick,  puncture  with  a  sharp-pointed  bistoury,  the  blade 
being  wrapped  with  thread,  and  cautiously  carried  into  the  passage  on  a 
grooved  director  or  along  the  finger ;  enlarge  the  puncture  by  a  crucial  in- 
cision ;  dilate  with  the  end  of  the  little  finger ;  pass  the  finger,  or  a  bougie 
of  suitable  size,  daily,  for  several  months. 

Absence  of  the  rectum  may  be  partial,  which  is  most  common,  or  com- 
plete, the  anus  being  normal.  When  only  partially  absent,  the  other  portion 
usually  terminates  in  a  cul-de-sac  at  a  greater  or  less  distance  from  the  sur- 
face of  the  body,  or  it  may  be  prolonged  as  a  narrow  tube  or  imperforate  cord, 
and  blended  with  adjacent  parts  ;  if  wholly  absent,  the  canal  may  open  in  some 
abnormal  situation.  The  diagnosis  is  made  by  examination  with  the  finger  or 
a  bougie.  If  the  occlusion  is  not  thick,  it  is  only  necessary  to  incise  the  in- 
tervening tissues  and  dilate.  If  the  part  is  very  thick  and  hard,  dilate  the 
anus,  if  necessary  add  lateral  incisions  ;  separate  the  mucous  membrane,  and 
draw  down  the  rectum  ;  cut  off"  that  portion  including  the  septum,  and  attach 
the  margin  by  suture  to  the  skin.  If  the  rectum  is  wholly  absent  and  the 
bowel  cannot  be  reached  by  dissection,  a  last  resort  is  to  make  an  artificial 
anus  in  the  left  groin. 

The  Anus. 

Contraction  of  the  anus  may  be  due  to  a  congenital  narrowing  of  the 
lower  part  of  the  rectum  and  the  anus,  or  of  the  anal  orifice  alone,  or  the  in- 
tegument may  extend  partially  over  the  anus ;  the  situation  and  form  of  the 
anus  are  generally  normal,  but  the  orifice  is  puckered  or  plicated ;  the  narrow- 
ing may  be  slight  or  only  admit  the  passage  of  a  probe.  The  symptoms  are 
absence  of  meconium  and  progressive,  painful  tension  of  the  abdomen,  and 
vomiting.  The  treatment  is  dilatation  :  Select  a  graduated  bougie,  the  tip  of 
which  readily  passes  the  contraction  ;  inject  a  little  oil  to  lubricate  the  parts ; 
or,  if  there  are  feces  in  the  rectum,  move  the  bowels  first  with  an  enema ; 
place  the  patient  on  the  back  with  the  thighs  well  flexed ;  warm  and  oil  the 
bougie,  and  pass  it  gently  but  firmly  into  the  constriction  ;  repeat  the  ope- 
ration, daily,  until  the  part  is  enlarged  to  at  least  its  normal  calibre  ;  the 
finger  may  be  substituted  for  the  bougie  when  the  stricture  is  sufficiently 
dilated. 

If  the  narrowing  is  extreme  and  very  rigid  and  unvarying,  incise  the  lateral 
surfaces  on  a  director,  and  in  the  direction  of  the  tuber  ischii,  to  such  a  depth  as  to 


488  MALFORMATIONS  AND  DEFORMITIES. 

allow  the  passage  of  the  feces  ;  if  the  first  incisions  are  not  sufficiently  deep,  repeat 
them  ;  but  it  is  necessary  to  divide  only  slightly  or  partially  the  sphincter.  If  the 
narrowing  is  due  to  extension  of  the  integument,  incise  it  in  several  places  on  the 
director,  and  dilate  daily  with  a  bougie  or  with  the  little  finger. 

Imperforate  anus  is  generally  caused  by  a  lamina  of  fibro-eellular  tissue, 
usually  thin  and  transparent,  permitting  the  meconium  to  be  seen  through  it, 
and  forming  a  small,  roundish  prominence,  which  is  most  distinct  when  the 
child  cries  or  strains ;  the  bulging  membrane  gives  to  the  finger  a  doughy 
feeling  and  sense  of  obscure  fluctuation  ;  on  pressure  it  recedes,  but  reappears 
on  removal  of  the  finger ;  the  membrane  may  be  very  thick  and  dense,  espe- 
cially at  the  circumference,  when  the  protrusion  will  be  less  prominent.  The 
nature  of  the  aff"eetion  is  apparent  on  inspection.  If  the  membrane  is  thin, 
incise  it  at  once  ;  if  it  is  thick,  and  there  is  a  doubt  as  to  the  continuation  of 
the  rectum,  delay  a  day  or  two  for  the  rectum  to  become  distended ;  then, 
while  the  child  is  held  on  its  back  on  the  knees  of  an  assistant,  the  thighs 
strongly  flexed,  make  a  crucial  incision  through  the  membrane,  the  point  of 
intersection  of  the  incisions  being  the  centre  of  the  anus ;  remove  the  inter- 
vening flaps  with  scissors,  and  dilate  the  opening  daily  with  the  finger  or  a 
bougie. 

Absence  of  the  anus  is  characterized  by  the  obliteration  of  every  trace 
of  the  orifice,  the  perineal  raphe  extending  from  the  scrotum  to  the  point  of 
the  coccyx  without  interruption,  and  the  space  of  the  anus  being  occupied 
with  cellulo-fibrous  tissue ;  there  are  no  external  signs  by  which  the  location, 
or  even  existence,  of  the  rectum  can  certainly  be  ascertained  ;  if  it  is  present, 
and  near  the  perineum,  fluctuation  may  sometimes  be  detected  by  the  finger  in 
the  perineum,  or  by  pushing  firmly  up  in  the  direction  of  the  rectum,  while 
with  the  left  hand  firm  pressure  is  made  upon  the  anterior  walls  of  the  abdo- 
men inward  and  down  toward  the  finger  in  the  perineum.  If  by  these  manip- 
ulations the  presence  of  the  rectum  is  detected,  an  operation  will  aff"ord  the 
desired  relief.  The  patient  being  held  by  the  assistant,  as  before  described, 
and,  if  necessary,  the  sound  introduced,  make  an  incision  in  the  median  line 
from  a  point  near  the  scrotum  to  the  extremity  of  the  coccyx  (Fig.  101), 
through  the  skin  and  superficial  fascia ;  repeat  the  incision,  but  of  gradually 
diminishing  length,  carefully  feeling  before  each  stroke  to  ascertain  by  fluctu- 
ation the  presence  of  the  blind  sac  of  the  rectum,  and  also  the  position  of  the 
bladder  or  vagina ;  if  the  rectum  is  not  found  in  the  middle  line,  search  pos- 
teriorly, as  the  extremity  is  sometimes  displaced  from  the  centre ;  the  bowel 
will  be  detected  as  a  fluctuating  tumor,  more  or  less  elastic,  and  of  a  dark- 
brown  color ;  when  recognized,  seize  it  with  strong-toothed  forceps,  or  pass 
a  needle  armed  with  a  double  ligature  through  it  and  gently  draw  it  down- 

FiG.  101.  Fig.  102. 


sj. 


Incision  for  imperforate  anus.  Bowel  attached  to  external  wound. 

ward  ;  adhesions  may  be  broken  up  with  the  fingers,  or  the  knife,  or  scissors  ; 
when  brought  down  to  a  level  with  the  integument,  open  the  cul-de-sac  lon- 
gitudinally, empty  its  contents,  thoroughly  cleanse  the  part,  and  unite  the 
margin,  by  six  points  of  suture  (Fig.  102),  to  the  integument  of  the  corre- 


THE    URINARY  BLADDER. 


489 


sponding  edges  of  the  perineal  wound  in  the  exact  situation  of  the  anus ;  the 
mucous  membrane  should  overlap  the  external  skin,  to  prevent  the  escape  of 
fecal  matters  into  the  cellular  tissue ;  close  the  wound  anteriorly  and  poste- 
riorly by  suture ;  bind  the  child's  legs  together  with  a  bandage,  and  apply 
antiseptic  dressings  to  the  wound ;  tendency  to  undue  contraction  must  be 
counteracted  by  dilatation. 


CHAPTER    II. 


THE  URINAKY   BLADDER. 


Extroversion  of  the  bladder  is  a  congenital  malformation,  occurring 
chiefly  in  males,  in  which  the  anterior  portion  and  the  parietes  of  the  abdo- 
men are  absent,  so  that  the  posterior  and  lower  part  of  the  bladder  protrudes 
Tinder  the  pressure  of  the  viscera  from  behind  as  a  round  red  tumor  covered 
by  mucous  membrane,  in  which  the  orifice  of  the  ureters  can  be  seen. 

The  linea  alba  bifurcates  at  the  upper  angle,  but  is  continued  on  either  side  of 
the  ossa  pubis,  formino;  a  triangle  ;  the  pubic  bones  are  not  united  by  a  symphysis ; 
the  penis  is  small,  the  ureter  and  corpus  spongiosum  are  deficient  in  their  whole 
extent,  and  the  only  remnant  of  the  urethra  is  a  groove  lined  by  mucous  membrane 
•on  the  dorsum  of  the  penis ;  the  glans  penis  is  full  and  large. 

This  deformity  leads  to  painful  and  distressing  results,  owing  to  the  con- 
stant flow  of  urine  over  the  groin  and  thighs,  but  it  is  in  no  respect  danger- 
ous to  life.  The  treatment  may  be  palliative,  by  the  application  of  an  appa- 
ratus to  collect  the  urine,  of  which  there  are  many  kinds.  But  even  the  best 
fitting  does  not  always  obviate  the  gradual  soaking  by  the  urine  of  the  skin  of 
the  abdomen,  groins,  and  perineum,  and  hence  operations  have  been  devised  to 
relieve  the  disgusting  deformity.  Efforts  have  been  made  (1)  to  open  com- 
munication between  the  ureters  and  the  rectum,  but  the  operation  is  very  dan- 
gerous, and  has  not  given  satisfactory  results  ;  (2)  to  cover  the  exposed  sur- 
face ;  some  of  these  operations  have  been  very  successful,  and  have  become 
legitimate  by  the  approval  of  good  authority. 

The  following  operations  are  advised :  Make  an  umbilical  flap,  1  (Fig.  106), 
and  turn  it  down  over  the  bladder ;  then  make  two  flaps  from  the  groin,  one 
on  either  side  (Fig.  103),  and  slide  them  over  the  central  flap,  and  attach  them  in 


Fig.  103. 


Fig.  104. 


Wood's  operation  for  extroverted  bladder : 
outline  of  incisions. 


Wood's  operation :  flaps  applied. 


490 


MALFORMATIONS  AND  DEFORMITIES. 


the  median  line  (Fig.  104) ;  the  result  is,  the  skin  surface  of  the  middle  flap  presents 
to  the  bladder,  and  the  raw  surface  is  covered  by  the  raw  surfaces  of  the  lateral 
flaps  ;  the  new  wound  is  left  to  cicatrize.     Or  dissect  ofi"  the  mucous  membrane  of 


Fig.  105. 


Fig.  106. 


Bigelow's  operation 


the  exposed  bladder  ;  make  lateral  flaps  from  both  inguinal  regions  (Figs.  105,  106)  ^ 
unite  them  upon  the  median  line  and  transversely  above  it,  the  points  a,  a,  a,  and 
B,  B,  being  brought  together,  as  the  skin  more  readily  yields  in  a  direction  obliquely- 
upward  ;  the  result  is  perfect  (Fig.  106). 


CHAPTER    III 


Fig.  107. 


THE  EXTKEMITIES. 

The  Upper  Extremities. 

A  supernumerary  digit  (Fig.  107)  appears  in  many  forms,  and  should  be 
treated  according  to  the  peculiarities.  (1)  If  it  is  attached  loosely  or  by  a 
narrow  pedicle,  divide  the  pedicle  close  to  its  point 
of  attachment  to  the  skin,  so  that  no  remains  may 
be  left ;  hemorrhage  must  be  carefully  suppressed. 
(2)  If  it  is  more  developed  and  articulates  with  the 
sides  of  the  metacarpal  or  phalangeal  bone  which  is 
common  to  it  and  another  digit,  operate  early,  and  so 
arrange  the  incision  as  to  leave  as  small  a  cicatrix  as 
possible.  (3)  In  cases  where  the  additional  digit  is 
connected  to  the  head  of  a  phalangeal  or  metacarpal 
bone  the  removal  is  likely  to  involve  the  opening 
of  the  joint  of  the  adjacent  phalanx  ;  removal  is 
advisable  only  in  case  the  additional  phalanx  impairs 
the  function  of  the  other.  (4)  If  the  supernumerary 
digit  is  fully  developed,  having  its  own  phalangeal  and 
metacarpal  bones,  removal  is  rarely  advisable,  but  if 
required  must  be  taken  away  so  as  to  leave  as  little 
deformity  and  impairment  as  possible.  (5)  There 
may  be  fusion  of  digits,  or  even  of  hands  (Fig.  120),^ 
in  which  no  operation  is  desirable. 


Supernumerarv  thumb. 


THE  EXTREMITIES. 


491 


The  union  of  digits,  webbed,  may  be  congenital,  when  it  is  generally  sym- 
metrical ;  or  it  may  be  the  result  of  injuries  and  burns.  The  uniting  medium 
may  be  the  skin  only,  or  the  skin  and  deeper  tissues,  and  even  the  bone. 
The  two  apposing  digits  may  be  united  throughout  their  entire  length  or 
only  in  part.  Webbed  toes  do  not  require  treatment.  When  the  union  is 
partial  and  does  not  involve  the  interspace  at  the  cleft,  divide  the  connecting 

Fig.  108.  Fig.  109. 


Apparent  fusion  of  the  hands. 


Seton  inserted. 


tissue,  and  maintain  the  fingers  apart  until  cicatrization  is  complete.  When 
the  union  of  the  cleft  is  complete  there  is  great  difficulty  in  preventing  reunion 
after  division.  Introduce  a  seton  at  the  base  of  the  cleft  (Fig.  109)  and  allow 
it  to  remain  until  the  opening  becomes  permanent,  when  the  remainder  of  the 
web  may  be  divided.  India-rubber  tubing  introduced  at  the  same  point  and 
tied  to  a  band  around  the  wrist  makes  a  good  seton. 

If  the  septum  is  very  dense,  operate  as  follows :  Make  two  flaps  of  the  web, 
anterior  and  posterior,  but  reversed  (Figs.  110,  111);   for  the  posterior  make  an 


Fig.  110. 


Fig.  111. 


Fig.  112. 


Diagram  of  flaps  in  operation  for  webbed  finger, 
with  thick  septum. 


Operation  for  webbed  finger :  a,  the  lines 

of  the  two  incisions  uniting,  so  as  to 
divide  the  web  and  leave  a  flap  on  each 
side ;  6,  the  flaps  detached  from  the  op- 
posite fingers  to  those  to  which  they 
are  adherent ;  c,  the  flaps  applied  to  the 
fingers  and  covering  in  the  raw  and 
exposed  surfaces  (Erichsen). 


incision  along  the  dorsal  aspect  of  one  finger  the  length  of  the  web,  and  transverse 
incisions  at  either  extremity  to  the  middle  of  the  dorsum  of  the  other  finger ;  repeat 
the  operation  on  the  palmar  surface,  but  make  the  longitudinal  incision  along  the 
palmar  surface  of  the  finger  which  forms  the  base  of  the  posterior  flap  ;  dissect  the 


492 


MALFORMATIONS  AND  DEFORMITIES. 


two  flaps  and  turn  them  back  ;  separate  the  fingers,  which  now  have  each  a  flap,  one 
attached  upon  the  dorsal  and  the  other  upon  the  palmar  surface  (Fig.  112) ;  apply 
the  flaps  to  their  respective  fingers  ;  the  union  of  these  flaps  efl"ectually  separates  the 
fingers.  Maunder  advises  to  'separate  the  web  along  one  finger,  unite  its  margins, 
and  thus  form  a  flap  for  the  apposed  digit ;  close  the  wound  left  upon  the  other 
finger  by  a  piece  of  skin  transplanted  from  the  hip,  the  hand  being  bound  to  the 
part  until  adhesion  has  taken  place. 

Flexion  of  the  phalangeal  joints,  so  as  to  permanently  distort  the  fingers, 
may  be  congenital  or  acquired.  When  the  deformity  can  be  overcome  by 
division  of  contracted  tendons  or  fascia,  this  operation  must  be  performed 
and  suitable  splints  applied.  If,  however,  the  conditions  are  unfavorable  to 
tenotomy,  the  affected  joint  should  be  exsected.  In  extreme  cases  amputa- 
tion is  the  only  successful  remedy. 

The  Knee. 

Genu  valgum  (knock-knee ;  in-knee)  is  very  common  in  children  suf- 
fering from  rickets.  It  is  usually  (Fig.  114)  bilateral.  Various  opinions 
have  been  given  by  writers  as  to  the  precise  local  changes  which  take  place. 
Formerly  the  deformity  was  believed  to  be  due  to  a  relaxation  of  the  inter- 
nal lateral  ligaments.  Later,  it  was  ascribed  to  an  overgrowth  of  the  internal 
condyle  of  the  femurs.  Recently,  Humphrey  has  contended  that  the  exter- 
nal condyle  has  ceased  to  grow  as  rapidly  as  the  internal  condyle, 
owing  to  undue  pressure  in  bearing  the  weight  of  the  body.  The  truth  is, 
that  these  and  other  conditions  exist  in  varying  degrees.  There  is,  pre- 
ceding the  deformity  at  the  knee,  a  noticeable  weakness  of  the  ankle  and  a 
disposition  to  a  flat  foot.  This  instability  of  the  ankle  and  foot  is  due  to 
impairment  of  the  attachments  of  the  ligaments  to  bones  undergoing  rachitic 
changes.  The  tendency  of  the  foot  would  be  to  turn  outward  in  walking, 
and  thus  change  the  bearing  of  the  lower  end  of  the  femur  upon  the  tibia 
in  such  manner  that  the  weight  of  the  body  would  fall  most  directly  upon 
the  outer  condyle.  The  result  would  be  diminished  growth  of  the  external 
and     increased     growth     of     the    inner 

condyle   of    the    femur.     Noble     Smith  Fig.  114. 

(^Snrg.  of  Deformities)  concludes  from 
his  examinations  that  the  change  is  in 
the  internal  condyle  of  the  tibia,  and 
not  in  that  of  the  femur.  There  is  also 
a  change  in  the  axis  of  the  femur,  an 
inward  curve  forming  in  the  lower  third 
(Fig.  113),  which,  according  to  Mac- 
ewen,  causes  the  internal  condyle  to 
descend  still  lower.  In  general,  bilateral 
knock-knee  is  arrested  before  the  knees 

Fig.  113. 


Extreme  genu  valgum  (from   a  photo- 
Femur  curved  by  rickets.  graph). 

interfere  with  each  other  in  walking,  but  in  extreme  cases  they  may  pass  each 


THE  EXTREMITIES. 


493 


other.     Instead  of  bilateral  knock-knee,  one  knee  may  be  valgus   and  the 
other  bowed. 

Owen  says :  "  The  explanation  of  this  association  is  from  the  mother  carrying 
the  child  always  on  one  arm,  whilst  she  throws  the  other  arm  around  the  knees  to 
make  them  fit  into  the  hollow  of  her  waist.  Thus,  if  the  child  be  carried  always 
upon  the  left  arm,  the  left  leg  will  be  valgus,  while  the  right  will  be  bowed.'" 

In  the  early  stages  of  this  deformity  it  may  be  difficult  to  determine  the 
fact  of  a  commencing  change.  The  most  marked  general  symptom  will  be  a 
complaint  of  fatigue  and  pains  in  the  knee  after  exercise.  If,  now,  the 
child  is  placed  on  the  back,  the  internal  condyles  will  be  too  prominent.  If 
the  knees  are  brought  together,  it  will  be  noticed  that  the  ankles  do  not 
readily  touch,  and  the  degree  of  separation  shows  the  extent  of  the  change 
at  the  knees.  Attempts  at  adduction  and  abduction  of  the  feet  prove  that 
the  internal  part  of  the  joint  is  unnaturally  lax  and  movable. 

The  TREATMENT  will  depend  upon  the  stage  of  progress  of  the  disease. 
When  rickets  is  found  to  exist  and  the  child  is  not  walking,  the  tendency 
to  knock-knee  is  so  slight  that  no  other  precaution  is  required  than  to  pro- 
tect the  child  from  wrong  positions,  and  by  skilled  massage,  with  forcible 
straightening  of  the  leg,  overcome  any  tendency  to  deformity.  If,  however, 
the  deformity  increases,  a  lateral  splint,  or  two  if  both  knees  are  involved, 
should  be  applied,  which  may  be  of  wood  and  well  padded  so  as  to  fit  the 
leg.  When  applied  it  should  extend  from  the  hip  to  the  foot  along  the 
outside  of  the  limb  (Fig.  115).  The  patient  must  not  walk.  The  splint 
should  be  removed  daily,  and  the  limb  rubbed,  stretched,  and  compressed 
outward  at  the  knee.  By  perseverance  the  deformity,  if  slight,  may  be 
overcome. 

If  both  knees  are  slightly  valgus,  Owen  recommends  that  a  flat  pillow 
be  fixed  between  the  knees  and  the  ankles  tied  together  by  a  handkerchief 


Fig.  115. 


Fig.  116. 


Splint  for  knock-knee  (Owen). 


Simple  treatment  of  double 
knock-knee  (Owen). 


or  strap  (Fig.  116)  ;  this  method   should  be  carried   on  day  and  night,  and 
to  prevent  rotation  of  the  tibiae  a  sand-bag  may  be  kept  across  the  knees. 

If  the  child  is  of  a  more  advanced  age,  it  may  not  be  required  to  pre- 
vent the  exercise  of  walking,  but  the  necessity  of  proper  support  at  the  knees 
will  be  increased.  An  effective  apparatus  is  that  which  is  so  arranged  as  to 
gently  but  firmly  compress  the  inner  surface  of  the  knee  outward  to  steel  splints 


494 


MALFORMATIONS  AND  DEFORMITIES. 


having  a  joint  at  the  knee  and  attached  to  shoes.    Truehart  has  devised  a  very- 
useful   splint  of  this  kind  (Fig.  117). 

If  the  case  appears  as  a  confirmed  knock-knee,  and  the  child  has  recovered 
from  the  attack  of  rickets,  the  treatment  assumes  an  altogether  new  character. 

We  have  then  to  consider  the  propriety  of  an 
Fig.  117.  operation  to  correct  the  deformity.    The  methods 

now  adopted,  and  the  success  which  is  assured, 
mark  one  of  the  great  advances  of  modern  sur- 
gery. Osteotomy  as  applied  to  the  correction 
of  genu  valgum  is  an  illustration  of  the  great 
capabilities  of  antiseptic  surgery.     Though  the 

Fig.  119. 


Fig.  118. 


a  a,  line  of  Ogton's  in- 
cision ;  56,  Reeves's ; 
b  c,  Macewen's. 


Apparatus  for  knock-knees. 


Drawing  illustrating  Dr.  Ogston's  ope- 
•  ration :  right  limb  shows  line  of  sec- 
tion of  the  inner  condyle  of  the 
femur;  left,  inner  condyle  brought 
to  required  position  (Bryant). 


knee-joint  is  to  be  entered  directly  with  a  rude  instrument,  either  a  saw  or 
a  chisel,  the  operation  may  be  undertaken  with  comparative  certainty  of 
success.  Barker  and  Owen  have  reported  fatal  cases,  but  with  proper  pre- 
cautions and  antisepsis  the  chances  are  altogether  favoi'able. 

There  are  several  methods  of  procedure :  Section  of  the  internal  condyle 
may  be  made  with  a  view  to  its  replacement  and  reunion  on  a  higher  level 
(Figs.  118  and  119).  The  condyle  may  be  separated  with  a  saw  (Ogston)  or 
with  a  chisel  (Reeves).  Section  with  a  saw  is  much  the  more  difficult  opera- 
tion, but  with  antiseptic  precaution  it  has  proved  very  successful.  The  ope- 
ration with  the  saw  is  as  follows : 

Flex  the  knee  as  far  as  possible  and  turn  the  thigh  outward  :_  introduce  a  long 
and  strong  tenotome  knife  three  and  a  half  inches  above  the  tip  of  the  internal 
condyle  on  the  inner  side  of  the  thigh,  and  as  far  back  as  the  opposite  ridge  of 
bone  running  between  the  linea  aspera  and  the  condyle ;  carry  the  blade  forward, 
downward,  and  outward  over  the  front  of  the  femur,  with  its  cutting  edge  directed 
to  the  bone  •,  when  its  point  is  felt  under  the  skin,  in  the  groove  between  the_  con- 
dyles where  the  patella  would  normally  have  been  lying  in  the  flexed  position, 
divide  the  soft  parts  and  periosteum  by  withdrawing  the  knife ;  through  the_  cut 
thus  made  introduce  a  narrow  saw  and  divide  the  condyle  nearly  to  the  popliteal 
space  ;  now  forcibly  straighten  the  knee,  and  the  remaining  attachments  of  the  con- 
dyle will  be  readily  fractured  (Fig.  119). 

Section  with  the  chisel  is  free  from  the  objections  which  apply  to  those 
methods  involving  a  more  or  less  free  opening  of  the  knee-joint : 


THE  EXTREMITIES. 


495 


Introduce  an  antiseptic  scalpel  above  the  most  prominent  part  of  the  internal 
tuberosity,  and  divide  the  soft  parts  and  periosteum  ;  insert  by  the  side  of  the  knife 
an  antiseptic  chisel,  and  with  a  few  strokes  of  the  mallet  penetrate  the  condyle  to 
its  greatest  depth,  but  only  as  far  as  the  cartilage  covering  it ;  the  direction  of  the 
chisel  should  be  first  toward  the  intercondyloid  groove,  then  the  chisel  should  be 
partially  withdrawn,  and  its  direction  altered  forward  and  backward  until  the  con- 
dyle is  loosened,  but  not  separated.  Straighten  the  limb,  breaking  off  the  divided 
condyle,  and  pushing  it  upward  with  the  head  of  the  tibia  (Fig.  119)  ;  close  the  in- 
cision, and  apply  an  immovable  apparatus,  as  gypsum,  and  retain  it  for  three  or  four 
weeks  m  children,  when  passive  motion  must  be  begun  and  persevered  in  until  the 
functions  of  the  joint  are  completely  restored. 

Macewen  accomplishes  the  purpose  by  partly  dividing,  with  a  mallet  and 
chisel,  the  femur  at  the  base  of  the  condyles,  then  fracturing  it  and  straighten- 
ing the  limb.  He  makes  the  incision  at  the  base  of  the  internal  condyle 
(Fig.  120),  but  most  operators  prefer  to  operate  from  the  outer  side  of  the 

Fig.  120. 


Appearance  of  limbs  before  and  after  Macewen's  operation. 

limb.  Macewen's  operation  is  the  more  simple,  and,  as  the  joint  is  not  inter- 
fered with,  it  is  the  safer.  The  results  are  quite  as  good  as  Ogston's  or 
Reeves's  operation,  as  will  be  seen  in  the  illustration  (Fig.  120). 

Genu  extrorsum  (out-knee)  is  the  result  of  a  bending  outward  of  the 
femur  and  tibia  without  inequality  in  the  condyles  of  the  femur.  It  may 
exist  on  one  side  and  knock-knee  on  the  other.  In  this  case  the  knock-knee 
has  caused  the  bow-leg  by  changing  the  axis  of  the  trunk  from  its  centre  to 
the  axis  of  the'thigh  of  the  affected  limb.  Out-knee  is  believed  to  be  caused 
in  many  rachitic  children  by  the  position  which  they  assume  in  sitting,  with 
their  legs  abducted  and  rotated  outward  (Wright),  the  knees  being  unsup- 
ported. 

The  TREATMENT  should  protect  the  limbs  from  the  weight  of  the  body  and 
from  any  position  assumed  by  the  child  liable  to  increase  the  deformity,  and 
at  the  same  time  existing  curvatures  should  be  overcome.  While  the  general 
treatment  for  rickets  is  pursued,  bathing  in  warm  salt  water,  rubbing  the 
entire  body  with  the  hands,  and  such  manipulation  of  the  curved  bones  as 
will  tend  to  straighten  them  are  very  useful.  In  these  efforts  to  straighten 
the  bones  no  strain  should  be  placed  on  the  knee,  lest  the  internal  lateral  liga- 
ments be  weakened.     All  the  force  must  be  applied  to  the  individual  bone. 

If  the  deformity  is  firmly  established  and  the  child  has  recovered,  osteot- 
omy must  be  practised  with  the  usual  antiseptic  precautions.  When  out- 
knee  is  due  chiefly  to  the  bending  of  one  bone,  as  the  femur  or  tibia,  it  will 
be  suflieient  to  straighten  that  bone  (Fig.  113).  But  iii  the  more  marked 
eases  both  the  femur  and  tibia  must  be  straightened  to  secure  the  required 
results. 


496 


MALFORMATIONS  AND  DEFORMITIES. 


Fig.  121. 


The  Leg. 

Bow-leg  proper  is  a  curvature  of  the  tibia,  and  fibula,  without  any  change 
in  the  femur.     It  comes  on  insidiously,  even  before  the  child  has  begun  to 

walk.  The  habit  of  sitting  with  the  legs 
crossed,  like  a  tailor,  gives  an  inclination  to 
the  tibia.  Wright  states  that  if  the  feet 
are  crossed  one  over  the  other,  the  curve 
will  be  most  marked  at  the  lower  third  of 
the  tibia,  and  the  leg  which  rests  upon  the 
other  will  have  more  of  an  anterior  and  less 
of  an  external  curve  (Fig.  121)  than  its 
fellow. 

The  TREATMENT  must,  as  in  instances 
already  given,  tend  to  prevent  the  deform- 
ity and  correct  those  that  have  taken  place. 
Bathing,  rubbing,  and  straightening  the 
affected  bones  must  be  persevered  in  until 
the  child  has  recovered.  The  mechanical 
appliances  should  maintain  an  equable  pres- 
Bow-legs  (Ashby  and  Wright).  Sure  on  the  curvatures.      Owen's  apparatus 

is  very  useful  and  easily  adjusted,  as  will 
be  seen  by  the  illustrations  (Figs.  122,  123).  A  more  expensive  apparatus 
may  be  employed  for  children  who  are  walking  (Fig.  124).    Two  upright  steel 


Fig.  122. 


Fig.  123. 


Fig.  124. 


Simple  apparatus  for  bow-legs  (Owen). 


* — « 


Apparatus  for  rickets. 


stems  are  fastened  below  to  a  shoe  and  terminated  above  in  the  calf-band ; 
a  leather  bandage  is  passed  around  the  stems  and  tightly  laced  in  front  over 
the  arc  of  the  curvature  (a),  or  a  strap  is  passed  over  the  arc  of  the  curva- 
ture and  fastened  to  a  spur  suspended  from  the  calf-band  behind  (c),  the 
points  of  resistance  being  in  either  case  the  heel  of  the  shoe  (i)  and  the 
posterior  trough  of  the  calf-band  (c). 

It  should  be  borne  in  mind  that  after  the  child  has  recovered  from  rickets, 
and  begun  to  resume  active  exercise,  there  is  a  strong  tendency  to  the  cor- 
rection of  slight  curvatures  of  the  tibia,  due  to  the  action  of  the  muscles. 
If,  however,  the  curvature  is  great  (Fig.  125)  the  tendency  will  rather  be  in 
the  direction  of  increased  deformity.  The  only  radical  cure  of  the  latter 
cases  is  straightening  the  curved  bones  by  osteotomy  (Fig.  126).  The  ope- 
ration is  very  simple : 

Prepare  the  limb  by  washing  and  shaving,  and  irrigate  the  wound  during  tlie 


THE  EXTREMITIES. 


497 


operation  with  the  bichloride  solution.     Select  an  osteotomy  chisel  (Fig.  127)  and 
mallet ;  make  a  longitudinal  incision  down  to  the  bone  with  the  scalpel ;  now  apply 


Fig.  125. 


Fig.  126. 


Result  of  osteotomy  for  bow-legs  (Ashhurst). 

the  cutting  edge  of  the  chisel  transversely,  and  with  repeated  blows  of  the  mallet 
nearly  divide  the  bone  ;  then  fracture  the  remaining  portion  ;  ap- 
ply a  catgut  drain  and  close  the  wound  with  the  continuous  su-  Fig.  127. 
ture ;  straighten  the  limb,  apply  iodoform  gauze,  and  finish  with 
plaster-of-Paris  dressing  extending  from  the  foot  to  the  hip. 


The  Feet. 

Distortions  of  the  feet  may  be  due  to  spasmodic  action 
of  one  class  of  muscles,  the  antagonizing  muscles  acting 
normally,  or  to  paralysis  of  one  class,  the  opposing  mus- 
cles being  healthy.  Careful  examination  of  each  case  will 
determine  whether  spasm  or  paralysis  is  the  cause ;  but  in 
general  congenital  cases  are  caused  by  spasm,  and  non-con- 
genital by  paralysis.  The  general  rule  of  treatment  is  to 
endeavor  to  overcome  by  appliances  those  deformities  which 
readily  yield  to  manipulation  and  are  caused  by  paralysis, 
and  to  divide  contracted  tendons  in  those  which  do  not  yield 
readily  and  are  caused  by  spasm.  The  object  of  treatment 
is  the  restoration  of  form  and  function,  and  the  means  to 
be  employed  are  physiological,  mechanical,  and  operative. 

Adams  very  justly  remarks :  "  The  scientific  treatment  of 
severe  deformities  can  only  be  accomplished  by  a  judicious 
combination  of  these  three  methods,  and  many  of  the  failures  are 
due  to  the  want  of  this  combination  of  principles  too  frequently 
considered  antagonistic  to  each  other." 


Macewen's  chisel. 


Selecting  talipes-equino-varus,  the  most  frequent  ex- 
ample of  club-foot,  the  rules  of  treatment  as  regards 
the  adoption  of  the  several  methods  are  as  follows:  (1)  If 
no  obstacle  exists  to  the  perfect  restoration  of  form  by  gentle  application  of 
force,  the  defect  may  be  remedied  by  the  manipulations  of  the  nurse,  aided, 
in  more  marked  cases  if  necessary,  by  simple  mechanical  appliances,  as  rub- 
ber plaster,  a  boot  with  springs.  (2)  If  the  foot  can  be  nearly  but  not  quite 
restored  to  its  natural  form  by  the  hand,  the  heel  remaining  somewhat  ele- 
vated so  as  to  limit  or  prevent  flexion  at  the  ankle-joint,  tenotomy  is  justi- 
32 


498 


MALFORMATIONS  AND  DEFORMITIES. 


fiable,  as  it  greatly  hastens  the  cure.  (3)  In  more  severe  grades  tenotomy 
is  indispensably  necessary ;  these  cases  are  recognized  by  the  following  fea- 
tures:  namely,  the  foot  cannot  be  fully  everted  or  brought  to  a  straight  line 
with  the  leg  by  manipulation,  and  in  the  attempt  to  effect  this  the  inner 
malleolus  does  not  become  prominent.  (4)  The  os  calcis  either  cannot  be 
depressed  at  all  or  only  to  a  slight  degree,  so  that  after  the  partial  ever- 
sion  of  the  foot  little  or  no  flexion  at  the  ankle-joint  can  be  obtained. 

The  following  summary  of  principles  of  treatment  of  congenital  club-foot,  laid 
down  by  Little  (of  London),  deserves  attention :  L  Whether  the  case  promises  favor- 
ably for  mechanical  treatment  only,  or  needs,  as  the  majority  of  cases  do  need,  ope- 
rative interference,  commence  the  treatment  as  soon  after  birth  as  practicable.  2. 
Reduce  the  distortion  from  the  state  of  a  compound  one  (varus)  to  the  simpler  form 
(equinus)  by  first  curing  the  inversion  of  the  foot  and  the  tendency  to  involution  of 
the  sole.  3.  Avoid  the  slightest  undue  pressure  upon  prominent  points  of  the  leg 
and  foot  by  careful  padding  of  the  hollow  parts,  and  by  using  only  gentle  pressure 
with  any  bandage ;  avoid  obstruction  of  the  returning  blood  from  the  limb.  4.  Re- 
move splint  and  bandage  daily,  practise  gentle  movements  of  the  foot  in  the  desired 
direction,  endeavor  to  prevent  the  part  remaining  for  an  instant  unsupported  and 
liable  to  fall  back  into  the  deformed  position,  until  it  is  found  that  the  foot,  on  re- 
moval of  the  bandage,  retains  a  perfectly  good  position  and  flexibility.  5.  Never 
permit  the  child  to  be  placed  on  the  feet  or  to  walk  until  the  form  and  movements 
are  complete,  whatever  may  be  the  age  of  the  patient.  The  only  apparatus  neces- 
sary to  carry  out  this  treatment  is  a  splint  of  tin  or  pasteboard  so  adapted  to  the 
external  parts  as  to  leave  a  space  between  the  foot  and  splint  when  bandages  are 
applied,  or  rubber  plaster  applied  to  the  anterior  part  of  the  foot  and  passing  up 
the  external  surface  of  the  leg,  to  which  it  is  fastened. 

Talipes  equinus  (Fig.  128)  is  usually  congenital.  There  are  also  vari- 
ous degrees  of  varus.     The  treatment  is  operative  and  mechanical.     The 


Fig.  128. 
Talipes  Equinus. 


Congenital 

Club-foot. 


Acquired 


G  TIEMANN  &.C0- 

Club-foot  shoe. 


tendo  Achillis  and  plantaris  may  alone  require 
division,  or,  in  addition,  the  plantar  fascia 
must  be  cut,  as  when  the  arch  of  the  foot 
is  strongly  contracted ;  the  foot  should  usually 
be  brought  into  position  at  once  and  retained 
by  splints  or  the  gypsum  dressing.  In  gen- 
eral it  will  be  more  advantageous,  especially  if  the  child  is  walking,  to  apply, 
within  a  week  or  two  after  the  operation,  the  club-foot  shoe.  There  are  many 
varieties,  as  Sayre's,  Shaffer's,  Taylor's.  The  Sayre  shoe  (Fig.  129)  generally 
gives  satisfaction. 

Its  construction   and  modes  of  action  are  as  follows :  A  cushioned  iron  cap  to 
receive  the  heel,  the  leather  covering  of  which  is  carried  over  the  instep  and  ankle 


THE  EXTREMITIES. 


499 


and  fastened  by  lacing ;  elastic  tubing,  N,  to  go  in  front  of  the  ankle-joint  further 

to   secure  the  heel  in  position,  and  fastening  at  C, 

an  iron  hook  on  outside  of  heel-cap ;    sole  of  shoe,  -p       i  qa 

D,  cushioned,   and   laced    securely  in   front   of  the 

medio-tarsal   articulation ;   ball-and-socket  joint,    E, 

connecting   sole  with   heel ;    elevated  plate  of  iron, 

F,  properly  cushioned,  to  make  pressure  against  base 

of  first  metatarsal  bone  ;  steel  bars,  G.  connecting  the 

shoe  with  strap,  H,  to  go  round  the  calf;  joint,  K, 

opposite   the   ankle ;    stationary   hooks,   L,   opposite 

the   toes,    for   attaching   the    India-rubber    muscles, 

M,  M,  M.     These   India-rubber   tubes   have   chains 

attached,  and  are  for  the  purpose  of  making  flexion 

and  eversion. 

Or  the  following  more  simple  apparatus  may  be 
used  :  The  sole  of  the  strong  leather  shoe  is  of  metal, 
with  the  joint  near  the  heel,  allowing  lateral  motion ; 
a  durable  spiral  spring,  a  (Fig.  130),  draws  the  foot 
outward  by  a  constant,  elastic,  and  easy  traction ; 
this  pressure  is  increased  or  decreased  at  will  by 
fastening  the  spring  in  a  series  of  sockets,  c.  The 
single  outside  upright  steel  bar,  with  joints  at  the 
ankle,  is  fastened  round  the  limb  below  the  knee- 
joint,  and  so  constructed  that  the  screw  at  the 
ankle-joint  forces  the  foot  flat  upon  the  floor, 
the  foot  in  almost  all  cases  being  turned  under 
as  indicated  (Fig.  129) ;  the  spiral  spring,  cZ,  at- 
tached to  a  catgut  cord  and  fastened  near  the  toes  Club-foot  apparatus. 
upon  the  outside  of  the  foot,  elevates  the  toes  and 
stretches  the  tendo  Achillis,  thus  drawing  the  foot  to  its  natural  position. 

Talipes  calcaneus  (Fig.  131)  is  both  a  congenital  and  non-congenital 
aflFection.     In  congenital  cases  the  deformity  consists  in  the  position  of  the 


Fig.  131. 


Fig.  132. 


Acquired 

Congenital 
Talipes  calcaneus. 

foot  being  an  exaggerated  degree  of  flexion,  owing 
to  paralysis  of  the  calf.  In  acquired  cases  there 
is  paralysis  of  the  muscles  of  the  calf  and  the  exten- 
sors of  the  toes.  In  congenital  cases  the  treatment 
required  is  passive  exercise  and  the  use  of  a  soft 
padded  splint  applied  in  front  of  the  leg  and  foot.  If 
there  is  much  contraction  of  the  anterior  muscles, 
the_  tendons  of  the  tibialis  anticus,  extensor  proprius  pollicis,  extensor  lon^us 
digitorum,  and  peroneus  tertius  may  require  to  be  divided.  ^ 

}..onW  ''PPt''^*"^  ^^^f  steel  spiral  spring,  placed  on  a  pivot  and  playing  between 
brackets  of  the  leg  and  ankle-stem  to  depress  the  front  part  of  the  foot^bv  exten- 
sion:  there  is  not  so  much  danger  of  falling  with  this  apparatus  when  descending 
stairs.  Ur,  instead  of  the  spring,  there  may  be  an  elastic  band  attached  to  the  heel 
ot  the  shoe  below  and  to  the  ring  above,  which  constantly  tends  to  elevate  the 


Shoe  for  calcaneus. 


500 


MALFORMATIONS  AND  DEFORMITIES. 


Non-congenital  calcaneus  is  usually  the  result  of  infantile  paralysis,  and 
as  a  consequence  tenotomy  is  seldom  required ;  palliative  treatment  alone 
must  be  attempted  by  the  application  of  a  proper  shoe. 

Fig.  133. 

Congenital  Varus. 


Club-foot— three  grades  of  severity. 


Talipes  varus,  usually  also  equinus,  in  its  severe  form  has  the  following 
external  characters  (Fig.  133)  :  namely,  the  anterior  portion  of  the  foot  is 
turned  inward,  forming  a  right  angle  ;  the  sole  looks  directly  backward  and 
the  dorsum  forward ;  the  inner  border  looks  directly  upward  and  the  outer 
directly  downward.  The  first  stage  of  treatment  consists  in  correcting  the 
varus  by  turning  the  foot  outward  into  a  straight  position  or  by  bringing  the 
sole  squarely  downward ;  the  second  stage  consists  in  overcoming  the  eleva- 
tion of  the  heel,  equinus,  if  that  exist.  If  the  foot  can  be  brought  around 
nearly  straight  with  comparative  ease,  the  eifort  should  be  made  by  manipu- 
lation and  bandaging  to  correct  the  deformity. 

This  may  be  eifected  by  many  methods  :  (1)  Apply  a  strip  of  adhesive  plaster 
around  the  anterior  part  of  the  foot,  commencing  on  the  dorsum  and  passing  around 
the  inside,  then  across  the  sole  to 


Fig.  134. 


Fig.  135. 


the  outside,  and  then,  while  the  foot 
is  turned  strongly  outward,  up  the 
outside  of  the  leg  to  the  knee  :  over 
this  dressing  apply  a  roller  band- 
age ;  repeat  the  dressing  every  sec- 
ond day  (Fig.  134).  (2)  Apply  a 
splint  adapted  to  the  outside  of  the 
limb  (Little),  with  a  foot-piece  at  an 
angle  with  the  foot,  and,  beginning 
at  the  upper  part,  bandage  the  leg 
and  foot  to  the  splint  (Fig.  135) ; 
change  the  dressing  every  second 
day,  giving  to  the  foot  strong  trac- 
tion externally.  (3)  Give  the  pa- 
tient chloroform,  and,  after  forcing 
the  foot  outward  fifteen  minutes, 
apply  a  gypsum  bandage  (Ogston)  ; 
repeat    the    dressing    weekly.     In 

cases  which  require  tenotomy  divide  the  tibialis  anticus  and  posticus,  and,  if  neces- 
sary, also  the  tendo  Achillis  and  flexor  longus  digitorum  ;  after  the  healing  of  the 
wounds  apply  the  club-foot  shoe. 

The  removal  of  a  triangular  mass  from  the  tarsus  (Colley)  on  the  outside  has 
been  successfully  practised  in  severe  cases;  the  steps  of  the  operation  and  the 
results  will  be  understood  by  the  illustrations  (Figs_.  136,  137,  138).  Phelps  has 
succeeded  in  overcoming  severe  forms  of  varus  by  incisions  dividing  all  of  the  con- 
tracted tissues  on  the  inside  of  the  foot.  These  extensive  operations  are  to  be  resorted 
to  when  milder  methods  have  failed,  and  in  older  children. 

Hopkins   of  Philadelphia  has  recently  successfully  corrected  inveterate 


Mode    of  stretching    foot   in 
talipes  varus,  by  strapping. 


Varus  treated  by 
bandage. 


THE  EXTREMITIES.  501 

talipes  varus  by  the  artificial  production  of  Potts  fracture  deformity.     He 
operated  as  follows : 

After  tenotomy  of  the  tendo  Achillis,  though  the  equinus  element  was  almost 
absent,  an  incision  two  inches  long  was  carried  down  to  within  half  an  inch  of  the 


Fig.  136. 


Fig.  137. 


Fig.  138. 


Foot  before  operation.       Bones  removed.    Foot  after  operation  (Bryant). 

external  malleolus.  The  fibula,  having  been  stripped  of  periosteum,  was  exposed 
and  three-eighths  of  an  inch  of  its  shaft  excised  with  cutting  forceps,  the  lower 
section  being  three-fourths  of  an  inch  above  the  lower  end  of  the  bone.  Forcible 
abduction  of  the  foot  brought  the  sole  beneath  and  a  little  beyond.     A  few  strands 

Fig.  139. 


The  case  before  and  after  operation. 


of  drainage  were  placed  in  the  wound ;  the  limb  was  dressed  antiseptically  and 
placed  upon  an  internal  straight  splint.  A  plaster-of-Paris  dressing  was  applied 
fourteen  days  later,  when  a  scanty  serous  oozing  had  ceased  and  the  wounds  were 
healed.  The  child  showed  no  inflammatory  reaction  after  the  operation ;  indeed, 
none  was  to  be  expected,  for  the  shaft  of  the  fibula  was  not  more  than  an  eighth  of 
an  inch  in  diameter  (Figs.  139,  140). 

Talipes  valgus  (Fig.  141)  is  rarely  congenital.  Marked  cases,  without 
rigid  muscular  contraction,  may  be  cured  mechanically  in  a  few  months  with- 
out tenotomy,  but  severe  cases  demand  a  combination  of  operative,  mechani- 
cal, and  physiological  means.     The  tendons  requiring  division  in  the  slighter 


502 


MALFORMATIONS  AND  DEFORMITIES. 


cases  are  the  peronei  and  extensor  longus,  and  the  tendo  Achillis  if  involved  ; 
in  very  severe  cases  the  tibialis  anticus  and  the  extensor  poUicis  must  also  be 


Fig.  141. 


Congenital 

Club-foot. 


Acquired 


divided.     The  mechanical    treatment   of    slight   cases    in    which   the  tendo 
Achillis  is  not  divided  is  as  follows : 

A  convex  pad  of  vulcanized  India-rubber  is  placed  inside  of  the  boot  in  the 
normal  situation  of  the  arch  of  the  foot  which  it  is  intended  to  support ;  it  should 
extend  half  way  across  the  sole  of  the  foot,  and  rise  on  the  inner  side  so  as  to  sup- 
port the  navicular  bone  ;  the  heel  should  be  raised  on  the  inner  side  about  a  quarter 
of  an  inch,  so  as  to  twist  the  foot  inward  and  throw  the  weight  on  the  outer  side. 
In  more  severe  cases  it  is  necessary  to  add  a  steel  support,  attached  to  the  outer  side 
of  the  boot  and  carried  up  to  the  calf  of  the  leg,  where  it  is  connected  with  a  semi- 
circular steel  plate  and  a  strap  which  encircles  the  leg;  a  free  joint  should  corre- 
spond with  the  ankle,  and  a  leather  strap  attached  to  the  inner  side  of  the  boot 
should  pass  across  the  ankle-joint  and  buckle  outside  the  steel  support.  In  the 
most  sevei-e  cases,  after  tenotomy  is  performed  a  shoe  must  be  applied  which 
effectually  brings  the  foot  by  degrees  into  position.  The  shoe  and  spring  of  Royal 
Whitman  are  very  effectual  in  accomplishing  this  result. 

Hollow  club-foot  (pes  cavus)  (Fig.  142),  is  due  to  paralysis  of  the  inter- 
ossei  muscles,  the  short  flexor,  and  adductor  of  the  great  toe ;  the  first 
phalanges  are  extended  upon  the  metatarsal  bones,  and  the  last  two  pha- 

FiG.  142. 


Hollow  club  foot,  pes  cavus  (Enchsen) 


langes  flexed  upon  the  first;  the  posterior  extremities  of  the  first  phalanges 
are  subluxated  upon  the  heads  of  the  metatarsal  bones ;  then  the  curve  of 
the  plantar  arch  becomes  increased  and  the  plantar  arch  shortened ;  then 
certain  articulations  and  their  ligaments  become  deformed  as  in  all  club-feet. 
From  the  position  of  the  toes  and  from  the  increased  arch  of  the  foot  the 
whole  pressure  in  walking  is  borne  upon  the  heel  and  upon  the  skin  covering 


THE  EXTREMITIES. 


503 


the  unnaturally  prominent  heads  of  the  metatarsal  bones,  which  latter 
become  tender  in  consequence,  especially  that  over  the  great  toe.  The  treat- 
ment consists  in  :  1,  stimulation  of  paralyzed  muscles  by  faradization  ;  2, 
the  division  of  the  tendons  of  those  muscles  which  their  tonic  contraction 
maintain  and  increase  the  deformity.  The  muscles  more  often  divided  are 
the  extensor  of  the  great  toe,  the  tendo  Achillis,  and  in  addition  a  very 
tight  band  of  the  inner  division  of  the  plantar  fascia.  The  Scarpa  shoe  may 
be  used  after  the  operation,  having  hinges  across  the  middle  and  rack-and- 

FiG.  144. 


Congenital  hypertrophy  of  toes  and  foot. 
(Plantar  aspect.)  (Dorsal  aspect.) 

pinion  movement,  so  that  the  depressed  heads  of  the  metatarsal  bones  may 
be  I'aised  by  the  anterior  half  of  the  sole. 

Congenital  hypertrophy  of  toes  and  foot  (Figs.  143, 144)  is  occasionally 
met  with.  The  only  remedy  is  the  adaptation  of  suitable  apparatus  to  meet 
the  deficiency  of  the  foot. 


PART    IV 


SEOTIOlSr   I. 

DISEASES    OF    THE    BLOOD. 

By  Frederic  M.  Warner,  M.  D. 


CHAPTER   I. 

HELENA    NEONATOEUM. 

Hemorrhage  from  the  gastro-intestinal  surface  occurs  in  children  from 
various  causes.  It  is  a  common  symptom  of  intussusception  in  infants.  It 
occurs  from  dysentery  and  purpura  and  from  the  syphilitic  dyscrasia.  It 
has  been  observed  in  polypus  of  the  rectum  and  in  anal  fissures.  In  rare 
instances  it  occurs  from  the  irritation  of  lumbrici,  from  foreign  substances 
which  have  been  swallowed,  and  from  the  ulceration  of  tj^phoid  fever.  Intes- 
tinal hemorrhage  from  such  causes  is  a  symptom  of  constitutional  or  local 
disease.  But  in  newly-born  infants  it  sometimes  occurs  without  other  symp- 
toms or  without  other  appreciable  disease,  and  therefore  is  regarded  as  an 
essential  malady. 

Melaena  neonatorum  was  mentioned  by  Storck  in  1750,  and  various 
writers  at  different  times  alluded  to  it  or  briefly  described  it  prior  to  1825. 
It  1825  it  was  more  fully  treated  of  by  Hesse  than  by  any  of  his  predeces- 
sors.^ The  monograph  published  by  him  was  valuable,  as  it  contained  his 
own  observations  and  those  of  contemporary  physicians  communicated  to 
him,  as  well  as  the  investigations  of  his  predecessors.  Dr.  Rahn-Escher  of 
Zurich  (1835),  Meisner  (1838),  Kiwisch  (1841),  Rumpe  (1841),  Hoffman 
(1842),  and  Helmbrecht  (1843)  published  memoirs  or  related  cases  of 
melaena.  Several  of  the  best-known  authors  on  diseases  of  children,  long 
recognized  as  authorities  in  this  branch  of  practice,  have  also  written  on 
intestinal  hemorrhage,  as  Billard,  Vogel,  Rilliet  and  Barthez,  Barrier,  Bou- 
chut.  West,  Eustace  Smith,  and  Goodhart,  so  that  the  literature  of  this  dis- 
ease is  no  longer  meagre. 

Age. — In  the  statistics  of  Billard,  embracing  15  cases,  8  were  between 
the  ages  of  one  and  six  days,  4  between  the  ages  of  six  and  eight  days,  and 
3  between  the  ages  of  ten  and  eighteen  days.  Of  20  cases  embraced  in  the 
memoir  of  Rilliet  and  Barthez,  9  were  at  or  under  the  age  of  thirty-six  hours 
when  the  hemorrhage  began,  5  between  the  ages  of  two  and  four  days,  2 
^  AnnaUn  von  Pierer,  1825,  Heft  6. 
504 


HELENA   NEONATORUM.  505 

between  sis  and  eleven  days,  and  2  at  the  ages  of  fifteen  and  twenty  weeks. 
Of  50  cases  collated  by  Croom  ^  from  various  sources,  gastro-intestinal  hem- 
orrhage took  place  in  30  between  the  first  and  sixth  days,  in  8  between  the 
sixth  and  eighth  days,  in  4  between  the  eighth  and  twelfth  days,  and  in  8 
between  the  twelfth  and  eighteenth  days.  The  bleeding  began  in  6  within 
the  first  twenty-four  hours.  These  statistics,  which  correspond  with  those 
of  other  observers,  show  that  in  a  large  majority  of  cases  the  hemorrhage 
occurs  within  the  first  twenty-four  hours.  Haematemesis  also  takes  place 
along  with  the  intestinal  hemorrhage  in  a  considerable  proportion  of  cases. 

Etiology. — The  cause  of  melaena  of  the  newly-born  is  involved  in  some 
■obscurity.  To  a  considerable  extent  the  causes  are  the  same  as  in  hemor- 
rhage from  the  umbilicus,  which  we  have  treated  of  in  a  foregoing  page.  A 
predisposition  to  this  and  other  forms  of  hemorrhage  is  sometimes  inherited. 
Dr.  Rahn-Escher  states  that  the  mothers  sometimes  have  digestive  ailments 
or  other  foi'ms  of  ill-health,  which  he  thinks  produce  atony  of  the  vessels  in 
their  infants.  The  bleeding  infant  sometimes  belongs  to  a  family  of  bleeders 
and  inherits  haemophilia.  In  the  Medical  Times  and  Gazette  for  October,  1880, 
Dr.  Croom  relates  4  cases  in  which  there  appeared  to  be  an  hereditary  tendency 
to  bleeding.  In  1  of  the  cases  the  father  was  subject  to  hemorrhages;  in 
another  the  pressure  of  the  forceps  produced  extensive  ecehymoses  on  both 
sides  of  the  head.  We  have  stated  in  our  remarks  on  umbilical  hemorrhage 
that  newly-born  infants  affected  by  syphilis  are  very  liable  to  intestinal 
and  other  forms  of  hemorrhage  from  the  dyscrasia  present  or  from  anatomi- 
cal changes  in  the  walls  of  the  minute  vessels,  or,  as  is  probable,  from  both 
causes.  Our  article  on  umbilical  hemorrhage  contains  the  statistics  of 
Mracek,  who  at  the  autopsies  of  160  syphilitic  infants  observed  internal 
hemorrhages  in  42,  but  in  only  4  of  these  was  extra vasated  blood  present  in 
the  intestines. 

But  the  majority  of  the  neonati  who  have  gastro-intestinal  hemorrhage 
do  not  appear  to  have  any  inherited  dyscrasia  or  taint  of  system.  Certainly 
the  instances  are  exceptional  in  which  the  infants  belong  to  families  of 
*'  bleeders  "  or  have  the  syphilitic  dyscrasia.  We  must  look  for  other  causes 
apart  from  these.  Billard  attributes  melaena  of  the  newly-born  to  conges- 
tion of  the  vessels.  Says  he :  "I  have  examined  15  cases  of  passive  intes- 
tinal hemorrhage Most  of  them  were  remarkable  for  the  plethoric 

■condition  of  their  bodies  and  the  general  congestion  of  their  integuments, 
....  In  all  the  large  abdominal  vessels,  the  liver,  spleen,  lungs,  and  heart 
were  considerably  engorged  with  blood."  He  adds  :  "  It  cannot  be  too 
strongly  recommended  to  accoucheurs  to  allow  the  umbilical  cord  to  bleed 
when  a  child  is  observed  to  be  in  a  state  of  asphyxia  ;  for  it  has  already 
been  seen  what  serious  effects  follow  from  a  superabundance  of  blood  in 
young  infants."^  Vogel  says:  "  The  turgeseence  of  the  mesenteric  arteries 
and  their  systems  of  capillaries,  seen  even  in  the  physiological  state,  and 
produced  by  the  sudden  closure  of  the  umbilical  arteries,  so  important  in 
the  foetus,  and  which  arise  directly  from  the  hypogastric  arteries,  may  be 
looked  upon  as  a  cause  of  this  disease.  An  especial  thinness  of  the  walls  or 
friability  of  the  affected  system  of  vessels  must  certainly  play  a  part  here, 
because  otherwise  this,  in  reality,  very  rare  form  of  hemorrhage  would  have 
to  occur  much  more  frequently.  The  closure  of  the  ductus  venosus  x\rantii, 
and  especially  that  of  the  branch  of  the  umbilical  vein  opening  into  the 
portal  vein,  deserves  more  frequent  and  stricter  investigation  to  explain  this 
hemorrhage." 

Eilliet  and  Barthez  attach  but  little  importance  to  the  causes  of  melaena 
assigned  by  writers  who  preceded  them,  but  state  that  it  is  easy  to  conceive 

^  Medical  Times  and  Oaz,,  Oct.,  1880.  ^  Treatise  on  the  Diseases  of  Infants. 


506  DISEASES  OF  THE  BLOOD. 

that  liyperaemia  of  the  intestinal  tube,  which  is  normal  in  the  newly-born^ 
might  be  increased  by  atony  of  the  vessels  or  impeded  abdominal  circulation, 
through  arrest  of  the  circulation  in  the  portal  vein,  so  that  hemorrhage 
would  be  likely  to  occur.  Incomplete  establishment  of  respiration,  in  which 
congestion  of  organs  occurs,  and  especially  of  the  intestines,  they  regard  as 
a  predisposing  cause.  They  admit  hereditary  influence  in  certain  cases,  as 
when  a  parent  has  been  subject  to  hemorrhage.  M.  Bouchut  ^  makes  three 
groups  of  cases  of  melsena,  according  to  the  supposed  etiology,  as  follows  : 
First,  melsena  from  purpura  ;  second,  from  passive  congestion,  the  result  of 
compression  at  birth  ;  third,  from  acute  or  chronic  inflammation  of  the  gas- 
tro-intestinal  surface.  Dr.  West  believes  that  tedious  and  difiieult  labor,  in 
which  the  head  of  the  child  is  compressed  and  abdomen  injured,  is  an  occa- 
sional cause  of  intestinal  hemorrhage.  The  tardy  and  difficult  establishment 
of  respiration  he  also  thinks  may  be  a  predisposing  cause,  but  he  adds  :  "  Very 
often  no  reason  can  be  assigned  for  it."  In  two  post-mortem  examinations 
which  he  made  no  adequate  cause  was  discovered.  Braun  ^  mentions  among 
the  probable  causes  congestion  of  mesenteric  vessels,  pressure  during  birth, 
heredity,  intra-uterine  malnutrition.  Steiner  ^  believes  that  intestinal  hemor- 
rage  occurs  sometimes  from  a  round  perforating  ulcer  due  to  fatty  degene- 
ration of  the  arteries.  Hecker,  Buhl,  Spiegelberg,  and  Leopold  Landau 
relate  cases,  six  in  all,  in  which  abscesses  or  ulcers  were  observed  in  the 
stomach  or  duodenum,  or  in  both.  Landau  expresses  the  opinion  that  these 
lesions  occurring  in  the  gastro-duodenal  surface  are  produced  by  small  embo- 
lisms. ReinhokP  relates  the  case  of  an  infant  born  May  15th  who  had 
hsematemesis  and  melasna  on  the  first  day,  and  died  May  17th.  There  was 
apparently  epigastric  tenderness.  All  the  organs  were  anaemic,  and  the 
stomach  contained  seven  or  eight  ulcers  with  edges  slightly  raised.  No  em- 
boli could  be  discovered,  but  the  umbilical  vein  contained  a  brownish-red  clot. 

On  the  other  hand,  J.  Halliday  Croom,  lecturer  on  midwifery  and  dis- 
eases of  women  at  the  School  of  Medicine,  Edinburgh,  made  the  autopsy 
of  a  child  that  died  of  melsena  at  the  age  of  half  a  day.  The  gastro-intes- 
tinal  surface  was  carefully  examined,  and  no  abscess,  ulcer,  or  erosion  was 
discovered,  but  some  congestion  was  observed  in  the  lower  part  of  the  intes- 
tine. He  alludes  to  another  case,  described  by  Helmbrecht,  in  which  the 
only  apparent  morbid  condition  was  congestion  of  the  rectum.  In  another 
case,  observed  by  Dr.  Croom,  an  infant  of  three  weeks,  previously  well,  died 
of  haematemesis  and  melaena.  Both  auricles  contained  firm  clots,  and  in  the 
aorta  was  a  clot  partly  decolorized.  The  only  abnormal  appearance  in  the 
digestive  tract  was  capillary  injection  of  the  duodenal  surface.^  In  a  case 
reported  by  Schiitze,®  no  ulceration  of  the  intestinal  mucous  membrane  was 
discovered  at  the  autopsy,  but  the  mouth,  pharynx,  oesophagus,  trachea, 
stomach,  bronchi,  lower  part  of  ileum,  and  larger  intestine  were  full  of  a 
dark  tea-colored  fiuid ;  there  were  ecchymoses  of  the  dura  mater,  and  the 
lungs  were  emphysematous. 

Epstein  of  Prague''  in  an  interesting  monograph  on  melaena  neonatorum 
states  that  hemorrhage  occurs  in  the  newly-born  from  various  causes — from 
disturbance  of  the  circulation  leading  to  congestion,  from  disease  of  the  ves- 
sels, and  from  disease  of  the  blood  itself.  In  infants  born  partly  asphyxiated 
after  tedious  labor,  or  in  weakly  infants  with  atelectasis,  Epstein  says  that 
hypersemia,  hemorrhagic  erosions,  ulcerations,  and  actual  hemorrhage  of  the 
gastro-intestinal  surface  are  likely  to  occur.     He  believes  that  the  most  com- 

^  Traite  pratique  des  Maladies  des  Nouveaux-nes. 

'^  Compendium  des  Kinderkeilkunde,  Vienna,  1871.  ^  Diseases  of  Children. 

*  Deutsche  med.  Woeh.,  No.  28,  1881.         ^  Medical  Times  and  Gaz.,  Oct.,  1880. 
6  Centralblattf.  Gyndkol,  No.  9,  1894.         '  Allgem.  Wien.  med.  Zeit,  No.  49,  1882. 


SIMPLE  OB  SECONDARY  ANMMIA.  507 

mon  cause  of  melaena  is  temporary  congestion  of  the  finer  capillary  vessels. 
"When  the  surface  of  the  stomach  has  been  sprinkled  with  ecchymoses,  small 
gastric  ulcei's  have  been  present,  caused  by  emboli  in  the  gastro-duodenal 
vessels,  resulting  from  thrombi  in  the  umbilical  vein. 

From  the  above  quite  numerous  observations  we  are  able  to  affirm  that 
hemorrhage  from  the  stomach  and  intestines  in  the  newly-born  occurs  from 
diff"erent  causes,  prominent  among  which  are — 1st,  hsemophilia  ;  2d,  inherited 
syphilis ;  3d,  congestion  of  the  gastro-intestinal  surface  ;  4th,  ulcers  occur- 
ring especially  in  the  stomach,  whether  produced  by  emboli  resulting  from 
thrombosis  in  the  umbilical  vein  or  from  other  causes. 

Diagnosis. — If  the  infant  vomit  blood,  the  nipple  of  the  mother  or 
wet-nurse  should  be  inspected,  for  a  considerable  amount  of  blood  is  some- 
times drawn  by  suction  from  the  nipple.  If  no  abrasion  or  sore  be  dis- 
covered upon  or  around  the  nipple  or  upon  the  lips  or  in  the  mouth  of  the 
infant,  we  may  assume  that  hemorrhage  is  occurring  from  the  stomach  or 
upper  part  of  the  intestines  of  the  infant.  The  presence  of  blood  upon  the 
diaper  without  any  fissure  upon  the  anus  or  external  source  of  its  occurrence 
is  evidence  of  intestinal  hemorrhage.  The  blood  is  dark  and  more  or  less 
changed  by  digestion  or  the  action  of  the  intestinal  secretions  if  it  have  lain 
some  time  in  the  intestines.  The  pallor  of  the  infant  and  increasing  feeble- 
ness are  evidence  of  the  loss  of  blood.  But  in  one  instance  myself  and  two 
other  physicians  were  deceived  by  a  midwife  who  had  loosely  ligated  the 
umbilical  cord,  so  that  fatal  hemorrhage  occurred  from  it.  The  case  was 
reported  as  one  of  intestinal  hemorrhage,  and  was  recorded  as  such  in  the 
statistics  of  the  Health  Board.  The  source  of  the  hemorrhage  was  ascer- 
tained by  a  post-mortem  examination  which  we  were  fortunate  in  obtaining. 
The  gastro-intestinal  surface  was  normal  except  its  extreme  bloodlessness 
and  pallor. 

Prognosis.— The  prognosis  is  in  most  instances  unfavorable,  but  if  the 
infant  be  strong  and  the  amount  of  hemorrhage  small,  we  may  hold  out  some 
encouragement  of  a  favorable  result.  It  is  possible,  indeed,  that  a  consider- 
able amount  of  blood  may  be  lost  and  the  infant  recover.  But  weakly  infants 
who  have  an  abundant  hemorrhage  sink  rapidly.  If  the  bleeding  do  not  cease 
in  twenty-four  hours,  death  will  probably  be  the  result. 

Treatment. — The  child  should  be  nourished  at  the  breast  if  possible, 
and  a  little  ice-water  be  given  with  a  spoon  along  with  the  breast-milk.  If 
the  infant  do  not  have  breast-milk,  peptonized  milk  may  be  employed.  The 
food,  of  whatever  kind,  should  be  given  cool.  It  has  been  recommended  to 
apply  the  ice-bag  over  the  abdomen  while  warm  applications  are  made  to  the 
extremities.  One  grain  of  tannic  or  gallic  acid  dissolved  in  cool  water  may 
be  given  every  hour,  or  one  or  two  drops  of  turpentine.  If  the  child  exhibit 
signs  of  failing  strength,  a  few  drops  of  brandy  should  be  given  at  short 
intervals  in  cold  peptonized  milk. 


CHAPTER    II. 

SIMPLE   OR   SECONDARY  ANiEMIA. 

By  simple  anaemia  we  mean  a  condition  resulting  almost  invariably  as  a 
consequence  of  previously  existing  disease,  excepting,  of  course,  post-hemor- 
rhagic  anaemia,  whereby  the  composition  of  the  blood  is  greatly  altered,  re- 
sulting in  the  impoverishment  of  the  vital  fluid  and  the  impairment  of  its 


508  DISEASES  OF  THE  BLOOD. 

function.  Should  this  condition  be  regarded  as  a  symptom  or  as  a  disease  ? 
Unquestionably  the  latter,  characterized  as  it  is  by  certain  anatomical  appear- 
ances and  a  train  of  well-marked  symptoms. 

In  children  simple  antemia  is  one  of  the  most  important  pathological  con- 
ditions we  meet,  frequently  encountered,  complicating  many  other  states,  in- 
fluencing other  and  grave  diseases,  always  of  much  significance.  In  common 
with  the  other  blood-diseases,  it  is  characterized  by  a  diminution  in  the  amount 
of  htemoglobin,  which  normally  constitutes  about  90  per  cent,  of  the  bulk  of 
the  red  cells.  The  red  blood-globules  may  be  only  slightly  reduced  in  num- 
ber, they  may  even  be  numerically  normal,  and  in  very  badly-nourished  chil- 
dren there  is  a  lessening  in  the  whole  amount  of  blood. 

Let  us  revert  briefly  to  a  consideration  of  the  corpuscular  elements  of  the 
blood,  and  the  relationship  of  their  state  or  condition  to  this  aff'ection.  The 
red  blood-cells  are  the  means  by  which  oxygen  is  carried  to  the  tissues ;  they 
vary  in  number  from  four  and  a  half  to  five  millions  per  cubic  miUimetre  in 
the  healthy  adult ;  at  birth  the  number  is  greater ;  within  a  short  time  it  is 
rapidly  reduced.     (Plate  III.  Fig.  1.) 

Nucleated  blood-cells,  which  are  normally  found  in  the  red  marrow,  are 
probably  intermediate  between  the  red  blood-cells  and  the  marrow-cells  ;  these 
are  not  found  in  the  blood  of  healthy  adults,  though  present  in  the  blood  of 
children  up  to  two  or  three  years  of  age  and  in  the  foetus.  According  to 
Erlich,^  they  may  be  found  in  the  blood  of  patients  sufi"ering  from  all  varieties 
of  anaemia  ;  they  are  a  little  larger  than  the  ordinary  red  blood-cells  and  con- 
tain one  or  more  nuclei. 

The  white  blood-corpuscles  are  larger  and  fewer  than  the  red  blood-cells 
in  number,  being  about  from  eight  to  fifteen  thousand  per  cubic  millimetre 
normally,  although  this  amount  may  be  greatly  increased  without  afiecting 
the  health. 

The  blood  of  children  contains  double  and  sometimes  treble  the  adult 
number  of  white  blood-cells,  and  in  exceptional  cases  even  a  greater  number, 
and  then  there  is  great  likelihood  that  this  condition  of  leukocytosis  may  be 
mistaken  for  leukseiuia. 

Infants  at  the  breast  are  said  to  have  present  in  the  blood  a  greater  per- 
centage of  leukocytes  than  those  fed  on  cow's  milk.  Personally  I  have  not 
been  able  to  demonstrate  this,  although  I  have  many  times  examined  the  blood 
of  infants  for  the  purpose  of  comparison.  It  is  an  undoubted  fact  that  in  all 
cases  of  anaemia  the  amount  of  haemoglobin  is  diminished,  the  sole  exception 
being  in  pernicious  anaemia,  where  the  haemoglobin  commonly  equals  or  ex- 
ceeds the  percentage  of  red  blood-cells,  and  this  may  be  demonstrated  by 
means  of  the  haemoglobinometer — an  instrument  which,  as  its  name  indicates, 
registers  accurately  the  percentage  of  haemoglobin  in  the  specimen  of  blood. 
The  simplest  instrument  for  practical  use  is  the  one  devised  by  Gowers. 

In  simple  anaemia  the  percentage  of  haemoglobin  is  diminished  to  a  much 
greater  extent  than  that  of  the  red  blood-globules.     (Plate  III.  Fig.  2.) 

In  studying  any  of  the  blood  diseases  much  may  be  learned  by  examina- 
tion of  the  blood — 1,  for  the  haemoglobin  as  I  have  above  suggested;  and 
2,  by  the  microscope,  for  a  determination  of  the  rough  proportion  between  the  red 
and  white  cells,  their  color,  shape,  and  size,  as  well  as  those  of  the  blood-plaques, 
the  presence  of  nucleated  blood-cells  or  of  foreign  bodies,  such  as  the  Plas- 
modium malarise. 

This  latter  method  is  simple,  and  is  readily  managed  by  any  one  with  a 
microscope  with  ordinary  lenses.  For  the  more  exact  determination,  how- 
ever, of  the  relation  between  the  red  and  white  corpuscles  special  apparatus 
is  required.  For  this  purpose  the  Thoma-Zeiss  haemacytometer  is  in  common 
^  Berliner  klinische  Wochenschrift,  1880,  p.  405. 


PLATE    III. 


FicT.  1. 


Fig.  2. 


^J      _   W  ^ 


Oc^ 


Normal     Blood. 


Blood    in    Anaemia. 


Fig.  8. 


Fig. 


®S?o 


/<^  <^°    ©    ®  "„    ®\. 

,r"  (5k^  ®      (£)     "^  @«     ^  ®     o^-r 


c 


Blood    in    Chlorosis, 
(x    SOO.) 


m  «.  O     "       ®        ^        «)     OQi 


n     ^0 


Blood    in 

Aeute    Lymphatic    Leukaemia. 

(X   SOO.) 


SIMPLE   OR  SECONDARY  ANEMIA.  509 

use,  and  is  very  simple  and  easily  managed.  It  consists  practically  of  a  slide 
with  a  centrally  depressed  disk,  which  is  divided  into  microscopic  squares. 
Upon  this  surface  properly  diluted  blood  is  dropped,  the  cells  being  counted 
within  the  given  space,  and  as  the  dilution  is  a  standard  one,  the  total  number 
of  white  and  red  corpuscles  per  cubic  millimetre  is  easy  to  calculate. 

In  various  wasting  diseases  accompanied  by  great  changes  in  the  blood  a 
condition  is  sometimes  obtained  in  which  marked  alterations  in  the  shapes  of 
the  red  corpuscles  occur  ;  they  become  variously  distorted,  and  may  even  take 
upon  themselves  amoeboid  movements.  This  is  sometimes  the  case  in  simple 
anaemia,  but  is  more  characteristic  of  the  condition  known  as  pernicious 
anaemia. 

Etiology. — The  causes  which  lead  to  the  condition  of  simple  anaemia  in 
children  are  various,  chief  among  them  being  malnutrition,  secondary  to  graver 
diseases,  such  as  scarlatina  and  inherited  disease,  tuberculosis,  syphilis,  im- 
proper and  scanty  food,  faulty  hygiene,  including  lack  of  fresh  air  ;  and  Haig,^ 
who  has  investigated  this  subject  pretty  thoroughly,  thinks  that  severe  anasmia 
is  sometimes  caused  by  a  condition  of  uric-acideemia.  This  I  believe  to  be 
often  the  case. 

Rachford,-  as  the  result  of  the  examination  of  the  blood  of  166  school- 
girls, has  been  led  to  the  conclusion  that  pronounced  anaemia  without  apparent 
cause  is  strongly  suggestive  of  concealed  tuberculosis,  and  that  antemia  in 
apparently  non-tubercular  girls  coming  from  tubercular  stock  is  very  probably 
due  to  a  deep-seated  and  hidden  glandular  tuberculosis. 

Symptoms. — -We  have  seen  that  in  anjemia — 1,  the  hasmoglobin  is  reduced, 
and  2,  the  red  blood-cells  may  or  may  not  be  diminished  in  number,  while  the 
total  bulk  of  the  blood  may  or  may  not  remain  practically  the  same.  There- 
fore, the  initial  symptom  to  which  our  attention  is  apt  to  be  called  in  this  dis- 
ease is  referable  to  this  condition — pallor,  ranging  all  the  way  from  almost 
marble  whiteness  to  dusky  yellow  ;  pallor  of  skin  ;  pallor  of  all  visible  mucous 
surfaces  ;  certain  portions  of  the  body  become  markedly  blanched,  the  ears, 
nose,  and  nails. 

In  some  cases  the  cheeks  may  be  bright  red  in  color,  while  the  conjunctiva, 
the  lips,  gums,  and  roof  of  mouth  betray  a  waxen  whiteness.  In  other  cases 
the  temperature  is  normal ;  in  others  an  irregular  pyrexia  may  develop,  the 
pulse  may  be  full  and  soft  or  small  and  weak,  with  the  heart's  action  irregu- 
lar, while  a  venous  hum  may  commonl}-  be  heard  over  the  jugulars.  Leu- 
korrhoea  may  develop  in  very  young  female  children,  and  catarrh  of  the  respi- 
ratory mucous  membranes  is  of  common  occurrence. 

When  the  anaemia  is  secondary  to  and  dependent  upon  other  disease — 
such  as  rickets,  for  example — it  is  often  the  first  symptom  noticed.  There  is 
a  peculiar  puffiness  of  face,  hands,  and  feet,  resembling  the  oedema  of  acute 
Bright's  disease.  Patients  complain  of  neuralgic  pains,  the  most  important 
and  characteristic  of  which  was  first  pointed  out  by  Flint  in  cases  of  so-called 
spinal  irritation,  where  pressure  over  the  cervical  and  dorsal  vertebrae  causes 
intercostal  and  cervico-oecipital  pains,  with  perhaps  the  association  of  nausea, 
vomiting,  palpitation,  and  a  nervous  cough. 

With  these  symptoms  great  weakness  and  prostration  are  of  frequent  occur- 
rence, associated  with  loss  of  appetite  and  obstinate  constipation,  which  latter 
condition  has  been  believed  by  Sir  Andrew  Clarke  and  some  other  observers  to 
be  one  of  the  causes  of  the  disease,  by  poisoning  the  patient  from  absorption 
of  ptomaines  from  the  impacted  intestinal  canal. 

Diagnosis.  —  The  diagnosis  must  be  made  from  chlorosis,  pernicious 
anaemia,  leukagmia,  beginning  pulmonary  tuberculosis,  and  acute  Bright's 
disease. 

^  Uric  Acid,  p.  218.  ^  Transactions  of  the  American  Pediatric  Society,  1892. 


510  DISEASES  OF  THE  BLOOD. 

From  Chlorosis. — The  age  of  the  patient,  as  this  is  an  exceedingly  rare 
affection  in  young  children  ;  also  the  hue  of  the  skin  in  chlorotic  patients  is 
unmistakable,  the  typical  greenish  pallor — particularly  true  of  brunettes — 
being  entirely  different  from  the  yellow-white  or  muddy  color  of  simple 
anremia.     (Plate  III.  Fig.  3.) 

From  Pernicious  Ansemia. — A  microscopic  examination  of  the  blood  in 
this  latter  condition  is  essential.  The  red  blood-corpuscles  are  rapidly 
reduced  in  number ;  they  may  reach  only  one-fifth  or  one-sixth  of  the  nor- 
mal amount,  while,  on  the  other  hand,  the  percentage  of  haemoglobin  is 
relatively  high.  The  red  blood-cells  are  either  much  larger  than  normal  or 
much  smaller,  and  may  take  upon  themselves  irregular  forms.  Nucleated 
blood-cells  are  constantly  present.  The  white  blood-corpuscles  are  also 
diminished,  but  not  to  a  corresponding  degree  with  the  red  cells. 

From  Leuksemia. — In  the  anaemia  of  infants  leukocytosis  is  apt  to  occur, 
and  it  is  due  to  this  fact  that  errors  in  diagnosis  are  of  common  occurrence. 
The  composition  of  the  blood,  however,  is  very  characteristic.  In  leukaemia 
(a  rare  affection  in  infants)  a  constant,  steady  increase  in  the  number  of  the 
white  cells  obtains,  while  there  is  a  like  steady  decrease  in  the  number  of  red 
cells.  In  leukocytosis  the  number  of  white  blood-corpuscles  varies  greatly  at 
different  times.  In  leukaemia  we  have  the  enlarged  liver,  spleen,  and  lymph- 
atic glands,  which  of  course  are  absent  in  anaemia,  except  in  a  form  which 
has  been  described  by  Von  Jaksch,^  and  which  he  calls  ansemia  infantmn 
or  'psendo-leuhmmia . 

From  Beginning  Pulmonary  Tuberculosis. — By  means  of  the  physical  signs 
and  characteristic  range  of  temperature. 

From  Acute  Brighfs  Disease. — By  means  of  the  presence  or  absence  of 
casts  and  other  symptoms  marking  this  affection. 

Treatment. — In  considering  the  treatment  of  this  affection  our  object  is 
primarily  to  increase  the  amount  of  haemoglobin  contained  in  the  blood. 
When  the  patient  is  the  victim  of  inherited  disease,  syphilis  or  tuberculosis, 
medication  appropriate  to  the  systemic  poison,  together  with  the  best  possible 
hygienic  conditions — fresh  air,  abundance  of  fatty  food  and  expressed  beef- 
juice  (the  neai'est  approach  to  the  administration  of  haemoglobin  at  our  com- 
mand), and  regular  exercise,  preferably  in  the  open  air — will  be  of  benefit. 
About  the  only  two  drugs  which  seem  to  be  of  efficacy  in  the  treatment  of 
anaemia  in  young  children  are  iron  and  arsenic. 

Iron. — The  blood  of  man  contains  one  part  of  iron  to  two  hundred  and 
fifty  parts  of  red  blood-globules.  In  health  a  mixed  diet  contains  sufficient 
iron  for  all  purposes ;  but  when  the  percentage  of  haemoglobin  falls  below 
the  normal  amount,  experience  proves  that  the  exhibition  of  iron  in  many 
cases  promptly  arrests  this  fall  and  restores  the  normal  balance. 

Forchheimer''*  insists  upon  the  intestinal  tract  as  the  principal  place  of 
origin  of  the  haemoglobin,  and  believes  that,  excluding  the  origin  of  anaemias, 
the  reduction  of  haemoglobin  is  due  to  either  diminished  formation,  excessive 
destruction,  or  both.  Therefore  he  treats  all  cases  of  simple  ansemia,  charac- 
terized, of  course  by  a  lessening  of  the  amount  of  haemoglobin,  by  intestinal 
antiseptics.  I  believe  that  anaemias  of  intestinal  origin,  such  as  undoubtedly 
exist,  may  rationally  be  treated  on  this  principle,  but  only  those.  The  same 
observer  believes  that  the  good  effect  obtained  by  the  employment  of  iron  in 
anaemia  is  partly  due  to  its  ability  to  prevent  the  formation  of  albuminous 
products  not  compatible  with  haemoglobin  formation.  Be  this  as  it  may.  the 
good  effects  produced  in  the  treatment  of  ansemia  with  iron  is  too  old  a  story 
to  repeat,  except  to  emphasize  the  fact  of  its  value  with  a  word  of  caution 

^  Annals  of  Universal  Medical  Science,  1890,  vol.  ii.  pp.  E.  12. 

^  "Ansemia  in  Children,"  Transactions  of  the  Pediatric  Society,  vol.  v. 


PRIMARY  ANEMIA.  511 

against  its  abuse.  I  believe  that  the  best  effects  are  obtained  by  the  adminis- 
tration of  small  doses,  for  in  this  way  it  acts  in  the  double  capacity  of  a  sto- 
machic tonic  and  a  blood  reconstructive.  In  large  doses  it  quickly  exhausts  the 
gastric  glands  by  over-stimulation,  and  it  is  then,  of  necessity,  discontinued. 

Arsenic,  in  combination  with  iron  or  alone,  in  proportionately  larger  doses 
than  adults  will  bear,  is  of  great  importance,  and  especially  viseful  in  chronic 
cases.  It  acts  by  increasing  the  appetite,  promoting  digestion,  and  improv- 
ing the  body  nutrition.  In  the  anemia  of  the  uric-acid  condition — which 
is,  although  of  frequent  occurrence  in  young  children,  commonly  overlooked, 
and  which  may  have  resisted  iron  given  in  the  usual  way  for  a  long  time — 
brilliant  results  will  sometimes  be  obtained  by  the  administration  of  the 
salicylate  of  soda. 

Dr.  Augustus  Caille  has  published  statistics  regarding  the  value  of  the 
employment  of  inhalations  of  nascent  ozone  in  the  anaemia  of  children,  which 
he  deems  considerable.  I  have  used  oxygen  in  a  number  of  cases,  and  believe 
that  it  has  been  of  service.  Exercise  in  the  open  air,  regularly,  is  probably 
equal  in  value  with  either.  The  treatment  is  therefore  thus  summed  up : 
Relieve,  if  possible,  the  constitutional  cause  of  the  anaemia ;  in  addition, 
give  iron  and  arsenic  sparingly,  in  tonic  doses ;  plenty  of  good  nutritious 
food  and  systematic  exercise  in  the  open  air. 


CHAPTER    III. 

PEIMAKY  ANEMIA. 

Leuksemia  (Leucocythsemia), 

A  DISEASE  characterized  by  a  steadily  progressive  increase  in  the  number 
of  white  blood-corpuscles,  and  a  diminution  in  the  number  of  red  blood-cells. 
In  many  cases  the  spleen  becomes  very  greatly  increased  in  size,  and  in 
others  the  lymphatics  become  enlarged,  and  marked  changes  may  take  place 
in  the  bone-marrow. 

Etiology. — The  origin  of  the  disease  is  obscure.  Tuberculosis,  syphilis, 
malaria,  anything  which  tends  to  seriously  alter  the  bodily  nutrition,  predis- 
poses to  the  disease.  According  to  the  observations  of  Cameron  (published 
in  1888)  and  those  of  Sanger  (in  1891),  intra-uterine  transmission  of  leukaemia 
from  mother  to  child  does  not  take  place.  It  is  of  rare  occurrence  in  chil- 
dren, but  is  in  many  cases  overlooked  when  actually  present.  It  may  follow 
the  exanthemata. 

Morbid  Anatomy. — The  spleen  is  generally  more  or  less  enlarged  in  the 
splenic  variety  of  the  disease  ;  it  may  be  so  large  as  to  seriously  interfere 
with  the  functions  of  other  organs.  The  lesions  consist  of  a  hyperplasia  :  on 
section  the  spleen  is  dark  red  in  color,  with  occasional  hemorrhagic  infarc- 
tions. The  lymphatic  glands  also  undergo  a  hyperplasia,  whitish  or  grayish- 
red  on  section  ;  the  liver  is  generally  large.  The  medulla  of  the  bones  may 
be  gelatinous  and  red,  or  white  from  the  number  of  leucocytes.  The  blood- 
changes  are  very  marked.  Normally,  the  pi'oportion  of  white  and  red  blood- 
cells  is  1  to  500  ;  in  this  disease  the  white  cells  may  equal  or  exceed  the  red 
blood-cells  in  number. 

In  acute  lymphatic  leulcsemia  the  white  cells  are  chiefly  lymphocytes — 
small  cells  about  the  size  of  red  blood-globules,  nearly  filled  with  a  single 
nucleus.     (Plate  III.,  Fig.  4.) 


512  DISEASES  OF  THE  BLOOD. 

In  leiikxmia  Unenlis  the  colorless  cells  are  much  larger  than  the  red 
blood-cells.  In  the  splenic  variety  of  the  disease  there  are  present  large 
colorless  cells,  which  do  not  occur  in  normal  blood,  and  which  differ  from  the 
other  large  white  cells  in  the  fact  that  they  contain  a  fine  granular  mass  in 
the  nucleus.  Blood-plaques  may  or  may  not  be  present.  The  Charcol-Xeu- 
mann  crystals  readily  separate  out  from  the  blood.     (Plate  IV.  Fig.  1.) 

Symptoms. — The  disease  begins  insidiously.  The  most  characteristic 
symptoms  are  the  blood-changes,  aside  from  which  occur  extreme  pallor,  en- 
largement and  tenderness  of  the  spleen,  enlargement  of  the  lymphatic 
glands,  in  which  caseation  and  suppuration  may  take  place  but  rarely. 
When  the  disease  affects  the  medulla  there  may  be  tenderness  on  pressure 
over  the  shafts  of  the  long  bones,  over  the  sternum,  and  over  the  spinal 
column.  Hemorrhages  may  occur  from  the  gums  and  the  nose  frequently — 
hagmatemesis  or  haematuria  rarely ;  cerebral  hemorrhage  may  take  place. 
Xausea,  vomiting,  and  diarrhoea  are  of  constant  occurrence.  Jaundice  and 
accumulation  of  fluid  in  the  peritoneal  and  pleural  cavities  occur,  and  we 
have  also  the  symptoms  of  anaemia— faintness,  dizziness,  and  headache.  A 
slight  elevation  of  temperature  is  pretty  constant,  but  at  times  it  may  be 
absent. 

Diagnosis. — An  examination  of  the  blood  can  alone  reveal  the  presence 
of  leukaemia,  but  this  is  characteristic  and  unmistakable. 

Prognosis. — A  fatal  termination  is  the  rule  ;  exceptionally  patients  have 
recovered,  but  when  this  occurs  a  relapse  after  a  longer  or  shorter  time  is  to 
be  looked  for. 

Treatment. — Arsenic,  iron,  inhalations  of  oxygen,  and  in  some  cases, 
where  seemingly  indicated  by  an  early  history  of  malarial  influences,  quinine, 
are  all,  at  times,  of  benefit,  arsenic  probably  being  of  more  real  utility  than 
any  other  drug.  Pure  air  and  good  food  are  essential.  There  is  seldom, 
however,  prolonged  benefit  from  any  line  of  treatment.  Excision  of  the 
spleen  has  been  performed,  but  is  not  to  be  advised. 

Pseudo -leukaemia  (Lymphatic  Anaemia ;  Hodgkin's  Disease) 

consists  in  a  hyperplasia  of  the  lymphatic  tissues  wherever  situated  in  the 
body,  notably  in  the  lymphatic  glands  and  spleen  ;  frequently  the  liver  is  in- 
volved, associated  with  anaemia  and  pyrexia,  and  generally  progressing  to  a 
fatal  termination. 

Etiology. — Generally  occurs  during  youth — very  frequently,  however,  in 
childhood.  A  majority  of  the  cases  are  in  males.  As  a  rule,  the  affection 
begins  in  an  insidious  manner  from  no  assignable  cause.  It  has  been 
ascribed  to  syphilitic  or  tubercular  antecedents.  In  other  cases,  however, 
local  irritation,  due  to  chronic  disease  of  the  ear,  a  decayed  tooth,  or  naso- 
pharyngeal catarrh,  gives  rise  to  disease  of  the  adjacent  lymphatic  glands, 
from  which  the  glands  in  various  parts  of  the  body  become  affected.  The 
main  pathological  change  is  an  increase  in  the  lymphatic  tissue  in  various 
organs  of  the  body. 

Morbid  Anatomy. — The  cervical  glands  are  most  frequently  primarily 
involved,  the  axillary  next,  and  then  the  inguinal.  Of  the  deep  glands,  the 
thoracic,  notably  the  bronchial,  are  most  often  enlarged.  The  glands,  at 
first  distinct,  later  become  amalgamated  into  masses.  The  spleen  is  generally 
of  large  size,  due  to  an  increase  in  the  lymphatic  tissue,  but  this  condition 
is  not  constant.  The  liver  may  be  larger  than  normal,  together  with  the 
kidney,  due  to  the  same  lymphatic  increase.  The  blood-changes  are  not 
constant.  In  the  early  stage  of  the  affection  there  is  no  change  ;  later,  how- 
ever, when  the  anaemia  has  become  marked,  the  blood  is  characteristic  of 


PLATE   IV. 


Fig.  1. 


Fig.  2. 


Blood    in    Leukaemia    Linealis. 
(X   400.) 


Charcot- Neumann     Crystals 

in    Leuksemie    Blood. 

(X  SOO.) 


Fig.  3. 


®  ®  \ 

®         ®      (?)       ?  / 
®       ®s,  ®  ® 


Blood    in    Pernicious    Anaemia. 
(X    SOO.) 


PRIMARY  ANJEMIA.  513 

this  condition,  thin  and  watery,  witli  a  diminution  in  the  number  of  red  cells, 
the  white  corpuscles  remaining  at  about  the  normal  number.  Occasionally 
the  latter  become  greatly  increased  and  true  leukgemia  may  supervene. 

Symptoms. — The  first  symptom  noticed  is  an  enlargement  of  the  cervical 
glands.  They  may  remain  in  this  condition  unchanged  for  months  or  years, 
or  they  may  grow  larger  rapidly,  fusing  together  in  great  masses.  At  the 
same  time  the  axillary  glands  increase  in  size,  followed  by  the  inguinal,  these 
bodies  taking  upon  themselves  like  changes.  Glands  deeply  situated  now 
become  enlarged,  as  is  demonstrated  by  the  mechanical  effects  produced  by 
the  pressure  of  the  larger  veins  upon  the  blood-vessels,  bronchi,  nerves,  etc. 

Anaemia,  intense  and  progressive,  supervenes,  associated  with  more  or  less 
fever  and  prostration  ;  pain,  caused  in  part  by  poverty  of  the  blood,  in  part 
by  pressure  on  nerves  ;  constipation  ;  sometimes  great  difficulty  in  swallow- 
ing ;  hoarseness,  caused  by  pressure  upon  the  larynx  itself  or  upon  the  pneu- 
mogastric  ;  nausea  and  vomiting. 

Diagnosis. — This  afi"ection  must  be  differentiated  from  tuberculous  and 
scrofulous  glands,  from  simple  adenitis  and  leukaemia — from  the  two  former 
by  the  family  history,  the  course  of  the  glandular  enlargement  in  groups, 
then  splenic  enlargement,  and  the  non-liability  to  suppuration  ;  from  simple 
adenitis  by  the  rapid  subsidence  of  the  latter  under  appropriate  treatment ; 
and  from  leukaemia  by  an  examination  of  the  blood. 

Prognosis. — Lymphatic  anaemia  progresses  almost  always  steadily  to  a 
fatal  termination.  Occasionally  a  case  recovers,  but  it  is  the  exception.  The 
disease  lasts  from  three  months  to  three  or  four  years.  Cases  have  been 
reported  of  longer  duration  of  the  disease  than  this,  but  this,  of  course, 
depends  upon  the  rapidity  with  which  the  lymphatic  tissue  increases,  and 
whether  the  masses  which  are  formed  affect  vital  parts  early  or  late. 

Treatment. — If  the  diagnosis  is  made  early  in  the  disease,  extirpation 
of  the  glands  affected  gives  the  most  hopeful  chance  for  recovery.  The 
usual  tonic  treatment  of  cod-liver  oil,  iron,  and  arsenic,  as  in  most  of  the 
blood  diseases,  generally  betters  the  condition  somewhat.  Salt-water  baths, 
iodide  of  potassium,  inunction  of  iodide  of  lead  and  lanolin,  good  diet,  and 
fresh  air  are  all  useful.  Pressure  effects  must  be  treated  as  occasion 
demands. 

Splenic  Anaemia, 

an  affection  of  which  the  essential  factor  is  an  enlargement  of  the  spleen, 
associated  with  a  waxen  olive  complexion. 

Etiology. — Enlargement  of  the  spleen  is  of  frequent  occurrence  in 
young  children,  and  is  generally  caused,  primarily,  by  syphilis,  tuberculosis, 
malarial  poisoning,  and  rachitis. 

Morbid  Anatomy. — The  principal  pathological  changes  occur  in  the 
spleen,  which  is  found  to  be  large,  smooth,  and  dense  in  consistency,  red  in 
color  on  section  ;  there  is  a  hyperplasia  of  the  fibrous  tissue  and  a  correspond- 
ing decrease  in  the  amount  of  the  normal  adenoid  substance.  The  number 
of  red  blood-cells  is  found  to  be  greatly  diminished,  while  the  white  blood- 
corpuscles  in  some  cases  are  increased  in  number,  and  in  others  they  remain 
about  the  same. 

Symptoms. — The  peculiar  pallor  which  accompanies  this  affection  is  often 
the  first  symptom  noticed,  and  the  large,  smooth,  firm  mass  appearing  below 
the  free  border  of  the  ribs  and  pushing  out  into  the  abdominal  region,  some- 
times occupying  the  whole  of  the  left  side.  Vomiting  and  diarrhoea  occur 
frequently  in  the  course  of  the  disease,  diminishing  the  strength  and  lower- 
ing the  vitality  of  the  patient ;  catarrhal  troubles,  notably  bronchitis  or 
broncho-pneumonia,  often  bring  the  case  to  a  fatal  termination. 
33 


514  DISEASES  OF  THE  BLOOD. 

Diagnosis. — In  all  cases  of  anaemia  in  young  children  attention  should 
be  at  once  directed  to  the  spleen ;  the  enlargement  of  this  organ,  from  its 
position,  mobility,  hardness,  and  smoothness,  is  not  difficult  of  detection, 
while  an  examination  of  the  blood,  which  should  always  be  made  in  these 
cases,  will  seem  to  differentiate  it  from  leukaemia.  In  pernicious  anaemia  the 
spleen  is  not  particularly  enlarged,  and  the  disease  differs  essentially  from 
lymphatic  anaemia  in  that  the  glands  are  not  affected  and  enlarged. 

Prognosis. — The  prognosis  of  splenic  anaemia  or  enlargement  depends 
entirely  upon  the  etiology.  Tubercular  and  syphilitic  cases  are  unfavorable, 
as  are  some  cases  of  rachitic  origin ;  others,  however,  improve  under  good 
care.  3Ialarial  influences,  which  undoubtedly  are  the  largest  factors  in 
producing  this  condition,  usuall}"  yield  readily  to  treatment  and  change  of 
climate. 

Treatment. — The  best  results  in  the  treatment  of  enlargement  of  the 
spleen  will  be  obtained  by  the  intelligent  employment  of  drugs  directed 
against  the  presumed  cause  of  the  disease,  and  sometimes  brilliant  results 
follow  the  use  of  mercurials  in  the  syphilitic  form,  and  quinine  and  arsenic 
in  the  malarial  variety  of  the  affection.  In  the  rachitic  and  tubercular 
enlai'gements  we  may  expect  that  attention  to  the  diet  and  the  hygiene 
of  the  little  patient  will  achieve  far  more  than  the  mere  taking  of  any 
special  remedy.  The  catarrhal  affections  complicating  splenic  ansemia  may 
be  best  combated  by  suitable  and  warm  clothing,  and  the  patient  must  be 
kept  out  of  doors  as  much  as  possible.  Simple,  easily-digested,  or  even 
predigested  foods  are  indicated,  and  other  complications  must  be  treated  as 
they  arise.  It  is  important,  moreover,  to  sustain  the  patients  to  the  fullest 
extent,  and,  after  they  have  started  on  the  road  to  recovery  to  guard  against 
relapse,  a  not  uncommon  occurrence. 

Pernicious  Anaemia  (Anaemic  Fever,  Idiopathic  Anaemia). 

This  affection  is  characterized  by  anaemia,  fever,  and  highly-colored 
urine,  from  excess  of  urobilin,  together  with  marked  changes  in  the  blood. 
It  is  of  rare  occurrence  in  children. 

Morbid  Anatomy. — The  white  blood-cells  are  diminished  in  number  ;  the 
red  corpuscles  are  very  greatly  lessened  ;  they  may  be  reduced  to  one-fifth  or 
even  less  of  the  normal  number,  while  the  haemoglobin  is  relatively  in- 
creased. The  red  blood-globules  are  very  irregular,  and  may  be  much 
larger  or  much  smaller  in  size,  and  may  possess  amoeboid  movements.  The 
blood  may  contain  nucleated  red  blood-cells,  which  some  observers  consider  to 
be  pathognomonic ;  the  blood-plaques  are  fewer  in  number.  Ecchymoses 
may  occur.  Fatty  degeneration  of  the  various  internal  organs — liver,  kid- 
neys, etc. — is  of  common  occurrence. 

Symptoms. — The  skin  is  generally  brown-tinted  in  color,  and  the  mucous 
surfaces  seem  absolutely  bloodless  and  of  a  pale  leaden  hue.  (Plate  IV. 
Fig.  3.)  The  pyrexia  is  not  constantly  present ;  it  may  come  and  go.  With 
these  special  symptoms  are  always  associated  those  of  simple  anaemia. 

Etiology. — The  cause  of  this  disease  is  very  obscure.  In  children  it 
has  been  known  to  occur  from  no  apparent  predisposing  element.  It  is  more 
apt  to  result,  following  grave  chronic  gastro-intestinal  disorders,  constant  liv- 
ing in-doors  in  rooms  not  often  or  well  ventilated,  and  from  insufficient  and 
improper  food. 

Treatment. — Arsenic  seems  to  be  the  only  drug  of  service  in  this  affec- 
tion. Rest  in  bed,  good,  nourishing  food,  and  attention  to  hygiene  give  the 
best  results ;  but  in  any  case  the  outlook  is  unfavorable. 


PRIMARY  ANMMIA.  515 

Haemophilia, 

an  hereditary  affection  characterized  by  the  sudden  development  of  more 
or  less  severe  hemorrhages,  either  spontaneously  or  from  slight  cause. 

Etiology. — "  Bleeders,"  as  the  subjects  of  this  affection  are  called,  are 
generally  males,  although  females,  while  escaping  themselves  as  a  rule,  most 
frequently  transmit  the  inherited  taint.  For  example,  if  a  bleeder  marries  a 
healthy  woman,  the  children  generally  remain  free  from  the  affection  ;  if,  on 
the  other  hand,  a  healthy  man  marries  a  woman  who  is  free  herself,  but  who 
comes  from  a  family  of  bleeders,  the  male  children  are  generally  bleeders. 

Anatomical  Appearances. — No  constant  changes  have  been  noted  in 
this  affection.  Importance  has  been  attached  by  some  observers  to  a  certain 
thinness  of  the  blood-vessels.  Probably,  however,  the  chief  morbid  process 
will  be  found  in  the  diminished  power  of  the  blood  to  coagulate. 

Symptoms. — The  first  symptom  of  the  affection  is  sometimes  discovered 
early  in  life  from  a  fatal  hemorrhage  following  the  separation  of  the  umbili- 
cal cord,  but  this  is  of  rare  occurrence. 

In  other  cases  trifling  cuts,  bruises,  knocks,  or  other  injuries  produce  per- 
sistent hemorrhages,  more  or  less  serious  in  character  according  to  the  amount 
of  blood  lost.  As  simple  an  affair  as  the  extraction  of  a  tooth  or  an  attack 
of  epistaxis  may  result  fatally.  The  hemorrhage  is  more  often  capillary, 
oozing  generally  from  the  bruised  surface  and  presenting  no  vessel  in  par- 
ticular to  tie. 

Diagnosis. — The  diagnosis  must  be  made  from  purpura  by  the  history, 
and  from  scurvy  by  the  absence  of  the  given  symptoms  in  addition. 

Prognosis. — The  prognosis  is  always  grave.  Constant  care  must  be 
taken  to  prevent  injuries  of  all  kinds,  and  no  surgical  operations  must  be 
performed  upon  these  patients. 

Treatment. — The  treatment  is  chiefly  preventive,  in  not  allowing  the 
females  to  marry,  in  order  to  stamp  out  the  disease.  During  an  attack  of  the 
hemorrhage  rest  in  bed,  ice,  and  astringents  may  be  employed.  Ergot  is  said 
to  be  of  service.  Free  purgation  is  advised ;  iron  and  arsenic  in  full  doses 
have  been  beneficial ;  and  in  desperate  cases  transfusion  is  advocated. 

Purpura, 

an  affection  characterized  by  extravasations  of  blood,  of  greater  or  less 
extent,  into  the  connective  tissue  beneath  the  skin,  into  the  skin  itself,  and 
into  the  submucous  tissue.  Purpura  may  be  simple  and  idiopathic  or  sec- 
ondary. 

Etiology. — Although  the  disease  may  occur  in  adult  life,  it  is  most  fre- 
quently observed  during  infancy  and  childhood.  It  is  probably  due  to  the 
invasion  of  micro-organisms,  and  it  may  exist  as  the  result  of  severe  eruptive 
disorders,  such  as  scarlatina,  smallpox,  measles,  and  typhoid  fever.  It  is 
associated  with  haemophilia  and  scorbutus.  Unsuitable  food  and  unhygienic 
surroundings  predispose  to  it ;  rheumatism  and  grave  gastro-enteritis  and 
jaundice  may  be  associated  with  it.  It  is  frequently  observed,  chiefly  around 
the  eyes,  accompanying  the  paroxysms  of  whooping  cough.  The  administra- 
tion of  certain  drugs  is  followed  in  some  instances  by  purpuric  spots ;  these 
are  principally  the  iodide  of  potash,  mercury,  chloral,  phosphorus,  ergot,  and 
belladonna. 

Anatomical  Appearances. — In  purpura  there  are  extravasations  of 
blood  into  the  skin,  subcutaneous  tissue,  and  mucous  and  serous  membranes. 
The  loss  of  blood  may  in  some  cases  be  so  serious  as  to  result  fatally. 

The  cause  is  uncertain.     Any  place  on  the  body  may  be  the  seat  of  the 


516  DISEASES  OF  THE  BLOOD. 

purpuric  spots,  except  in  the  rlieumatic  variety  of  the  disease,  when  they  are 
situated  in  the  neighborhood  of  the  joints. 

In  purpura  hemorrhagica  hjematuria  may  be  the  chief  symptom.  Hem- 
orrhage from  the  bowels  and  epistaxis  frequently  occur.  The  disease  may 
assume  the  foudroT/ant  character,  terminating  fatally  within  a  few  hours. 

Symptoms. — In  simple  purpura  there  may  or  may  not  be  prodromata ; 
commonly  there  exists  a  slight  rise  in  temperature,  with  pain  and  aching  in 
the  arms'and  legs,  and  occasionally  nausea  and  vomiting.  Then  small  pete- 
chial spots  appear  on  various  parts  of  the  body,  preferably  upon  the  arms 
and  legs,  but  also  on  the  chest  and  abdomen,  rarely  upon  the  face.  The 
buccal  and  conjunctival  mucous  membranes  are  favorite  sites  for  these  hem- 
orrhagic spots.  They  vary  in  size  from  a  pin-point  to  an  inch  or  more  in 
diameter ;  they  may  disappear  in  a  few  days,  and  reappear  in  successive 
crops. 

In  the  rheumatic  variety,  called  peliosis  rheumatica^  there  exist  pain  and 
tenderness  of  the  joints — a  decided  arthritis — and  occasionally  an  endocar- 
ditis, together  with  hemorrhagic  spots  associated  with  urticaria  in  the  neigh- 
borhood of  the  aifected  joints. 

In  purpura  hsemorrhagica^  called  also  morbus  maculosis  Werlhofii,  the  hem- 
orrhages may  be  so  severe  as  to  cause  death  within  a  few  hours  or  days. 
The  disease  commonly  lasts,  however,  from  two  to  four  weeks,  and  relapses 
are  of  frequent  occurrence. 

Profound  anaemia  sometimes  results  from  the  loss  of  blood,  and  hemor- 
rhages may  occur  from  the  lungs,  kidneys,  bowels,  and  stomach.  Albumin 
may  be  present  in  the  urine. 

Prognosis. — The  prognosis  is  always  favorable,  except  in  the  exceptional 
cases  of  purpura  haemorrhagica,  when  the  disease  suddenly  ends  with  high 
fever  and  when  the  actual  loss  of  blood  is  considerable. 

Diagnosis. — The  diagnosis  must  be  made  from  scorbutus,  where  the 
chai-acteristic  gums  in  children  whose  teeth  have  erupted  and  the  previous 
history  are  the  chief  differential  points,  and  from  haemophilia,  which  is  an 
hereditary  constitutional  condition. 

Treatment. — Perfect  quiet  in  bed  and  symptomatic  treatment  according 
to  the  indications,  together  with  a  general  effort  to  sustain  the  strength  by 
nourishing  food  and  to  improve  the  quality  of  the  blood  by  arsenic  in  full 
doses,  rapidly  pushed  as  high  as  possible,  will  give  the  best  results ;  nothing 
else  seems  to  be  of  any  avail. 

Scorbutus  (Scurvy), 

a  disease  of  which  the  essential  points  are  a  swollen  and  spongy  condition 
of  the  gums,  extravasations  of  blood  into  various  parts  of  the  body,  pain 
on  handling,  and  intense  anaemia. 

Etiology. — In  infants  and  children  the  causes  of  this  affection  are  the 
same  as  in  adults — dietetic.  Scurvy  is  developed  in  those  who  are  fed 
upon  artificial  foods  prepared  with  milk  and  water  or  with  water  alone.  The 
true  cause  of  the  disease  is  absence  of  fresh  food  from  the  daily  regimen, 
and  it  is  apt,  from  the  nature  of  things,  to  be  associated  more  or  less  with 
rickets. 

Scurvy  seldom  occurs  in  nursing  infants,  but  in  those  who  are  taken  from 
the  breast  and  given  patent  foods  or  condensed  milk  and  water,  to  the  exclu- 
sion of  fresh  cow's  milk  and  beef-juice ;  in  such  the  conditions  exist  for  the 
occurrence  of  the  disease.  Cow's  milk  itself  is  an  undoubted  antiscorbutic, 
and  it  is  only  when  it  is  given  in  small  amount  and  much  diluted  that  chil- 
dren receiving  it  are  attacked  by  scurvy. 


PRIMARY  ANEMIA.  517 

Morbid  Anatomy. — Extravasations  of  blood,  varying  in  size  from  a 
pin-point  to  very  large  masses,  may  occur  in  any  part  of  the  body ;  the  most 
important  of  these  is  the  subperiosteal  hemorrhage  which  takes  place 
between  the  shaft  of  one  or  more  of  the  long  bones,  most  commonly  the 
femur,  and  the  periosteum  ;  it  may  be  so  extensive  that  the  membrane  is 
detached  from  the  bone  through  its  entirety,  retaining  its  connection  only  at 
the  epiphyses  ;  the  joints  are  never  involved.  The  bone  itself  may  become 
easily  fractured,  due  to  a  softening  of  the  osseous  structure.  Hemorrhages 
may  also  take  place  between  the  muscles  or  into  the  muscular  tissue,  into 
the  various  organs,  and  into  the  subcutaneous  and  submucous  tissues. 

Symptoms — The  first  symptom  of  scurvy  is  generally  the  manifestation 
of  ecchymoses,  occurring  quite  suddenly  in  various  parts  of  the  body.  In 
one  of  my  own  cases  an  extensive  efi'usion  of  blood  into  the  cellular  tissue 
of  the  orbit  first  called  attention  to  the  child's  condition.  The  production 
of  pain  upon  handling,  causing  the  child  to  scream  whenever  touched,  calls 
attention  to  the  lower  extremities :  one  or  both  thighs  or  legs  may  be  swollen 
and  exquisitely  sensitive  to  the  touch,  while  the  child  lies  immovable  and 
cries  with  fear  and  apprehension  whenever  approached.  This  condition  may 
exist  also  in  the  upper  extremities,  but  more  commonly  in  the  lower.  In 
the  course  of  time  the  swelling  begins  to  diminish  and  another  extremity 
becomes  afiected. 

The  gums  are  apt  to  be  swollen  and  spongy,  bleeding  easily,  especially 
if  the  teeth  have  erupted. 

As  the  disease  progresses  complications  may  be  discovered  at  the  extrem- 
ities of  the  limbs  alfected,  due  to  separation  of  the  epiphyses.  The  patient 
becomes  profoundly  cachectic.  The  rise  in  temperature,  although  generally 
constant,  is,  as  a  rule,  not  very  high,  rarely  more  than  three  degrees. 

When  the  case  goes  on  to  a  favorable  termination  we  find  a  gradual 
subsidence  of  all  symptoms.  The  temperature  drops ;  the  petechias  dis- 
appear ;  the  pain,  swelling,  and  tenderness  over  the  long  bones  gradually 
diminish  ;  separated  extremities  unite ;  and  the  color,  strength,  and  appetite 
improve. 

Diagnosis. — In  syphilis  similar  changes  take  place  in  the  bones :  if,  how- 
ever, the  other  signs  of  syphilis  are  absent — viz.  repeated  miscarriage  on  the 
part  of  the  mother,  snuffles,  hoarseness,  condylomata,  etc. — and  if  there  be 
present  spongy  and  swollen  gums  and  evidences  of  localized  hemorrhages  in 
various  parts  of  the  body,  the  diagnosis  is  easily  made. 

The  diflPerentiation  from  rickets  is  more  difficult.  In  fact,  these  two  dis- 
eases often  coexist ;  but  the  chief  point  of  difference  is  that  of  great  tender- 
ness and  swelling  over  the  long  bones  and  not  at  the  extremities.  From 
symptoms  the  history  is  generally  sufficient. 

Prognosis. — As  a  rule,  patients  recover  from  this  condition  rapidly  after 
being  put  upon  suitable  food.  Where  the  disease  results  fatally,  it  is  on 
account  of  exhausted  nutrition. 

Treatment. — The  disease  generally  manifests  itself  between  the  first  and 
second  years  as  a  result  of  the  use  of  improper  food  after  the  child  has  been 
taken  from  the  breast.  We  usually  find  these  children  being  fed  with  one 
of  the  various  prepai'ed  infants'  foods  or  condensed  milk  and  water.  The 
diet  should  consist  of  fresh  cow's  milk,  undiluted,  unless  it  would  be  more 
easily  digested  by  the  addition  of  a  little  barley-water  or  rice-water  or  strained 
oatmeal ;  beef-juice  expressed  from  raw  beef,  freshly  prepared,  scraped  beef; 
a  raw  egg  beaten  up  with  fresh  milk,  sweetened,  with  a  little  brandy  added. 
Orange-juice  should  be  given  freely.  It  often  causes  marked  improvement 
of  the  gums  and  other  parts. 

In  the  way  of  medication  the  citrate  of  iron  and  quinine  or  the  tincture 


518  DISEASES  OF  THE  BLOOD. 

of  iron  in  conjunction  ^ith  cod-Uvei-  oil  or  with  cream  and  whiskey  or  brandy, 

"■' Sc*"ap^'LSr3- hot  wet  cloths  maybe  made  to  the  tender  limbs 
and  wlen  'he  epiphyses  have   separated  the   affected  extremtty   mnst  be 

"'"ne'pain'in'the  affected  tabs  ma,  be  so  great  that  it  will  be  necessary 
to  administer  an  opiate. 


PART  Y. 

LOCAL    DISEASES. 


SEOTIOI^    I. 
INJURIES  AND  DISEASES   OF   THE   OSSEOUS   SYSTEM. 


CHAPTER    I. 

CAEIES  OF  THE  VEKTEBE^. 

Vertebral  caries  (Pott's  disease)  is  of  frequent  occurrence  in  childhood. 
It  is  an  ostitis  of  the  bodies  of  one  or  more  vertebras,  usually  of  tuberculous 
origin.  It  is  more  common  in  the  city  than  in  the  country,  where  better 
hygienic  conditions  produce  a  more  vigorous  constitution.  In  some  cases 
there  is  no  apparent  exciting  cause,  but  generally  there  is  the  history  of  a 
fall  upon  or  some  injury  of  the  spine.  Caries  may  occur  in  the  cervical, 
dorsal,  or  lumbar  portions  of  the  spinal  column,  but  it  is  more  common  in 
the  lower  dorsal  region  than  elsewhere. 

The  pathological  processes  are  those  of  tuberculous  infection.  The  pro- 
cess is  in  the  cancellous  tissue  of  the  vertebral  centre,  and  the  inflammation 
results  in  a  cheesy  metamorphosis,  beginning  in  the  interior  of  the  mass 
of  granulations  and  gradually  extending  in  all  directions.  These  deposits, 
chiefly  situated  in  the'anterior  half  of  the  bodies  of  the  vertebrae,  soften  into 
a  pus-like  fluid,  which  escapes  by  stripping  off'  the  periosteum  and  the  longi- 
tudinal ligaments  of  the  column  in  front  of  which  it  accumulates,  and  then 
gravitates  downward.  The  intervertebral  disks  either  escape  the  inflamma- 
tory changes  altogether  or  become  involved  at  a  relatively  late  stage  of  the 
disease.  The  result  of  the  disorganization  is  relaxation  of  the  union  be- 
tween the  vertebrae,  which  favors  dangerous  displacements,  as  of  the  atlas, 
and  angular  curvatures  in  other  regions  of  the  spine. 

The  disease  begins  very  insidiously  with  obscure  symptoms  referable  to 
the  nerves  of  the  affected  region.  If  in  the  lumbar  region,  there  are  pains 
in  the  legs  and  hypogastrium";  if  it  originate  in  the  dorsal  region,  the  pains 
will  be  in  the  epigastrium,  and  are  frequently  treated  as  indications  of  stomach 
and  bowel  derangements  ;  if  in  the  upper  cervical  region,  the  pains  are  in  the 
chest  or  back  of  the  neck  and  head.  As  the  destructive  ulceration  progresses 
there  is  increasing  weakness  of  the  spine,  with  languor,  inability  to  stand  long 
erect,  avoidance  of  all  jarring  movements,  and  if  the  upper  cervicals  are 
diseased,  a  disposition  to  support  and  protect  the  head  with  the  hands  applied 
to  the  chin  and  occiput ;  displacement  in  the  form  of  a  sharp  posterior  angle 
next  appears,  revealing  positively  the  nature  of  the  afi"ection.  Finally,  pus 
gravitating  from  the  affected  vertebrae  accumulates  as  a  congestive  abscess 
beneath  Poupart's  ligament  or  in  the  lumbar  region. 

The  DIAGNOSIS  is  often,  from  the  nature  of  the  disease,  obscure  and 
uncertain  for  a  time.     The  long  continuance  of  pain  in  the  chest  or  abdo- 

519 


520 


LOCAL  DISEASES. 


men,  or  perhaps  in  the  thighs,  without  any  cause  which  can  be  detected 
located  at  the  seat  of  the  pain,  shouki  excite  suspicion  of  spinal  disease. 
Such  pain  may  be  produced  by  spinal  irritation,  but  in  this  malady  pressure 
on  the  spine  is  badly  tolerated,  and  when  we  touch  a  certain  part  the 
neuralgic  pain  is  intensified.  In  caries  firm  pressure  upon  the  spine  is  tole- 
rated, and  it  does  not  increase  the  neuralgia.  At  a  later  period  in  caries 
there  are  stiffness  in  the  movements  of  the  spine ;  pain  in  the  spine  on 
sudden  movement  or  jarring  the  body  ;  impaired  appetite  and  general  health  ; 
and  an  instinctive  desire  to  sit  or  recline  in  such  a  way  as  to  relieve  the  spine 
partially  of  the  weight  of  the  head  and  shoulders. 

lu  the  course  of  the  examination  undress  the  patient  so  as  to  completely 
expose  the  spine,  and  note  any  irregularities  of  the  spinous  processes.  In 
infants,  sitting,  there  is  a  uniform  bending  of  the  whole  spine,  which  makes 
the  spines  prominent,  but  no  one  is  markedly  projecting ;  this  has  been  mis- 
taken for  caries.  Direct  the  patient  to  pick  some  article  from  the  floor,  which 
act  reveals  a  stiffness  of  the  spine.  The  patient  inclines  to  sit  down,  rather 
than  stoop,  to  avoid  bending  the  spine  (Fig.  145).  If  the  disease  is  cervical, 
a  slight  tap  on  the  head  causes  pain  ;  if  it  is  dorsal  or  lumbar,  the  patient 
shrinks  from  rising  on  his  toes  and  falling  heavily  on  his  heels.  There  is 
rarely  any  local  pain  or  marked  tenderness  at  the  seat  of  the  disease,  except 
on  percussion. 

When  the  disease  is  more  advanced  there  is  a  prominent  backward  curve, 
a  pendulous  abdomen,  and  a  slightly  stooping  attitude  (Fig.  146).  The  most 
prominent  spine  always  indicates  the  body  of  the  vertebra  originally  involved. 


Fig.  145. 


Fig.  146. 


Early  dorsal  caries :  child  cannot  bend  the  back  in 
stooping,  and  supports  weight  by  hand  on  knee. 


Attitude  of  child  in  angular  cur- 
vature in  advanced  stage. 


The  COURSE  of  this  malady,  even  when  the  caries  is  slight  and  the  symp- 
toms mild,  is  tedious.  In  the  most  favorable  cases  the  general  health  is  but 
slightly  impaired,  the  caries  is  confined  to  one  vertebra,  and  is  early  diagnos- 
ticated and  properly  treated.  On  the  other  hand,  if  the  general  health  be 
decidedly  poor,  the  child  anaemic  and  wasted,  the  curvature  great,  and  an  ab- 
scess have  occurred,  the  case  is  very  serious.  Between  these  two  extremes  is 
every  grade. 

The  PROGNOSIS  is  more  favorable  in  the  child  than  in  the  adult.     The  few 


GABIES  OF  THE    VERTEBBM.  521 

adults  wliom  I  have  seen  with  it  all  died.  It  is  less  favorable  in  the  cervical 
region  than  in  the  dorsal  or  lumbar.  A  mild  case  occurring  in  a  good  con- 
dition of  health  may  become  grave,  and  even  fatal,  by  neglect  and  improper 
treatment.  A  majority  of  the  patients,  if  the  disease  be  not  too  far  advanced 
when  recognized,  recover  if  properly  treated,  but  the  deformity  which  results 
may  prove  serious  in  after-life.  The  incomplete  expansion  of  the  lungs  in 
the"  humpbacked  greatly  increases  the  dyspnoea  and  the  danger  in  subsequent 
years  if  bronchitis  or  pneumonia  occur,  and  if  the  caries  has  been  at  a  low 
point  in  the  spine  and  the  patient  a  female,  the  deformity  will  probably  present 
an  obstacle  to  childbearing. 

The  TREATMENT  must  be  constitutional  and  local,  hygienic,  medical,  and 
mechanical.  It  is  of  the  utmost  importance  to  improve  the  general  health, 
as  it  is  in  all  chronic  inflammation  and  scrofulous  ailments.  Pure  air,  sun- 
light, personal  cleanliness,  and  plain  but  the  most  nutritious  diet  are  required. 
Tonic  and  antistrumous  remedies  are  indicated.  It  is  advisable  to  give,  three 
times  daily,  cod-liver  oil,  to  which  the  syrup  of  the  iodide  of  iron  is  added ; 
two  or  three  drops  of  the  latter  to  a  child  of  one  year,  and  one  additional  drop 
for  each  additional  year.  The  judicious  use  of  alcoholic  stimulants  will  often 
be  found  serviceable  if  the  appetite  be  poor  and  the  general  health  seriously 
impaired,  as  will  also  the  vegetable  bitters. 

The  mechanical  treatment  consists  in  applying  such  apparatus  as  will  so 
support  the  upper  part  of  the  trunk  that  the  pressure  will  be  taken  from  the 
bodies  of  the  diseased  vertebrae.  Of  all  the  means  yet  employed,  the  plaster- 
of-Paris  dressing  is  at  once  the  most  available  and  most  efficient.  It  can  be 
applied  by  every  practitioner,  and  only  requires  a  careful  attention  to  the 
following  details : 

Select  crinoline  or  cheese-cloth  for  bandages,  and  a  good  quality  of  plaster  of 
Paris,  such  as  dentists  use.  Tear  the  crinoline  into  strips  "1^  inches  wide  and  3 
yards  long ;  with  a  table-knife  rub  the  plaster  into  the  bandage  as  it  is  rolled,  so 
that  all  the  interstices  are  well  filled,  roll  it  up  loosely  ;  apply  to  the  patient  a  tightly- 
fitting  shirt  of  elastic,  soft  woven  or  knitted  material,  without  arms,  extending  to 
the  middle  of  the  pelvis  and  fastened  over  the  shoulder  by  tabs.  Now  have  the 
patient's  arms  raised  above  the  head  and  held  in  that  position.  The  bandages, 
placed  on  the  end  in  a  basin  of  water  until  the  bubbles  cease  to  rise,  are  squeezed 
until  the  surplus  water  escapes,  and  then  passed  round  and  round  the  trunk,  begin- 
ning at  the  smallest  part,  and  extending  downward  a  little  beyond  the  crest  of 

Fig.  147.  Fig.  148. 


Fenestra  over  curvature.  Fenestra  over  stomach. 

the  ilium,  then  upward  in  a  spiral  direction  until  the  entire  body  is  encased  from 
the  pelvis  to  the  axillae ;  pads  of  cotton  are  to  be  applied  over  any  very  prominent 
spinous  process  or  other  bony  projection  which  maybe  inflamed  from  previous  pres- 
sure or  liable  to  be  irritated.     The  bandage  should  be  placed  smoothly,  but  not 


522 


LOCAL  DISEASES. 


tightly,  round  the  body,  being  simply  unrolled  with  one  hand  and  smoothed,  so  a& 
to  be  adapted  to  all  the  irregularities,  by  the  other ;  after  one  or  two  thicknesses 
have  been  applied,  narrow  strips  of  roughened  tin  or  zinc  should  be  placed  on  either 
side  and  parallel  with  the  spinous  processes,  and  others  added  at  intervals  of  two  or 
three  inches  until  they  surround  the  body  ;  over  these  apply  other  bandages.  The 
patient  must  remain  quiet  in  the  recumbent  position  until  the  dressing  is  firm,  when 
he  may  rise ;  fenestrge  are  often  required  at  the  curvature  or  where  sinuses  are 
discharging. 

If  the  diseased  vertebrae  are  in  the  lumbar  or  lower  dorsal  region,  the 
bandage  need  not  be  applied  higher  than  the  axillae,  but  if  the  caries  exist  in 
the  upper  dorsal  region,  there  must  be  additional  support  of  the  upper  part 
of  the  thorax,  and  this  is  obtained  by  continuing  the  bandage  over  the  shoul- 
ders, and  thus  encasing  the  entire  trunk  in  the  common  dressing  (Fig.  148). 
When  this  form  is  used  the  arms  must  not  be  in  the  sling,  but  should  hang  by 
the  side.  By  this  means  the  spine  can  be  permanently  maintained  erect.  When 
the  caries  attacks  the  cervicals,  means  must  be  used  to  so  support  the  head 
that  the  contiguous  vertebrae  may  not  be  compressed.     This  may  be  accom- 


FiG.  149. 


Fig.  150. 


P^IG.  151. 


Plaster  dressing  for  cervical  caries.  Jury-mast  (Sayre).  Apparatus  for  disease  of  cervical 

or  upper  dorsal  spine :  plaster 
jacket  with  "jury-mast." 

plished  by  supporting  the  chin  or  by  lifting  the  head  entire.  The  chin  may  be 
sustained  by  extending  the  plaster-of-Paris  jacket  upward  as  a  cravat,  well 
lined  with  cotton  batting  or  other  soft  material  (Fig.  149).  Or  the  head  may 
be  raised  entirely  from  the  column  by  an  appliance  (Fig.  150)  so  incorpo- 
rated in  the  plaster  bandage  that  it  has  a  firm  basis  of  support,  and  by  a  sling " 
which  accurately  fits  the  chin  and  occiput  and  lifts  the  head  directly  upward 
(Fig.  151). 

To  apply  the  apparatus  the  patient  is  suspended  or  lifted  from  the  axillae  or 
chin  and  occiput,  and  the  plaster  bands  applied,  as  usual,  over  a  tight-fitting 
knit  or  woven  shirt.  After  the  bandage  has  been  accurately  applied,  the  patient 
is  removed  from  the  suspending  apparatus  and  carefully  laid  upon  a  firm  bed 
until  the  plaster  has  hardened  or  "set."  The  patient  can  then  stand  up,  and  the  . 
apparatus  for  suspending  the  head  is  applied  in  its  proper  position,  over  the  back 
of  the  plaster  jacket,  and  the  lower  portion  of  it  bent  and  moulded  until  it  accu- 
rately fits  all  its  various  curves.  The  loose  tin  strips,  being  very  flexible,  can  then 
be  smoothly  moulded  around  the  jacket  which  has  already  been  applied  to  the 
trunk,  and  another  plaster  bandage,  having  been  wetted  in  water,  is  to  be  carefully 
and  tightly  applied  over  the  apparatus  and  jacket  first  applied  in  sufiicient  number 
of  layers  to  make  it  perfectly  secure.     The  tin  being  rough  and  perforated,  a  suffi- 


CARIES  OF  THE   VERTEBBM. 


523 


Fig.  152. 


Breast-plate  and  collar  for  cer- 
vical or  high  dorsal  caries 
(Owen). 


cient  amount  of  plaster  will  be  incorporated  into  its  holes  and  meshes  to  prevent 
any  possibility  of  displacement.  We  have  novr  a  secure  point  of  support  from  the 
pelvis  and  trunk,  and  the  head  can  be  sustained  by 
properly  adjusting  the  movable  rod  and  securing  it  by 
screws  (Fig.  151). 

While  it  is  true  that  the  jury-mast,  well  adjusted 
and  maintained,  usually  gives  good  results,  it  is  a 
somewhat  troublesome  apparatus  to  apply,  and  patients 
are  occasionally  intolerant  of  its  use.  More  con- 
venient appliances,  which  equally  support  the  head, 
may  be  employed.  Owen  of  London  recommends  a 
simple  apparatus.  He  says  :  ^  "  I  have  given  the  jury- 
mast  of  Dr.  Sayre  a  fair  and  extensive  trial,  and  have 
now  entirely  discarded  it.  It  is  heavy  and  cumber- 
some, and  offers  no  advantage  over  the  leather  cervical 
collar  (Fig.  152),  which  bears  up  the  chin  and  occiput. 
The  rotary  movement  of  the  neck,  which  the  jury- 
mast  is  constructed  to  permit,  is  an  absolute  disadvan- 
tage ;  rest,  and  always  rest,  is  the  one  indication  for 
treatment  in  all  these  cases.  The  cervical  collar  gives 
relief  by  ensuring  this  rest,  rather  than  by  lifting  up  the  superimposed  weight,  as  may 
be  inferred  from  the  fact  that  its  influence  is  equally  beneficial  in  high  dorsal  caries,'''' 

The  gypsum  dressing  may  be  worn  without  change  from  two  weeks  to  two 
months,  according  to  the  effect  which  it  produces ;  when  renewed  the  patient 
should  be  thoroughly  washed,  but  without  assuming  the  upright  position,  ex- 
cept when  the  head  is  well  supported.  The  final  cure  is  rarely  completed  in 
the  most  successful  cases  in  one  year. 

There  are  several  kinds  of  useful  apparatus  for  spinal  caries  more  or  less 
complicated  in  their  mechanism,  and  requiring  great  experience  and  care  in 
their  successful  management,  but  the  plaster-of-Paris  jacket  is  to  be  preferred 
on  account  of  its  efficiency,  durability,  and  economy. 

A  spinal  brace  may  be  so  applied  as  to  take  the  weight  of  the  trunk  above  the 
point  of  disease  from  the  bodies  of  the  vertebrae  and  throw  it  on  the  articular  pro- 
cesses. There  are  two  pieces  or  levers  passing  up  the  back,  not  over  the  spine,  but 
each  side  of  it,  so  that  it  is  firmly  held  from  lateral  devia- 
tions ;  to  the  upper  end  of  these  two  curved  pieces  of  steel 
are  fastened  diagonally  on  both  sides  of  the  neck ;  they 
pass  directly  forward  and  around  the  shoulder,  and  thus 
prevent  a  great  loss  of  force  by  diagonal  action.  The 
arrangement  entirely  obviates  the  painful  and  injurious 
ligaturing  of  the  arms,  which  would  occur  if  the  straps 
passed  forward  from  one  point.  At  the  part  opposite  the 
point  of  disease,  the  point  where  the  fulcrum  pads  are 
placed  is  made  of  chamois  skin  or  canton  flannel,  filled 
with  cork  filings,  which  have  no  felting  qualities,  or,  if 
desirable,  can  also  be  made  of  hard  rubber  ;  the  shoulder- 
straps  and  the  band  around  the  hips  are  likewise  pro- 
vided with  similar  pads  to  protect  the  skin  from  pressure 
and  abrasion  ;  the  instrument,  like  the  spine  itself,  acts 
like  a  double  lever,  with  a  common  fulcrum  at  the  curva- 
ture ;  this  action  is  directly  backward  at  the  hips  and 
shoulders  and  directly  forward  at  the  middle  of  the  back, 
or  wherever  the  diseased  part  is  located;  thus  the  pos- 
terior portion,  the  only  healthy  portion  of  the  diseased 
vertebrge,  is  made  to  support  a  part  of  the  weight  of  the 
body,  and  the  intervertebral  cartilage  and  bodies  of  the 
vertebrge,  where  the  disease  exists,  are  relieved  of  pres- 
sure. The  abdomen  is  still  further  sustained  in  the  up- 
ward direction  by  an  apron  in  front,  which  is  fastened  on  each  corner. 
^  Surg.  Dis.  Children,  p.  248. 


Fig.  153. 


Spinal  brace  (Taylor). 

If  the 


524  LOCAL  DISEASES. 

disease  is  in  the  upper  dorsal  or  cervical  region,  an  apparatus  is  constructed  for 
such  cases  with  an  attachment  for  sustaining  the  head  ;  the  efiFect  and  form  of  this 
attachment  is  that  of  a  lever,  acting  backward  to  raise  the  head  and  neck. 

Spinal  abscesses  may  find  their  way  to  the  surface  by  very  circuitous 
routes,  and  appear  at  unusual  points  quite  unexpectedly.  In  general,  how- 
ever, they  appear  as  lumbar,  iliac,  or  psoas  abscesses.  They  should  be  opened 
antiseptically  as  soon  as  discovered.  By  delay  in  operating,  especially  on 
iliac  abscesses,  they  increase  in  size,  involve  new  areas,  impair  the  general 
health,  and  constantly  menace  the  life  of  the  patient.  By  opening  them  no 
danger  of  suppuration  is  incurred  as  formerly,  but,  on  the  contrary,  the  gen- 
eral health  is  improved  and  the  carious  process  may  be  arrested.  '  Operate  as 
follows : 

The  surfaces  having  been  well  cleaned  and  shaved  and  the  operator's  hands 
being  disinfected,  under  irrigation  with  bichloride  solution,  1 :  1000,  make_  a  free 
incision  through  the  overlying  tissues  into  the  abscess.  If  the  abscess  is  iliac,  the 
dissection  must  be  more  cautiously  made.  The  cavity  being  exposed,  cleanse  it  of 
all  dead  tissues  and  scrape  off  the  granulations  :  now  explore  the  cavity,  and  if  the 
sinus  leading  to  dead  bone  can  be  found,  gently  pass  a  soft  catheter  along  the  track 
and  carry  it,  if  possible,  to  the  abscess-cavity.  Along  that  track  it  may  be  possible, 
especially  in  the  lumbar  and  lower  dorsal  regions,  to  dissect  a  passage  so  as  to  give 
a  full  exposure  of  the  carious  vertebra  and  enable  the  operator  to  remove  the  dead 
bone  and  cleanse  the  cavity  of  all  debris.  If  the  carious  cavity  cannot  be  exposed, 
it  may  still  be  irrigated  through  the  catheter,  and  the  disease  may  be  arrested.  The 
abscess  should  be  thoroughly  washed  out  with  a  weak  bichloride  solution,  ]  :  5000,  a 
drain-tube  inserted,  the  wound  closed,  and  iodoform  dressings  applied ;  daily  irri- 
gating of  the  entire  cavity  should  be  practised  with  disinfectants. 

Absorption  of  a  spinal  abscess  may  occur  when  the  diseased  vertebrae  are 
maintained  in  a  condition  of  perfect  rest. 

Case  (Owen  '). — Lilian  G ,  six  years,  came  under  treatment  (in  November, 

1880)  for  dorsi-lumbar  caries,  for  which  she  was  kept  lying  down  for  nine  months, 
during  which  time  night-shriekings  and  pains  on  movement  disappeared.  She  was, 
as  her  mother  said,  "  ever  so  much  better."  A  plaster-of-Paris  jacket  was  applied, 
which  she  wore  continuously  and  with  the  greatest  advantage  for  five  months,  gain- 
ing five  pounds  in  weight.  The  next  she  w^ore  six  months,  but  on  its  being  taken 
ofi"  the  child  complained  of  pains  in  the  area  of  distribution  of  many  of  the  cuta- 
neous branches  of  the  right  anterior  crural  nerve,  and  especially  along  the  inner 
side  of  the  ball  of  the  great  toe.  Abscess  was  detected  in  the  right  iliac  fossa. 
Another  jacket  was  ajoplied,  and  was  worn  continuously  for  fifteen  and  a  half 
months ;  on  its  removal  there  was  not  a  trace  of  abscess,  the  child  was  free  from 
pain,  quite  well,  and  strong. 

These  abscesses  may  find  their  way  into  the  intestines  at  diiferent  points 
from  the  duodenum  to  the  anus,  into  the  bladder,  and  in  various  localities  on 
the  surface  in  the  region  of  the  pelvis  and  thighs. 

In  some  cases,  as  in  paraplegia,  the  operation  of  laminectomy  has  been 
performed,  which  consists  in  the  excision  of  the  laminae  of  two  or  three  ver- 
tebrae for  the  purpose  of  opening  the  canal  of  the  spine  and  cleansing  and 
curetting  it.  Macewen  disapproves  the  operation  while  the  tuberculous  pro- 
cess is  active  in  other  organs,  or  when  fracture  has  followed  as  a  result  of 
caries,  or  when  paraplegia  has  suddenly  appeared.  The  operation  is  as  fol- 
lows (Power)  : 

Place  the  child  on  the  left  side  and  make  an  incision  over  the  projecting  part  of 
the  spine ;  separate  the  soft  parts  on  each  side  and  the  periosteum  of  two  or  three 
vertebrae  :  divide  the  lamina  of  a  vertebra  with  strong  cutting  forceps  and  twist  it 
out  of  place.  A  second  and  third  is  removed  in  a  similar  manner,  until  the  canal 
is  sufficiently  exposed.  All  tuberculous  matter  must  be  carefully  removed.  The 
cord  and  its  sheath,  lying  along  the  anterior  surface  of  the  canal,  must  be  gently 
'  Sury.  Lis.  Children,  p.  247. 


LATERAL   CURVATURES  OF  THE  SPINE. 


525 


drawn  one  side  with  broad  retractors  to  permit  of  scraping  away  granulations.  The 
cavity  is  to  be  swabbed  with  a  solution  of  1 :  15  zinc  chloride,  and  then  flushed  with 
sterilized  water  of  a  temperature  of  105°.  The  cord  is  replaced  and  pulsation 
looked  for ;  the  soft  parts  are  united  without  drainage,  the  purpose  being  to  obtain 
immediate  union. 


CHAPTER    II 


LATEEAL   CUEVATUEES   OF  THE   SPINE. 


Lateral  curvatures  occur  in  children  who  have  suffered  from 
rickets,  and  these  deformities  depend  upon  the  period  when  they  occur, 
whether  before  or  after  the  child  has  commenced  to  walk.  It  must  be  re- 
membered that  before  the  child  has  walked  there  is  but  a  single  curve  of  the 
entire  spine — viz.  posterior.  The  normal  curves  of  the  adult  spine  do  not 
form  until  the  child  has  been  walking  for  some  time.  It  follows  that  the 
rachitic  curves  of  the  spine  which  occur  in  a  child,  suffering  from  rickets 
before  the  period  of  walking,  differ  greatly  from  the  curvatures  which  take 
place  when  the  normal  curves  of  the  spine  have  formed.  In  the  former  case 
the  curve  is  usually  an  exaggeration  of  the  posterior  curve  of  infancy, 
kyphosis  (Fig.  154),  or,  there  may  be  a  simple  lateral  curve  in  any  region 
of  the  spine,  or,  finally,  there  may  be  an  anterior  curve,  lordosis  (Fig. 
155).     The  posterior  curvature  of  rickets  is 

nearly  uniform  throughout  the  entire  length  Fig.  156. 

of  the  spinal  column,  and  is  distinguished 
from  the  normal  curve  by  the  inability  of 
the  child  suffering  from  rickets  to  straighten 
its  spine  fully.     The  tendency  is  to  sit  with 


Fig.  154. 


Fig.  155. 


Kyphosis. 


Lordosis. 


Lateral  curvature  in  a  ricketv  child. 


the  head  falling  forward  (Fig.  156).  If  the  child  is  placed  on  a  flat  surface, 
the  curve  will  disappear. 


526 


LOCAL  DISEASES. 


When  the  curvature  forms  after  the  normal  curves  are  perfected,  the  first 
deviation  takes  phicein  the  lumbar  region,  usually  to  the  left  ;  this  is  followed 
by  a  compensative  curvatui'e  to  the  right  in  the  dorsal  region,  and,  finally,  ia 
severe  cases,  there  is  a  cervical  curvature  to  the  left  and  forward.  The  initial 
deviation  to  the  left  is  caused  by  a  lateral  inclination  of  the  body  to  that  side 
as  the  child  sits  or  stands  long  in  that  position.  Girls  far  more  frequently  than 
boys  assume  this  attitude,  owing  to  their  comparatively  sedentary  habits.  The 
secondary  curve  to  the  right  is  an  efibrt  to  preserve  the  centre  of  gravity  of  the 
upper  part  of  the  body,  while  the  cervical  curve  is  designed  to  place  the  head  in 
a  similar  position.  In  addition  to  these  curves,  true  lateral  curvature  at  later 
periods  is  attended  with  a  partial  rotation  of  the  bodies  on  their  axes.  In 
the  lumbar  region  the  spinous  processes  are  carried  around  to  the  left ;  in 
the  dorsal  region  they  are  found  far  to  the  right  of  the  centre.  Another 
noticeable  feature  of  this  form  of  curvature,  known  as  rotary  lateral  curva- 
ture, is  the  elevation  of  the  left  hip  and  right  shoulder.  These  are  diag- 
nostic signs  of  much  value,  and  it  not  infrequently  happens  that  the  dress- 
maker first  detects  the  curvature  by  the  displacement  of  the  scapula. 

While  the  predisposing  cause  of  curvature  in  these  cases  is  rickets,  the 
exciting  cause  will  be  any  condition  which  temporarily  deflects  the  spinal 
column.  The  position  in  which  a  nurse  continually  holds  the  child  may  give 
an  improper  inclination  of  the  spine.  In  a  similar  manner  a  curvature  may 
take  place  in  older  children  who  sit  long  in  a  one-sided  position,  as  at  school, 
or  who  have  one  leg  shorter  or  weaker  than  the  other,  as  in  infantile  paralysis. 
It  is  more  frequent  in  girls  than  boys,  owing  chiefly  to  the  fact  that  the 
former  are  more  restricted  in  vigorous  exercise,  and  hence  have  a  less  sym- 
metrically developed  muscular  system.  The  more  quiet  and  sedentary  life 
forced  upon  them  in  the  formative  period  of  the  osseous  system  tends  to 
enfeeble  the  muscles,  and,  at  the  same  time,  to  induce  postures  of  the  body 
which  cause  deviations  of  the  spinal  axis. 

The  DIAGNOSIS  of  lateral  curvature  of  the  spine  in  the  child  is  of  great 
importance,  for  it  is  at  the   very  commencement  of  the  deviation  that  the 

Fig.  157. 


From  Hoffa. 


progress  of  the  deformity  may  be  arrested,  and  by  very  simple  measures. 
In  proportion  as  it  progresses  the  changes  of  structure  tend  to  become  more 
and  more  permanent.  It  is  advisable,  therefore,  always  to  make  frequent 
examinations  of  the  spine  of  a  child  that  is  passing  through  a  course  of  treat- 


LATERAL  CURVATURES  OF  THE  SPINE. 


527 


ment  for  rickets.  In  this  examination  it  must  be  remembered  tbat  the  spine 
of  the  child,  up  to  the  time  of  walking,  and  oftentimes  for  a  considerable 
period  after,  has  not  the  ordinary  curves  of  the  adult  spine.  On  the  con- 
trary, the  child  has  a  uniform  convexity  of  the  spine  backward,  most  marked 
when  it  is  in  a  sitting  posture,  and  more  prominent  in  the  dorsal  region.  The 
peculiarity  of  this  curvature  is— 1,  that  no  one  spinous  process  of  a  vertebra 
stands  out  abruptly  from  the  two  which  articulate  with  it,  as  in  angular 
curvature  or  Pott's  disease  ;  and,  2,  that  there  may  be  lateral  inclinations  of 
portions  of  the  spine  without  disease  when  a  child,  is  feeble.  An  important 
fact  in  determining  the  existence  of  a  curvature  due  to  disease  is  this :  if  it 
is  caused  by  disease,  it  will  be  unyielding  in  the  movements  of  the  spine. 
The  best  test  is  the  following  :  If  the  child  is  laid  on  its  face  and  its  legs  are 
raised,  thus  lifting  the  lower  part  of  the  body  from  the  surface,  the  back  be- 


FiG.  158. 


Fig.  159. 


From  Hoffa. 

comes  concave  if  there  is  no  permanent  curvature,  and  all  apparent  devia- 
tions of  the  spine  will  at  once  disappear  (Fig.  157).  If,  however,  there  is 
a  permanent  curve,  as  in  angular  curvature  (Pott's  disease),  the  curvature 
becomes  even  more  prominent  (Fig.  158). 

For  proper  examination  the  back  should  be  entirely  exposed.  Then 
trace  the  course  of  the  spinous  processes  from  the  head  to  the  sacrum  by 
drawing  the  end  of  the  finger  along  their  tips. 
A  red  line  is  formed  which  shows  the  curva- 
tures if  they  exist.  The  ends  of  the  spinous 
processes  may  also  be  marked  with  a  pencil 
(Fig.  156)  to  make  the  line  more  distinct.  If 
the  patient  now  bend  forward,  the  deformity 
becomes  more  marked.  If  lateral  curvature 
is  established,  the  chest-walls  are  also  de- 
formed. There  is  a  flattening  on  one  side 
and  a  bulging  on  the  other,  which  may  be 
very  prominent  at  the  junction  of  the  ribs  and 
their  cartilage  (Fig.  159). 

The  TREATMENT    of   Spinal    curvature   in 
a  child  suffering  from  rickets  is  twofold — viz. 
1.  The  general  treatment,  which  should  aim  to 
restore  the  health  of  the  child  by  measures  already  given ;  and  2.  The  protec- 
tion of  the  spine  from  permanent  curvature.     If  the  child  does  not  walk,  care 


Section  of  chest,  showing  deformity 
consequent  on  lateral  curvature 

(Shaw). 


528 


LOCAL  DISEASES. 


should  be  taken  to  so  change  its  position  from  time  to  time  that  no  continuous 
curve  of  the  spine  can  be  maintained.  If  there  is  a  tendency  to  antero-posterior 
curvature,  the  child  should  frequently  be  maintained  in  the  prone  position. 
In  this  position  the  weight  of  the  upper  portion  of  the  body  is,  for  the  time, 
taken  from  the  spine,  and  the  curvature  is  completely  reduced.  Gentle  rub- 
bing of  the  muscles  of  the  spine,  with  the  hands  well  oiled,  increases  their 
nutrition  and  growth.  A  light  pasteboard  splint  may  be  applied  to  the  back 
for  short  periods  as  a  support  to  the  spine,  but  must  be  employed  only  tem- 
porarily. If  the  child  is  older  and  true  lateral  curvature  is  impending,  the 
treatment  must  be  modified  only  to  meet  the  conditions  which  the  ability  to 
walk  imposes.  The  general  muscular  system  should  be  developed  by  mas- 
sage and  such  kinds  of  exercise  as  will  tend  to  relieve  the  spinal  column  of 
the  weight  of  the  upper  part  of  the  body,  as  swinging  from  a  bar,  climbing 
a  rope,  lying  prone  and  exercising  the  arms  by  stretching  them  above  the 
head,  and  grasping  handles  to  weights  raised  over  pulleys.  The  question 
of  applying  apparatus  is  very  important,  and  should  always  be  regarded  as 
an  accessory  and  temporary  expedient  in  the  aid  of  the  measures  already 
described.     In  general  it  is  better  to  avoid  all  apparatus  in  the  early  stages, 


Fig    160 


Fig.  161. 


Curvature  before  suspcnbion  C~d>  re) 

and  persistently  apply  those  means  which  will  de- 
velop strong  and  healthy  muscles,  and  constantly 
guard  the  patient  against  assuming  positions  tend- 
ing to  deflect  the  spine.  When  not  engaged  in 
suitable  exercise  it  is  better  to  recline  on  a  sofa 
or  in  a  chair,  which  takes  the  weight  of  the  shoul- 
ders and  head  from  the  spine.  The  ordinary  steamer- 
chair  is  well  adapted  for  this  purpose. 

If  the  child  is  older,  and  the  deformity  is  already  well  advanced  toward 
permanent  rotary  lateral  curvature,  the  treatment  must  be  governed  by  the 
condition  of  the  patient  when  first  brought  under  notice.    If  the  distortion  be 


Curvature  reraoved  by  sus- 
pension (Say  re). 


LATERAL   CURVATURES  OF  THE  SPINE.  529 

aggravated  by  inequality  in  the  length  of  the  lower  extremities,  or  owing  to 
a  congenital  malformation,  or  to  disease  of  the  joints  or  fracture,  thus  caus- 
ing obliquity  of  the  pelvis,  the  shortened  limb  must  be  artificially  lengthened 
sufficiently  to  equalize  the  length  of  the  two  limbs  before  any  other  treat- 
ment can  be  effectual.  If  the  deformity  be  caused  by  muscular  debility  or 
want  of  tone  in  the  general  system  to  keep  the  body  erect,  we  must  by 
proper  training,  gymnastic  exercises,  massage,  nutritious  diet,  and  tonics 
restore  lost  vitality  and  increase  muscular  power.  Careless  habits  in  sitting, 
walking,  or  standing  must  be  guarded  against  and  the  vicious  tendencies  cor- 
rected. Extension  of  the  spinal  column  by  Sayre"s  apparatus  is  useful. 
This  is  affected  by  means  of  a  leather  collar  passing  under  the  chin  and 
occiput,  two  straps  passing  from  this  up  on  either  side  of  the  head  to  an  iron 
cross-bar  secured  by  means  of  a  rope  and  pulley  to  a  hook  or  beam  in  the 
ceiling.  The  patient  is  expected  to  raise  the  arms  over  the  head  to  their 
fullest  extent,  and,  seizing  the  rope  in  the  hands,  commence  to  climb  up  hand 
over  hand  until  the  heels  are  gradually  raised  from  the  floor,  barring  the 
discomfort  before  this  point  may  be  reached ;  the  toes,  however,  should 
never  leave  the  ground.  The  effect  of  this  form  of  suspension  upon  the  cur- 
vatures is  very  marked,  as  seen  in  the  illustrations  of  the  same  person  before 
and  during  suspension  (Figs.  160  and  161). 

The  hand  on  the  side  to  which  the  concavity  of  the  spine  faces  should  always 
be  the  one  uppermost  when  the  patient  has  reached  the  height  where  the  heels  are 
raised  from  the  floor  (Fig.  161).  While  holding  herself  in  this  position  the 
patient  should  take  three  full  inspirations ;  then  slowly  descend  until  she  once  more 
rests  firmly  on  the  floor,  allowing  the  arms  to  fall  by  the  sides  and  to  rest  there  a  few 
moments ;  the  same  course  is  to  be  repeated,  in  all,  three  times  ;  for  the  greater 
convenience  of  holding  on  to  the  rope  three  or  four  wooden  balls  should  be  strung 
upon  it  and  secured  at  a  certain  point  after  the  patient  has  found  out  the  limit  of 
extension.  It  is  necessary,  in  the  performance  of  this  partial  self-suspension,  that 
the  patient  should  always  keep  the  arm  extended  in  a  perfectly  straight  line,  and 
simply  make  each  hand  go  over  the  other,  and  no  more,  so  that  the  muscles  of  the 
trunk,  rather  than  the  neck,  may  bear  the  strain.  The  apparatus  for  this  purpose 
may  be  arranged  in  one's  own  room,  and  may  be  used  for  exei'cise  night  and  morn- 
ing three  times,  as  before  described,  until  after  some  weeks,  when  the  number  of 
imposed  tasks  may  be  increased  according  to  the  hints  already  given. 

A  very  useful  exercise  is  to  stand  in  front  of  the  patient  while  she  is  sitting 
upon  a  chair  or  stool,  compelling  her  to  turn  and  twist  her  trunk  in  the  opposite 
direction  in  which  the  deformity  exists,  Avhile  you  resist  this  movement.  Another 
exercise  is  that  of  sitting  upon  a  stool  with  the  arm  upon  the  concave  side  raised 
in  front  on  a  level  with  the  thorax,  while  the  arm  upon  the  convex  side  of  the 
deformity  is  placed  behind  the  back ;  then,  seizing  a  rubber  strap  in  either  hand, 
the  ends  of  which  are  secured  to  staples  in  the  wall  or  door,  the  patient  endeavors 
by  muscular  action  to  unwind,  as  it  were,  the  rotation  of  the  spine,  and  thus  over- 
come the  deformity.  Suspension  also  may  be  made  from  two  horizontal  bars,  as 
recommended  by  Adams,  one  being  from  two  to  four  inches  above  the  other — the 
hand  upon  the  concave  side  of  the  curvature  of  the  spine  being  the  one  to  grasp 
the  upper  bar  -,  exercise  upon  these  bars  may  be  indulged  in  as  often  during  the 
day  as  the  yjatient  may  desire.  Rings  attached  to  ropes  of  unequal  length  efi'ect 
the  same  object.  Yet  another  exercise  is  to  stand  upon  a  block  or  box  upon  the 
foot  of  the  convex  side,  and  swing  the  leg  upon  the  concave  side,  at  the  same  time 
reaching  upward  with  the  arm  of  the  same  side  as  far  as  possible,  the  hand  grasp- 
ing a  weight  of  from  two  to  four  pounds,  and  while  in  this  position  to  take  three 
full  inspirations.     This  also  may  be  repeated  several  times  daily. 

Sayre  attaches  great  importance  to  the  plaster-of-Paris  jacket,,  applied 
while  the  vertebral  column  is  extended  (Fig.  161).  The  principles  governing 
its  application  have  already  been  given. 


34 


530  LOCAL  DISEASES. 

CHAPTER    III. 

INJURIES  OF   BONES. 

The  examination  of  a  child  that  has  been  injured,  for  the  purpose  of 
determining  the  existence  of  a  fracture,  should  be  made  in  such  manner  as 
to  secure  its  confidence.  It  is  already  suffering  from  the  fright  which  the 
injury  caused,  and  hence  will  be  intensely  excited  at  the  approach  of  the 
sm-geon.  Hamilton's  dii-ections  are  admirable,  and  should  be  implicitly  fol- 
lowed.    He  says : 

"  It  is  important  on  first  approaching  a  patient,  especially  a  child,  suifering 
from  fracture,  to  inspire  him  with  a  confidence  that  he  is  not  to  be  unnecessarily 
hurt :  sit  quietly  beside  him  and  inquii-e  minutely  into  all  the  circumstances  relat- 
ing to  the  accident ;  remove  the  clothes  from  the  injured  limb  with  the  utmost  care  ; 
notice  its  position,  contour,  points  of  abrasion,  discoloration,  or  swelling ;  pass  the 
fingers  lightly  along  the  surface  of  the  limb,  pressing  more  firmly  at  points  where 
there  are  appearances  of  injury ;  finally,  to  solve  all  doubts,  grasp  the  limb  so  as  to 
make  traction  of  the  lower  fragment,  rotate  to  obtain  crepitus,  and  make  lateral 
motions  to  indicate  the  false  point  of  motion  ;  in  the  application  of  the  necessary 
dressings  let  gentleness  and  a  manifest  regard  for  the  patient's  sufferings  character- 
ize every  act,  and  throughout  the  subsequent  treatment  of  the  case  proceed  slowly, 
thoughtfully,  and  systematically,  for  rude  and  awkward  manipulations,  by  which 
pain  is  needlessly  inflicted,  are  frequent  sources  of  inflammation,  suppuration,  and 
gangrene.'" 

In  the  treatment  of  the  injuries  of  bones  of  children  special  care  must  be 
taken  in  their  treatment.  Children  will  not  tolerate  the  same  restrictions  as 
the  adult.  Bandages  around  recently  injured  limbs  must  be  avoided  as  far 
as  possible  ;  splints  should  be  protected  by  soft  and  yielding  padding  ;  plaster- 
of-Paris  dressings  must  be  carefully  watched.  In  restoring  motion  to  stiffened 
joints  after  fracture  the  force  used  must  be  slight  as  compared  with  that 
which  is  proper  in  the  adult. 

Injuries  of  the  Skull. 

Depression  of  the  bones  of  the  skull  without  apparent  fracture  is  most 
often  seen  in  the  parietal  and  frontal  regions.  It  is  the  result  of  violence 
applied  by  a  body  which  has  a  flat  or  a  round  surface.  The  bending  is  not 
unlike  that  which  occurs  in  the  long  bones.  Though  the  patient  may  be 
insensible  from  the  immediate  effects  of  the  concussion,  there  are  no  indica- 
tions of  compression,  as  paralysis. 

The  DIAGNOSIS  is  readily  made  when  the  patient  is  seen  immediately  after 
the  injury.  But  after  a  few  days  a  hard  ridge  forms  around  the  depressed 
area,  which  has  often  been  mistaken  for  the  limits  of  a  fracture. 

The  TREATMENT  should  be  rest  and  an  application  of  a  spirit  lotion  when 
there  are  no  evidences  of  compression  of  the  brain,  as  paralysis.  The 
depressed  bone  gradually  resumes  its  natural  shape,  chiefly  owing  to  the 
pressure  of  the  expanding  brain  underneath. 

Fractures  of  the  skull  in  children  require  the  same  rules  of  treatment  as 
in  adults. 

Injuries  of  Long  Bones. 

The  long  bones  of  children  differ  from  those  of  the  adult  in  these  import- 
ant particulars:  viz.  1,  the  epiphyses  are  united  to  the  shafts  by  cartilage; 
2,  the  tissue  of  the  bones  is  yielding ;  and  3,  the  bones  are  liable  to  be  im- 


INJURIES  OF  BONES.  531 

paired  in  their  integrity  by  rickets.  Owing  to  these  peculiarities,  injuries  to 
the  bones  of  children  may  result  in  three  conditions  rarely  found  in  adult 
persons — viz.  1,  separation  of  the  epiphysis  from  the  diaphysis  (diastasis)  ; 
2,  bending  ;  3,  partial  fracture  (green-stick)  ;  4,  transverse  fractures. 

The  separation  of  the  epiphysis  is  regarded  by  Holmes  ^  as  chiefly  a  frac- 
ture, for  after  the  examination  of  a  large  number  of  specimens  he  states  that 
the  fracture  occurs  not  very  rarely  at  or  in  the  immediate  neighborhood  of 
the  epiphyseal  line,  and  that  the  line  of  fracture  coincides  in  these  cases 
partially  with  that  of  the  epiphyseal  cartilage,  but  seldom  completely.  Chas- 
saignac  and  Marjolin  had  previously  maintained  the  opinion  that  separation 
of  the  epiphysis  strictly  in  the  line  of  the  cartilage  rarely  occui's.  The 
chief  importance  of  this  fracture  is  the  effect  which  it  may  have  upon  the 
future  growth  of  the  bone  in  length.  It  would  follow  that,  if  the  result- 
ing inflammation  should  be  attended  by  suppuration,  the  integrity  of  the 
uniting  cartilage  would  be  destroyed  and  the  growth  of  the  bone  would  be 
impaired ;  or,  if  the  cartilage  quickly  ossified,  the  growth  of  the  bone  would 
be  arrested  and  deformity  would  result. 

Owen  gives  the  following  very  judicious  "general  caution"  in  regard  to  frac- 
tures near  a  joint  or  through  an  epiphysis :  "  In  every  case  of  fracture  near  a  joint 
or  through  an  epiphysis  it  is  desirable  that  the  surgeon,  however  skilled  and  com- 
petent he  may  be,  do  not  take  the  undivided  responsibility  of  the  case.  Some  un- 
toward event  is  apt  to  be  associated  with  the  injury  which  no  exercise  of  art  can 
with  certainty  avert.  Thus,  suppuration  may  occur  and  death  follow  from  pyemia  ; 
or  synostosis  or  other  form  of  permanent  stiffness  may  result ;  or  there  may  be  some 
deformity  ;  the  humerus  may  fail  to  be  properly  developed,  and  the  limb  may  be  less 
useful  than  was  anticipated.  Over  the  result  of  the  treatment  of  injuries  near  a 
joint,  skilful  as  it  may  have  been,  great  unpleasantness  is  apt  to  ensue.  See  that 
the  parents  should  be  made  at  once  to  thoroughly  understand  the  serious  nature  of 
the  injury,  at  least  as  regards  the  future  effect;  they  should  not  be  caused  needless 
alarm,  but  should  see  the  advisability  of  adopting  precautions.  A  shoulder  or 
elbow  left  permanently  stiff  may  wellnigh  ruin  a  professional  reputation  ;  its  ex- 
istence is  never  forgotten.  In  every  country  village  some  brother-practitioner  can 
and  should  be  found  to  help  with  anaesthetic  and  counsel.  If,  when  all  swelling 
has  subsided,  union  be  taking  place  with  some  deformity,  the  surgeon  should  think 
twice  before  breaking  it  down  with  the  idea  of  resetting  the  bone.  Such  inter- 
ference might  result  in  fracture  of  the  bone  in  a  fresh  place,  or  might  be  followed 
by  serious  local  disturbance." 

The  DIAGNOSIS  of  epiphyseal  separation  is  often  difl&cult,  owing  to  its 
proximity  to  a  joint  and  the  absence  of  crepitus.  It  is  often  mistaken  for  a 
dislocation,  and  efibrts  are  made  at  reduction.  These  mistakes  are  most  fre- 
quent at  the  upper  and  lower  extremities  of  the  humerus.  An  error  can  be 
avoided  by  giving  especial  attention  to  the  fact  that  the  deformity  can  be 
overcome  with  ease  compared  with  a  dislocation,  and  that  when  the  apparent 
dislocation  is  reduced  the  deformity  recurs  when  traction  ceases.  Moreover, 
the  head  of  the  bone  will  be  found  in  the  joint.  These  signs  determine  the 
fact  that  there  is  a  lesion  of  the  bone,  while  the  absence  of  crepitus  and  the 
proximity  of  the  joint  prove  that  the  condition  is  neither  a  fracture  nor  a 
dislocation.  The  logical  conclusion  must  be  that  there  is  a  separation  of  the 
epiphysis. 

The  TREATMENT  of  this  form  of  injury  does  not  difiier  materially  from 
that  of  a  complete  fracture.  Every  possible  effort  should  be  made  to  place 
the  fragments  in  complete  apposition  in  order  to  secure  perfect  union.  When 
the  separation  is  reduced  the  ordinary  dressings  for  fracture  at  the  same 
point  are  indicated. 

The  hending  of  the  long  bones  of  children  occurs  at  an  early  period.     The 

^  Surg.  Treatment  of  Children' s  Diseases. 


532  LOCAL  DISEASES. 

accident  is  not  frequently  alluded  to  by  writers,  because  the  bone  usually 
quickly  recovers  its  former  position,  and  Hamilton's  experiments  prove  con- 
clusively the  possibility  of  the  bending,  but  (juick  recovery,  of  the  long  bones 
of  the  young.  They  also  show  that  if  the  bent  position  continues  there  has 
been  a  partial  fracture. 

Partial  fracture  occurs  when  on  one  side,  the  convex,  a  fracture  takes 
place  involving  only  the  surface,  while  on  the  opposite  side,  the  concave,  there 
is  an  impaction  of  tissue.  It  is  most  frequently  seen  in  the  clavicle.  In 
some  cases  the  bone  undoubtedly  recovers  very  nearly  its  normal  position 
when  the  violence  is  removed. 

Case  (Hamilton). — An  infant  boy,  three  years  old,  fell  from  the  hands  of  the 
nurse.  The  child  cried,  but  the  point  of  injury  was  not  detected  until  the  third  or 
fourth  day,  although  the  mother  examined  the  shoulders  and  neck  carefully  at  the 
time.  She  is  quite  certain  that  if  any  swelling  or  discoloration  had  been  present 
she  would  have  seen  it  then  or  on  the  subsequent  days  while  washing  and  dressing 
the  child.  When  first  seen  it  was  very  distinct,  but  not  so  large  as  at  present. 
Seven  days  later  the  child  was  brought  "^to  me.  A  little  to  the  sternal  side  of  the 
middle  of  the  right  clavicle  there  was  an  oblong  node-like  swelling,  of  the  size  of 
the  half  of  a  pigeon's  egg,  hard,  smooth,  and  feeling  like  bone ;  thei-e  was  no  dis- 
coloration or  swelling  of  the  integuments ;  no  crepitus  or  motion  ;  the  line  of  the 
clavicle  seemed  nearly  or  quite  unchanged. 

The  only  evidence  which  remains  of  a  previous  fracture  is  a  subsequent 
nodule  which  forms  at  the  seat  of  the  lesion  of  the  bone. 

In  the  TREATMENT  of  these  forms  of  injury  it  must  be  remembered  that 
there  is  a  constant  tendency  to  a  recovery  of  the  proper  position.  In  bend- 
ing and  in  partial  fracture  with  slight  displacement  there  is,  therefore,  no  other 
treatment  required  than  protection  from  further  injury.  Moderate  efforts  may 
be  made,  under  chloroform,  by  pressure  of  the  fingers  on  the  convexity  of  the 
bone,  to  restore  its  position,  but  care  must  be  taken  not  to  make  such  strong 
compression  as  will  produce  a  complete  fracture.  A  sling  for  the  arm  of  the 
side  on  which  the  clavicle  is  fractured ;  a  splint  on  the  concave  side  of  the 
arm  ;  one  on  the  anterior  and  one  on  the  posterior  surface  of  the  bent  fore- 
arm ;  a  splint  on  the  concave  surface  of  the  bent  femur,  the  interior  surface 
of  the  leg,  in  which  the  fibula  is  bent, — comprises  the  treatment  of  the  cases 
which  will  come  under  the  care  of  the  practitioner. 

Hamilton  remarks :  "  But  we  need  not  be  over-anxious  to  straighten  the  bone 
completely,  since  experience  has  shown  that  after  the  lapse  of  a  few  weeks  or  months 
the  natural  form  is  usually  restored  spontaneously.  I  am  not  now  speaking  of  those 
cases  in  which  the  restoration  occurs  immediately,  in  which  it  is  probable  that  the 
splintered  fibres  oS%v  no  resistance  to  the  restoration,  but  only  of  those  in  which  the 
bone  straightens  so  gradually  as  to  induce  a  belief  that  the  broken  ends  are  the 
cause  of  the  resistance.  In  a  case  mentioned  by  Gulliver  it  required  about  four 
weeks'  time  to  render  the  bones  of  the  forearm  perfectly  straight ;  and  in  one  case 
mentioned  by  Jurine  at  the  end  of  six  months  it  was  '  difiicult  to  say  which  arm 
had  been  broken,  and  at  the  end  of  one  year  it  was  impossible.'  " 

Fractures  in  the  new-born  may  have  occurred  in  utero  or  at  the  time  of 
birth.  They  represent  all  of  the  peculiarities  seen  in  the  fractures  of  the 
child  in  early  life. 

_  Case. — A  woman  in  the  sixth  month  of  pregnancy  was  injured  in  the  abdomen  by 
striking  against  a  table.  Her  child  had  a  separation  of  the  lower  epiphysis  of  the 
tibia.     The  end  of  the  shaft  had  perforated  the  skin  and  was  necrosed. 

Simple  bendings  of  bones  are  met  with  at  birth,  and  simple  fractured 
bones  which  have  united  with  deformity.  Even  compound  fractures  in  utero, 
which  have  united  before  birth,  have  been  reported. 


INJURIES  OF  BONES. 


533 


Case. — Proudfoot  of  New  York  has  related  a  case  of  compound  fracture  in  utero 

■which  was  apparently  caused  by  external  violence.     Mrs.  F ,  during  the  sixth 

month  of  gestation,  while  attempting  to  pass  through  a  very  narrow  passage,  was 
severely  pressed  upon  the  abdomen,  and  immediately  experienced  a  severe  pain  in  that 
region,  accompanied  with  nausea  and  faintness.  The  following  day  uterine  hemor- 
rhage, with  pain,  commenced,  and  these  symptoms  continued  at  intervals,  in  a  form 
more  or  less  severe,  up  to  the  period  of  her  delivery,  which  occurred  at  full  time  and 
was  perfectly  natural.  At  birth  the  right  foot  of  the  child,  a  female,  was  found  to  be 
much  distorted  and  in  a  condition  of  valgus  with  equinus,  the  outer  side  of  the  foot 
being  laid  against  the  side  of  the  leg  above  the  external  malleolus.  The  tibia  also 
of  the  same  limb,  near  its  middle,  seemed  to  have  been  the  seat  of  a  compound  frac- 
ture, the  two  ends  of  the  Vjone  having  united  at  an  angle  slightly  salient  anteriorly, 
and  the  skin  presenting  over  the  point  of  fracture  an  old  cicatrix.^ 

The  TREATMENT  of  these  forms  of  injury  is  to  be  conducted  on  the  same 
principles  as  in  children.  It  will  often  be  difficult  to  adapt  suitable  splints  to 
the  child's  limbs  and  retain  restrictive  dressings,  but  very  thin  and  light  paste- 
board splints,  well  padded,  can  be  employed  and  retained  by  bandages  or 
rubber  plasters,  care  being  taken  that  they  are  not  too  tightly  applied. 

The  clavicle  is  more  frequently  bent  or  fractured  in  children  than  any 
other  long  bone.  This  is  due  to  the  frequency  of  their  falling  upon  the 
shoulder  and  the  several  curves  of  that  bone.  The  indications  of  treatment 
are  to  place  the  shoulder  in  a  position  upward,  backward,  and  outward.  In  very 
young  children  a  sling,  supporting  the  elbow  and  arm,  is  the  best  appliance. 
Recovery  occurs  in  most  cases  with  but  little  deformity.  In  older  children 
the  adhesive  strip  of  Sayre  secures  the  position  of  the  arm  most  effectually. 

Select  strong  adhesive  plaster,  and  cut  it  into  two  strips  three  or  four  inches 
wide,  but  narrower  for  children  ;  one  should  be  of  length  to  encircle  the  arm  and 
the  body,  and  the  other  to  reach  from  the  sound  shoulder  around  the  elbow  of  the 
fractured  side  and  back  to  the  place  of  starting.  Pass  the  first  piece  around  the 
arm  just  below  the  axillary  margin,  and  stitch  in  the  form  of  a  loop  sufiBciently 
large  to  prevent  strangulation,  leaving  a  large  portion  on  the  back  of  the  arm 
uncased  by  the  plaster ;  draw  the  arm  downward  and  backward  until  the  clavicular 
portion  of  the  pectoralis  major  muscle  is  put  sufficiently  on  the  stretch  to  overcome 


Fig.  162. 


Fig.  163. 


First  adhesive  strip. 


Second  adhesive  strip. 


the  sterno-cleido-m'astoid,  and  thus  pull  the  inner  portion  of  the  clavicle  down  to 
its  level ;  carry  the  plaster  smoothly  and  completely  around  the  body,  and  pin  to 
itself  on  the  back  to  prevent  slipping  (Fig.  162).  This  first  strip  of  plaster  fulfils 
a  double  purpose :  first,  by  putting  the  clavicular  portion  of  the  pectoralis  major 

^  New  York  Journal  of  Medicine,  1846. 


534 


LOCAL  DISEASES. 


Fig.  164. 


muscle  on  the  stretch,  it  prevents  the  clavicle  from  riding  upvrard  ;  and,  secondly^ 
actin,£5  as  a  fulcrum  at  the  centre  of  the  arm  when  the  elbovF  is  pressed  downward, 
forward,  and  inward,  it  necessarily  forces  the  other  extremity  of  the  humerus  (and 
with  it  the  shoulder)  upward,  outward,  and  backward.  And  it  is  kept  in  this 
position  by  a  second  strip  of  plaster,  which  is  applied  as  follows :  Commencing  on 
the  front  of  the  shoulder  of  the  sound  side,  draw  it  smoothly  and  diagonally  across 
the  back  to  the  elbow  of  the  fractured  side,  where  a  slit  is  made  in  its  middle  to 
receive  the  projecting  olecranon.  Before  applying  this  plaster  to  the  elbow  an 
assistant  should  press  the  elbow  well  forward  and  inward  and  retain  it  there,  while 
the  plaster  is  continued  over  the  elbow  and  forearm,  pressing  the  latter  close  to  the 
chest  and  securing  the  hand  near  the  opposite  nipple  ;  crossing  the  shoulder  at  the 
place  of  beginning,  it  is  there  secured  by  two  or  three  pins. 

The  humerus  may  be  fractured  at  many  points,  but  those  most  frequent 
and  important  in  children  are  separation  of  the  epiphyses  and  fractures  at  the 
elbow-joint.  Separation  of  the  upper  epiphysis 
(Fig.  164)  is  recognized  by  the  location  of  the  false 
point  of  motion,  absence  of  crepitus,  and  the  pres- 
ence of  the  head  in  its  proper  position.  It  is  most 
frequent  on  the  right  side.  When  separation  of 
the  lower  epiphysis  occurs,  the  elbow  has  the  ap- 
pearance of  a  dislocation  backward  of  the  ulna,  but 
its  easy  reduction  and  the  return  of  the  dislocation 
without  any  spreading  of  the  joint,  as  occurs  in 
separation  of  the  condyle,  determines  its  nature. 

Fractures  at  the  elbow  are  as  follows  :  At  base 
of  condyles,  often  difficult  of  diagnosis,  owing  to 
swelling ;  most  reliable  signs  are  mobility,  crepitus ; 
easy  reduction,  but  immediate  return  of  deformity  ; 
great  prominence  of  olecranon,  like  a  dislocation ; 
pronation  of  hand.  At  the  base  of  the  condyles, 
with  longitudinal  fracture  between  them,  some- 
times comminuted ;  this  fracture  has  the  same 
symptoms  as  the  last,  with  widening  of  joint  and 
crepitus  of  condyles.  Fracture  of  either  condyle 
is  known  by  separate  movement  of  the  condyle.  Separation  of  epicondyles 
is  detected  by  grasping  the  fragments. 

Fractures  of  the  arm  at  all  points  are  best  treated  in  children  by  a  gutter 

splint  extending  from  the  shoulder  to  the 
hand  in  order  to  preserve  absolute  rest. 

Select  a  piece  of  light  felt  or  binder's- 
board  long  enough  to  extend  from  above  the 
acromion  process  to  the  hand,  and  wide  enough 
to  enclose  about  one-half  of  the  circum- 
ference of  the  limb ;  cut  it  partially  down  on 
each  side  at  the  elbow^,  so  as  to  bend  it  at  a 
right  angle  ;  mould  it  while  wet  to  the  outside 
of  the  arm  and  forearm,  and  allow  it  to  become 
dry ;  protect  the  splint  with  cotton-wool ;  re- 
duce the  fracture  and  apply  the  splint  with  a 
roller  bandage.  In  case  of  separation  of  the 
upper  epiphysis  a  cotton-wool  pad  should  be 
placed  in  the  axilla.  If  the  fracture  is  at  or 
near  the  elbow-joint,  place  the  forearm  at  a 
right  angle  with  the  humerus,  and  maintain  it 
in  this  position  by  a  right-angled  splint,  well 
covered  with  a  woollen  or  cotton  sack,  and  se- 
cure it  to  the  forearm  by  a  roller.  The  front  or  bend  of  the  elbow  should  always 
be  well  covered  with  cotton  batting  before  enclosing  the  elbow-joint  in  the  turns 


Humerus,  shaft,  epiphyses,  and 
inner  condyle  detached. 


Fig.  165. 


Dressing  (jt  fractured  humerus. 


INJURIES  OF  BONES. 


535 


Fig.  166. 


of  the  roller,  to  prevent  strangulation.  Passive  motion  must  be  commenced  in  about 
tvro  weeks  by  loosening  the  dressing,  supporting  the  parts  thoroughly  at  the  joint, 
and  making  slight  flexion  and  extension  ;  repeat  this  manoeuvre  occasionally. 

The  ulna  may  be  fractured  in  any  part  of  its  shaft  by  direct  violence  ;  the 
diagnosis  is  readily  made.  The  treatment  is  by  lateral  splints  of  thin  paste- 
board, the  bones  being  maintained  parallel  and  separated  by  small  pads  on  the 
anterior  and  posterior  aspect ;  the  splints  should  be  wider  than  the  arm,  and 
be  retained  in  position  by  two  adhesive  strips,  one  near  the  elbow  and  the 
other  near  the  wrist,  passed  completely  around  the  splints. 

The  radius  may  be  fractured  through  its  head,  generally  in  injuries  in- 
volving the  joint.  Adjust  it  and  apply  an  angular  splint,  supporting  the 
elbow  in  a  state  of  flexion.  If  the  neck  is  fractured,  the  biceps  will  elevate 
the  lower  fragment ;  the  treatment  is  the  same  as  for  the  former  accident.  Al\ 
fractures  above  the  attachment  of  the  pronator  quadratus  must  be  so  ad- 
justed that  the  proper  axis  of  the  bone  is  maintained  to  secure  the  restora- 
tion of  its  normal  movements.  The  elbow  should  be  semiflexed,  the  forearm 
and  hand,  excepting  the  fingers,  supported  between  a  dorsal  and  a  palmar 
splint  padded,  and  secured  by  adhesive  plaster  passed  completely  around  the 
splints  ;  the  limb  should  be  accurately  fixed  in  supination  at  an  angle  of  120° 
by  means  of  angular  pads ;  the  thumb  in  this  position  is  brought  nearly  into 
a  line  with  the  outer  fleshy  border  of  the  supinator  radii  longus. 

The  epiphysis  at  the  lower  extremity  of  the  radius  is  liable  to  be  sepa- 
rated, giving  the  appearance  of  a  Colles  fracture.  It  is  usually  the  result  of 
a  fall  upon  the  palm  of  the  hand,  in  which  two  forces 
act  in  an  opposite  direction — viz.  the  weight  of  the  body 
and  the  resistance  of  the  ground ;  the  bone  yields  near- 
est the  point  of  impact,  where  the  vibration  is  greatest 
and  the  bone  is  weakest — viz.  the  epiphyseal  junction. 
The  chief  deformity  is  due  to  the  projection  of  the  lower 
end  of  the  radial  fragment  upon  the  palmar  surface,  and 
of  the  carpal  fragments  upon  the  dorsal  surface,  which 
give  the  peculiar  silver-fork  appearance. 

The  TREATMENT  should  be  the  same  as  for  fracture 
of  one  of  the  bones,  but  the  splints  should  extend  down 
to  the  middle  of  the  hand.  Small  pads  over  the  project- 
ing fragments  aid  in  reducing  the  displacement. 

The  femur  is  liable  to  forcible  separation  of  its  upper 
epiphysis  only  as  the  result  of  extreme  violence.  The 
slighter  injuries  which  have  heretofore  been  supposed  to 
cause  separation  of  the  epiphysis  have,  it  has  been  shown 
by  Whitman,  caused  a  partial  fracture  of  the  neck.  The 
femur  of  the  infant  may  be  fractured  at  birth  when  an 
operation  is  performed,  either  by  manipulation  or  with 
instruments.  At  other  periods  of  infancy  fracture  of  the  femur  is  of  rare 
occurrence,  and  is  rarely  met  with  except  in  severe  accidents.  These  frac- 
tures are  usually  so  nearly  transverse  that  but  little  traction  is  required  to 
retain  the  fragments  in  apposition. 

The  TREATMENT  of  fractures  of  the  femur  at  birth  must  be  limited  to 
supporting  the  affected  thigh  by  bandaging  it  to  the  other  with  a  compress, 
as  a  napkin,  placed  between  them.  In  infants  under  one  year  of  age  the 
same  method  is  as  useful  as  any  that  can  be  adopted.  For  children  between 
one  and  five  years  of  age  Schede's  method  has  been  preferred  by  some, 
notably  by  Bryant  of  London.     It  is  called  "  vertical  extension." 

It  is  as  follows  (Fig.  166) :  A  long,  continuous  band  of  plaster  is  fixed  to  both 


Position    with    limbs 
suspended  (Bryant). 


536 


LOCAL  DISEASES. 


sides  of  the  injured  limb  as  high  as  the  seat  of  fracture,  and  applied  so  as  to  form 
a  free  loop  below  the  sole.  This  long  strip  is  then  secured  in  the  ordinarj^  way  by 
circular  strips  of  plaster  and  by  circular  turns  of  a  bandage.  The  leg.  having  been 
elevated,  is  then  kept  in  a  vertical  position,  with  the  corresponding  side  of  the  pelvis 
suspended  by  means  of  a  piece  of  cord  fixed  to  a  loop  of  plaster,  and  either  attached 
above  to  some  object  over  the  bed  or  slung  over  a  pulley,  with  its  free  extremitj^  sup- 
porting a  Aveight.  This  does  not  necessitate  constant  and  complete  rest  on  the  back. 
The  extension  is  removed  at  the  end  of  three  weeks,  and  the  limbs  are  allowed  to 
rest  on  the  bed. 

Hamilton  remarks  of  the  treatment  of  these  fractures :   "  Fractures  of 
the  thigh  in  children  have  generally  been  found  more  difficult  to  manage 

than  fractures  of  the  same  bone  in  the  adult, 
Fig.  167.  owing  chiefly  to  the  shortness  and  softness  of 

the  limb,  the  delicacy  of  the  skin,  its  liability 
to  become  excoriated  or  to  become  soiled,  and 
the  restlessness  of  the  patient."  As  a  result 
of  a  large  experience  in  the  use  of  various  ap- 
pliances in  the  fracture  of  the  femur  in  older 
children  he  devised  the  following,  which  is 
simple  and  very  eff'ectual : 

Two  long  side-splints  connected  by  a  cross-piece 
at  the  lower  ends,  and  reaching  upward  to  near  the 
axillge,  separated  a  little  more  widely  below  than 
above,  so  as  to  render  the  perineum  more  accessi- 
ble, are  laid  upon  each  side  of  the  body.  The  four 
short  thigh-splints,  made  of  binder's  board  and 
covered  with  cotton  cloth,  are  secured  in  place  by 
four  or  five  strips  of  bandage  tied  in  front  and  then 
stitched  to  the  covers  of  the  splints.  These  must 
not  embrace  the  long  side-splint.  The  broken  limb 
below  the  knee,  and  the  opposite  thigh  and  leg  are 
held  in  place  by  bandages  passed  around  the  splint. 
Thus  secured  and  laid  upon  a  bed,  such  as  I 
have  already  described  as  appropriate  for  children, 
the  least  possible  annoyance  will  be  given  to  the 
surgeon.  The  dressings  are  but  little  liable  to  be- 
come wet  with  urine,  and  when  the  bed  is  soiled 
the  child  can  be  taken  up  with  the  splint  and  car- 
ried to  another :  indeed,  this  may  be  done  as  often 
as  the  patient  becomes  restless  or  weary,  without 
any  risk  of  disturbing  the  fracture.  In  case  the 
surgeon  desires  to  use  extension  with  adhesive  plas- 
ter and  weights,  the  necessary  apparatus  may  be 
made  fast  to  the  bedstead  and  taken  off  when  the 
child  is  moved  :  or  it  may.  if  thought  best,  be  made 
fast  to  the  foot-piece  of  the  splint.  Occasionally, 
with  children.  I  employ,  as  a  means  of  extra  safety, 
a  perineal  band  drawn  moderately  tight,  and  fast- 
ened to  the  top  of  the  splint  on  the  side  correspond- 
ing to  the  broken  limb.  The  best  perineal  band  is 
a  piece  of  soft  cotton  cloth,  one  or  two  yards  long 
by  three  inches  wide,  folded  lengthwise  to  a  flat 
band  of  one  inch  in  breadth,  and  enclosing,  where  it  passes  through  the  perineum 
and  under  the  nates,  a  few  thicknesses  of  paper.  The  paper  prevents  its  drawing 
into  a  round  cord.  Sometimes  I  place  between  the  paper  and  the  folded  cloth, 
on  the  side  which  is  to  be  laid  next  to  the  skin,  one  or  two  thicknesses  of  cotton 
wadding.  To  absorb  the  moisture  it  is  well  to  lay  a  piece  of  sheet  lint  between  the 
band  and  the  skin.  The  perineal  band  may  be  removed  daily  and  renewed,  and  the 
perineum  examined  and  washed.  Four  or  five  weeks  is  generally  a  sufiicient  length 
of  time  for  perfect  consolidation  in  children  under  five  years  of  age. 


Dressing  lui  iiacture  of  the  femur 
in  children,  complete  (Hamilton). 


INJURIES  OF  BONES.  537 

Separation  of  the  lower  epiphysis  of  the  femur  occurs  from  various 
-applications  of  violence.  It  has  resulted  from  traction  on  the  legs  at  birth, 
from  attempts  to  break  up  ankylosis  at  the  knee,  and  while  examining  a  case 
of  hip-joint  disease.  The  violence  may  be  so  great  as  to  cause  protrusion  of 
the  upper  fragment  through  the  skin.  In  several  recorded  instances  the 
limb  was  caught  in  a  wagon-wheel.  No  prescribed  method  of  treatment  can 
be  given  in  complicated  cases,  but  a  double-inclined  plane,  with  side-splints, 
in  ordinary  simple  cases  would  best  meet  the  indications.  The  following 
severe  forms  of  this  injury  illustrate  their  peculiarities  and  dangers: 

Case  1. — Little  presented  to  the  Xew  York  Pathological  Society  a  specimen 
obtained  from  his  own  practice.  A  boy,  £et.  eleven,  while  hanging  on  the  back  of 
a  wagon,  had  his  right  leg  caught  between  the  spokes  of  the  wheel,  which  was  in 
Tapid  motion.  A  few  hours  after  the  accident  he  found  the  upper  fragment  of  the 
femur  projecting  through  an  opening  in  the  upper  and  outer  part  of  the  popliteal 
•space.  On  examination  the  wound  did  not  appear  to  communicate  with  the  knee- 
joint.  Under  the  influence  of  an  anaesthetic  the  fragments  were  reduced,  the  re- 
duction occasioning  a  dull  cartilaginous  crepitus.  There  was  at  the  time  no  pulsa- 
tion in  the  posterior  tibial  artery,  and  the  limb  was  cold.  The  limb  was  laid  over 
a  double-inclined  plane.  The  following  day  the  upper  fragment  was  again  dis- 
placed, and  it  was  found  that  it  could  only  be  kept  in  place  by  extreme  flexion  of 
the  leg.  This  position  was  therefore  adopted  and  maintained ;  considerable  trau- 
maticlfever  followed,  with  swelling,  and  on  the  thirteenth  day  a  secondary  hemor- 
rhage occurred  from  the  anterior  tibial  artery  near  its  origin,  and  it  became  neces- 
sary to  amputate.  The  boy  made  a  good  recovery.  The  specimen  showed  that  the 
line  of  separation  had  not  followed  the  cartilage  throughout,  but  had  at  one  point 
traversed  the  bony  structure.^ 

Case  2. — .Smalhvood,  a  boy,  aged  twelve,  had  his  right  leg  caught  in  the  spokes 
•of  a  wagon-wheel,  breaking  the  thigh  at  the  junction  of  the  lower  epiphysis  with 
the  diaphysis,  the  lower  end  of  the  upper  fragment  protruding  five  inches  through 
the  flesh.  The  end  was  nearly  square.  The  lad  being  under  the  influence  of 
«ther.  it  was  reduced  within  one  hour  by  violent  extension  and  flexion  of  the  leg 
over  his  knee,  one  finger  being  in  the  wound  and  adjusting  the  fragments.  Lateral 
splints  were  employed.  The  wound  closed  in  about  nine  months,  and  in  the  mean- 
while two  small  fragments  of  bone  escaped.  He  had  also  a  sharp  attack  of  syno- 
vitis. On  recovery  the  leg  was  straight,  but  shortened  three-quarters  of  an  inch. 
There  is  complete  ankylosis  of  the  knee-joint,  but  the  muscles  of  the  leg  are  well 
■developed  and  he  walks  with  very  little  limp.^ 

Fracture  of  condyles  in  children  is  rare,  and  results  only  from  direct  vio- 
lence.    The  following  case  of  fracture  of  the  internal  condyle  is  instructive: 

Case  (Riggs,  Homer,  N.  Y.). — A  lad,  aet.  fifteen,  was  kicked  by  a  horse,  the  blow 
being  received  upon  the  right  knee.  The  internal  condyle  of  the  right  femur  was 
broken  ofi",  carrying  away  more  than  half  the  articulating  surface  of  the  joint :  the 
tibia  and  fibula  were  at  the  same  time  dislocated  inward  and  upward,  carrying 
with  them  the  broken  condyle  and  the  patella.  The  displacement  upward  was 
about  two  inches,  and  the  sharp  point  of  the  inner  fragment  had  nearly  penetrated 
the  skin.  There  was  no  external  wound.  The  knee  presented  a  very  extraordi- 
nary appearance,  and  the  lad  was  suff'ering  greatly.  The  first  attempt  at  reduction 
was  unsuccessful ;  but  in  the  second  attempt,  when  the  men  aiding  him  were  nearly 
exhausted  in  their  efforts  at  extension  and  counter-extension,  and  while  pressing 
forcibly  Avith  both  hands  upon  the  two  condyles,  the  bones  suddenly  came  into 
position,  except  that  the  breadth  of  the  knee  seemed  to  be  slightly  greater  than  the 
other — a  circumstance  which  was  probably  due  to  the  irregularities  of  the  broken 
surfaces,  which  prevented  perfect  coaptation.  Neither  splints  nor  bandages  were 
required  to  maintain  the  bones  in  place :  the  limb  was  placed  upon  "  a  double- 
inclined  plane,"  which,  being  supplied  with  lateral  supports,  would  prevent  any 
deflection  in  either  direction  in  case  the  limb  was  disposed  to  such  displacement. 
The  subsequent  treatment   consisted  in   the    use  of  cold-water  dressings.     Very 

^  New  York  Jown.  Med.,  1865. 

^  Hamilton  on  Fractures  and  Dislocations,  p.  427,  1891. 


538  LOCAL  DISEASES. 

little  inflammation  followed.  A  portion  of  the  integument  sloughed,  but  the  bone 
•was  not  exposed,  and  it  healed  rapidly.  On  the  twenty-fourth  day  passive  motion 
was  used,  and  this  was  repeated  at  intervals  until,  at  the  end  of  three  months,  h& 
was  al)le  to  walk  with  a  cane.  At  the  end  of  a  year  the  knee  Avas  a  very  little 
larger  than  the  other,  and  flexion  was  not  quite  as  complete.  In  all  other  respects 
it  was  perfect,  and  the  boy  himself  declared  it  was  as  good  as  the  other. ^ 

The  tibia  is  less  liable  to  fracture  in  children  than  the  femur.  Separa- 
tion of  the  upper  epiphysis  rarely  occurs,  and  is  to  be  treated  by  properly 
adjusted  plaster-of- Paris  dressings,  unless  the  tissues  are  too  much  injured. 
Fractures  in  the  shaft  are  rarely  displaced,  and  require  only  adjustment.  In 
infants  employ  a  thin  pasteboard  splint  moulded  while  wet  to  the  leg  poste- 
riorly and  nearly  meeting  in  front.  It  should  be  well  protected  by  cotton 
batting.  Separation  of  the  lower  epiphysis  and  fractures  at  the  ankle  are  sa 
rare  as  to  require  no  further  notice. 

The  fibula  is  rarely  fractured.  Separation  of  the  upper  epiphysis  has 
been  recognized  at  autopsies,  but  has  no  practical  importance. 

Fracture-sprains  (Callender)  at  the  ankle  are  now  more  frequently  seen 
among  boys  engaged  in  athletic  sports.  The  foot  turns  in  or  out,  and  either 
fractures  a  malleolus,  generally  the  outer,  or  the  lateral  ligament  drags  off 
the  end  of  the  bone.  These  cases  should  receive  applications  of  very  hot 
water  for  twenty-four  hours,  and  then  the  limb  should  be  encased  in  a  plas- 
ter-of-Paris  dressing,  well  padded,  for  four  weeks. 


CHAPTER    IV. 

DISEASES  OF  BONE. 

Inflammation  of  the  bones  of  children  has  some  marked  peculiarities. 
Owing  to  the  prolonged  process  of  ossification  of  the  cartilage  of  the  epiph- 
ysis of  long  bones,  these  highly  vascular  structures  are  peculiarly  susceptible 
to  traumatism,  cold,  and  invasions  of  the  pus-microbe  and  tubercle  bacilli. 
The  short  bones,  and  especially  the  irregular  bones  of  the  carpus,  tarsus, 
and  vertebras,  are  for  the  same  reasons  very  susceptible  to  inflammation. 
The  progress  of  these  affections  is  also  more  rapid  even  in  the  chronic  form, 
and  the  effects  differ  from  the  same  diseases  in  the  adult.  In  children 
superficial  necrosis  is  much  less  frequent,  as  the  supply  of  blood  through 
the  nutrient  arteries  is  more  abundant,  thus  supplying  the  bone  when  the 
periosteum  is  elevated,  as  by  pus.  Acute  and  chronic  inflammations  are 
more  exhausting  in  childhood,  and  yet  operative  procedures  are  highly  suc- 
cessful, both  in  the  recover}-  of  patients  and  in  the  reparative  results. 

In  the  ETIOLOGY  of  inflammatory  affections  of  bone  in  children  we  have 
a  striking  peculiarity  as  compared  with  the  adult  in  the  frequency  of  infec- 
tion by  the  tubercle  bacilli. 

This  affection  deserves  the  most  careful  study,  for  on  its  timely  recognition 
will  depend  the  success  of  the  treatment.  The  tubercular  inflammatory  pro- 
cess is  due  to  the  lodgement  of  the  pus-microbe,  whether  it  follows  an  injury 
or  is  the  result  of  a  tubercular  focus  in  other  tissues.  It  may  commence  in 
the  periosteum,  the  bone-tissue,  or  in  the  medulla  ;  in  either  case  all  of  the 
structures  are  liable  to  be  involved  in  the  final  issue.  Acute  inflammation 
more  often  attacks  the  diaphyseal  extremities  of  the  long  bones,  owing  to 
'  Hamilton  :  Fractures  and  Dislocations,  1891,  p.  424. 


DISEASES  OF  BONE.  539 

the  great  vascularity  of  the  epiph3-seal  connection,  where  the  process  of 
ossification  of  cartilage  is  actively  in  progress.  On  the  walls  of  the  imper- 
fectly formed  vessels  the  pns-microbe  becomes  implanted,  and  develops  the 
active  process  of  inflammation.  At  these  points  an  acute  endostitis,  ostitis, 
or  periostitis  may  commence  and  rapidly  spread  to  the  adjacent  vascular 
structures.  It  is  noticeable,  however,  that  the  layer  of  unossified  cartilage 
acts  as  a  barrier  against  the  extension  of  the  products  of  inflammation  into 
the  epiphyses,  and  hence  in  the  direction  of  the  joints.  But  the  periosteum, 
by  its  connection  with  the  cartilage,  induces  these  products  to  spread  rapidly 
along  the  loose  subperiosteal  areolar  tissue,  thus  raising  the  periosteum  from 
the  bone.  If  the  inflammation  is  less  severe,  the  periosteum  may  become 
more  firmly  attached  to  the  bone,  and  thus  prevent  the  extension  of  purulent 
matters  along  the  bone  under  the  periosteum.  Ulceration  takes  place,  and 
the  pus  escapes  externally  at  the  epiphyseal  junction. 

Acute  inflammations  of  bones  may  be  classified  as  follows  :  1.  Periostitis: 
a,  subperiosteal ;  b,  supraperiosteal.  2.  Osteomyelitis  :  a,  epiphysitis  ;  6,  di- 
aphysitis. 

Periostitis  is  a  disease  of  youth,  and  rarely  of  infancy.  It  may  be  caused 
by  injury,  cold,  or  from  the  extension  of  osteomyelitis.  When  the  disease  is 
due  to  an  injury,  there  is  a  lowering  of  the  vitality  of  the  tissue,  which  pre- 
pares it  for  the  action  of  the  pus-microbes  in  the  circulation.  The  attack 
may  follow  the  injury  after  several  days,  during  which  the  microbes  slowly 
find  access  to  the  blood-clot. 

When  the  periosteum  alone  is  involved,  as  from  traumatism,  the  inflam- 
mation will  be  located  at  the  seat  of  injury,  but  if  it  is  secondary  to  other 
inflammations,  it  will  appear  at  the  diaphyseal  extremity  of  long  bones. 
Acute  periostitis  often  occurs  during  low  forms  of  fever  and  during  epidemics 
of  the  exanthemata.  The  lowered  vitality  of  such  patients  renders  them 
more  susceptible  to  the  action  of  germs.  In  the  same  manner  we  must  ex- 
plain the  occurrence  of  several  cases  in  succession  among  persons  living  in 
close  association. 

The  SY3IPT0MS  of  the  two  forms  of  periostitis  diifer  only  in  intensity.  In 
one  the  active  inflammation  is  between  the  bone  and  deep  fibrous  layer  of  the 
periosteum,  the  pus  forming  the  true  subperiosteal  abscess.  The  other  occurs 
in  the  superficial  areolar  tissue  of  the  periosteum.  The  former  is  liable  to  be 
followed  by  necrosis,  while  the  latter  does  not  affect  the  bone,  but  terminates 
in  superficial  abscess.  The  symptoms  are  alike,  but  are  less  severe  in  the 
latter  case. 

In  the  subperiosteal  form  rigors,  followed  by  a  temperature  of  103°  to 
105°  or  106°  F.,  and  subsequent  delirium,  are  early  indications  of  the  severity 
of  the  attack.  Drowsiness  supervenes,  and  if  the  inflammation  is  subperios- 
teal the  child  utters  piercing  screams,  owing  to  the  distention  of  the  perios- 
teum, though  as  yet  it  may  give  no  indications  of  the  source  of  pain,  and 
there  may  be  no  local  conditions  directing  attention  to  the  seat  of  disease.  At 
this  stage  the  nature  of  the  aflFection  is  very  liable  to  be  overlooked  if  the 
disease  is  subperiosteal,  and  the  symptoms  are  often  attributed  to  meningitis 
or  other  disease.  If  the  inflammation  is  superficial,  the  general  symptoms 
are  not  as  severe,  and  the  local  swelling  early  determines  the  exact  location 
of  the  trouble.  In  the  subperiosteal  variety,  where  there  may  at  first  be  no 
swelling,  there  is  one  characteristic  symptom  present  which  must  always  be 
sought  for  in  a  suspicious  case  of  this  kind,  and  that  is  local  tenderness  on 
pressure.  Whatever  may  be  the  condition  of  the  patient's  mind,  he  will  in- 
stantly scream  when  pressure  is  made  over  the  afl^ected  part.  If  the  bone 
lies  deeply,  as  the  femur,  prolonged  search  may  be  necessary  to  finally  reach 
the  exact  locality,  but  by  care  it  can  always  be  found. 


540  LOCAL  DISEASES. 

At  a  later  period  the  periosteum  is  perforated,  and  diffuse  cellulitis  estab- 
lished ;  the  limb  becomes  swollen,  often  very  largely,  tense,  and  shining,  and 
frequently  the  neighboring  joint  is  involved. 

As  a  rule,  the  extension  of  the  inflammation  toward  the  joint  is  prevented 
by  the  attachment  of  the  periosteum  to  the  epiphyseal  cartilage.  At  this 
point,  however,  it  may  extend  more  deeply,  and  detach  the  epiphysis  from  the 
shaft,  and  even  establish  an  osteomyelitis.  The  extent  of  necrosis  of  the 
shaft  depends  upon  the  interruption  of  the  circulation  in  the  bone.  It  may 
be  superficial  when  the  periostitis  is  limited,  or  it  may  involve  the  entire 
thickness  of  the  shaft,  or  the  whole  shaft  may  perish  by  the  interruption  of 
the  circulation  of  all  of  the  nutrient  arteries,  both  external  and  internal. 

The  diseases  for  which  acute  periostitis  have  been  mistaken  are  fever, 
erysipelas,  and  rheumatism.  Periostitis  may  be  mistaken  for  fever  when 
there  is  slight  swelling  and  the  most  marked  symptom  is  fever. 

Case  (Macewen). — Child  admitted  to  Glasgow  Fever  Hospital  as  a  case  of 
fever.  She  was  quite  insensible  and  in  extremis.  Examination  of  both  legs  showed 
scarcely  a  perceptible  difference  in  size ;  pressure  on  left  tibia  gave  rise  to  the  cha- 
ractei-istic  scream ;  no  tenderness  elsewhere.  Autopsy  showed  the  periosteum 
stripped  from  the  whole  tibial  diaphysis  by  a  pus  which  swarmed  with  staphylo- 
cocci. 

This  case  impresses  the  great  importance  of  an  examination  of  the  long 
bones  by  pressure  when  the  case  is  doubtful. 

Periostitis  most  resembles  erysipelas  when  the  inflammation  involves  only 
the  superficial  layer  of  periosteum.  But  there  is  never  the  defined  and 
rapidly-spreading  redness  of  erysipelas,  while  the  severe  and  localized  pain 
and  dusky  skin  mark  periosteitis.  When  the  swelling  involves  the  parts  in 
the  vicinity  of  a  joint,  the  pain  and  swelling  have  a  slight  resemblance  to 
rheumatism,  but  a  careful  examination  of  the  parts  readily  shows  that  the 
joint-structures  are  not  involved. 

Case. — A  girl,  aged  seven,  was  seized  with  rigors,  severe  pain  at  the  upper  part 
of  the  leg:  temperature  104°  F. ;  pulse  110;  sw^elling  just  below  the  knee.  Was 
treated  as  rheumatism  for  one  w^eek.  Then  periostitis  w^as  recognized ;  an  incision 
evacuated  a  large  quantity  of  pus,  with  great  relief;  a  superficial  necrosis  followed, 
and  patient  eventually  recovered. 

The  TREATMENT  should  be  prompt  relief  of  the  distended  tissues  by  in- 
cisions down  to  the  bone.  These  should  never  be  more  than  two  inches  in 
length,  and  should  be  made  in  the  long  axis  of  the  bone.  It  may  be  neces- 
sary to  make  such  incisions  in  different  parts  of  the  limb,  and  care  should  be 
taken,  when  there  is  extensive  suppuration,  to  make  a  sufficient  number  to 
completely  evacuate  the  pus  and  to  admit  of  thoroughly  cleansing  the  cavity. 
If  no  pus  appears,  one  or  two  incisions  only  may  be  necessary  to  relieve  the 
tension,  but  strict  antiseptic  measures  must  be  taken  to  prevent  the  introduc- 
tion of  pus-microbes. 

If  there  is  suppuration,  do  not  use  force  in  exploring  the  wound,  as  by 
inserting  the  finger,  that  the  periosteum  may  not  be  unnecessarily  raised  from 
the  bone.  The  entire  cavity  and  all  of  its  recesses  should  be  irrigated  with 
carbolic  solution  (1:40),  or  bichloride  (1:1000),  or  boric  acid.  Peroxide 
of  hydrogen  should  be  injected  during  the  period  of  profuse  suppuration. 
The  limb  should  be  squeezed  as  little  as  possible  to  force  fluids  out.  It  is 
well  to  make  such  incisions  as  will  most  effectually  drain  the  wound  by  gravi- 
tation. Iodoform  gauze  next  to  the  wound  and  antiseptic  coverings  complete 
the  dressings.  The  dressing  and  cleansing  of  the  wound  should  be  repeated 
every  two  or  three  days,  and  as  the  discharge  diminishes  the  interval  may 


DISEASES  OF  BONE.  541 

be  increased.  At  the  first  dressings  strips  of  iodoform  gauze  may  be  pushed 
into  the  recesses  of  the  abscesses. 

The  subsidence  of  the  severe  symptoms  on  relieving  the  tension  by  incis- 
ion, and  on  evacuating  a  large  cavity  distended  with  pus,  is  usually  very 
great,  but  the  patient  should  be  vigorously  sustained  by  tonics,  as  quinine, 
iron,  strychnine,  cod-liver  oil,  etc. 

If  the  symptoms  do  not  markedly  improve,  examine  the  limb  carefully  in 
order  to  detect  any  possible  collection  that  has  not  been  reached.  In  the 
upper  part  of  the  leg.  where  the  disease  seems  to  be  chiefly  on  the  anterior 
face  of  the  tibia,  pus  sometimes  accumulates  on  its  posterior  surface,  and 
until  that  is  reached  the  fever  will  continue.  In  some  instances  the  inflam- 
mation has  penetrated  the  medulla,  and  osteomyelitis  results.  The  treatment 
must  now  be  adapted  to  that  disease,  or  symptoms  of  pyaemia  may  appear, 
with  rigors,  sweats,  pallor,  and  rapid  exhaustion.  The  cavity  of  the  abscess 
should  be  explored  to  discover  any  cul-de-sac  or  concealed  focus  which,  in 
spite  of  the  irrigation.  stiH  retains  decomposing  pus.  All  such  places  must 
be  rendered  aseptic  by  vigorous  cleansing  and  the  tonic  treatment  pursued. 

Necrosis  is  one  of  the  results  of  periostitis  always  to  be  anticipated.  It 
does  not,  however,  necessarily  occur  even  when  the  periosteum  has  been 
completely  separated  from  the  bone  over  a  large  surface.  The  shaft  of  the 
bone  may  continue  to  receive  a  sufficient  supply  of  blood  from  the  epiphyseal 
cartilages  and  the  nutrient  arteries  to  maintain  its  vitality  until  the  perios- 
teum again  becomes  united. 

Case. — A  girl,  seven  years  old,  suflPered  from  extensive  periostitis  of  the  left 
thigh  ;  pus  formed  and  burrowed  extensively.  On  incision  down  to  the  bone  a 
large  amount  of  pus  was  discharged,  and  the  bone  was  found  to  be  completely 
exposed  the  entire  length  of  the  shaft.  After  a  long  period  of  suppuration  the 
periosteum  again  became  united  and  the  child  recovered  without  necrosis. 

When  necrosis  takes  place  the  treatment  of  the  dead  bone  must  be  very 
judicious.  As  a  rule,  no  attempt  to  remove  the  sequestrum  should  be  made 
until  it  has  so  far  separated  that  it  is  movable.  The  period  at  which  this 
will  occur  varies  from  one  to  many  months,  chiefly  according  to  the  extent 
of  the  necrosis.  It  is  impossible  to  determine  at  an  early  period  how  exten- 
sive the  necrosis  will  be,  and  if  efforts  are  made  to  separate  the  apparently 
dead  bone  from  the  living,  to  which  it  is  firmly  attached,  there  is  liable  to  be 
a  destruction  of  nutrient  vessels  which  will  result  in  the  death  of  bone  that 
might  have  been  saved. 

If  the  entire  thickness  of  the  shaft  of  a  long  bone  becomes  necrotic,  no 
rude  attempts  should  be  made  to  separate  the  mass  until  it  is  movable,  lest 
the  involucrum  be  injured  or  broken.  Free  drainage  should  be  maintained, 
and  such  cleansing  of  the  dead  structures  by  irrigation  with  antiseptic  solu- 
tions as  will  prevent  the  retention  of  putrid  pus.  When  there  are  evidences 
that  the  sequestrum  is  loose,  the  cavity  should  be  opened  in  the  direction  of 
a  sinus ;  the  cloacae  in  the  involucrum  must  be  sufficiently  enlarged  with  a 
chisel  or  the  gnawing  forceps,  and  the  mass  seized  with  strong  forceps.  The 
first  efi"orts  to  detach  the  dead  bone  from  the  living  should  be  by  gentle 
movements  in  its  long  axis ;  then  more  direct  traction  will  dislodge  it,  but 
care  must  be  taken  not  to  fracture  the  bony  investment.  The  after-treatment 
should  be  antiseptic. 

If  the  entire  shaft  dies,  the  case  will  assume  a  more  serious  aspect,  but 
under  judicious  management  a  favorable  result  may  generally  be  secured. 
The  treatment  should  aim  to  prevent  the  collection  of  pus,  to  keep  the  cavity 
free  from  putrefactive  materials,  and  support  the  general  health.  When  the 
shaft  has  loosened  or  has  become  enclosed  in  new  bone,  the  entire  dead  bone 
should  be  removed  in  the  manner  above  described. 


542  LOCAL  DISEASES. 

Chronic  periostitis  is  characterized  by  a  mild  grade  of  symptoms  as  com- 
pared with  those  of  the  acute.  It  may  be  due  to  injury  or  an  exanthematous 
fever,  or  to  a  specific  cause,  as  syphilis  or  tuberculosis.  If  it  follow  an  injury, 
there  may  be  a  thickening-  of  the  membrane  simply,  and  then  of  the  bone,  or 
pus  may  form,  with  a  more  or  less  extensive  abscess.  When  it  appears  as  a 
sequela  of  an  eruptive  fever,  it  resembles  the  periosteitis  sometimes  seen  dur- 
ing pyfemia.  and  is  probably  really  due  to  the  lodgement  of  some  septic  mat- 
ters transmitted  through  the  circulation  from  the  local  eruption.  The  sub- 
jects of  this  form  are  feeble  and  poorly  nourished,  and  the  suppuration  is 
often  extensive,  without  any  marked  symptoms. 

In  the  tubercular  form  the  child  usually  has  the  signs  of  a  strumous  diath- 
esis. The  progress  of  the  case  may  be  very  slow,  but  occasionally  it  is  more 
acute  ;  in  any  case  it  tends  to  the  formation  of  purulent  collections.  It  may 
subside  on  the  evacuation  of  the  pus  or  inflammation  may  extend  to  the 
medulla. 

Syphilitic  periostitis  may  be  due  to  the  congenital  or  acquired  form  of 
syphilis.  AVhen  congenital  it  more  often  appears  after  the  fourth  year,  and 
is  generally  found  in  several  bones,  especially  of  the  upper  limbs  and  the 
tibia.  It  is  often  symmetrical  in  its  attacks,  nodes  appearing  at  the  same 
point  of  the  same  bones  of  the  opposite  limbs. 

The  TREATMENT  consists  in  sustaining  the  general  health,  the  evacuation 
of  collections  of  pus,  and  cleansing  cavities  by  curetting  and  disinfection,  and 
the  removal  of  dead  bone.  If  the  disease  is  of  a  syphilitic  origin,  antisyph- 
ilitic  remedies  must  be  employed. 

Acute  epiphysitis  (circumscribed  osteomyelitis)  is  more  frequent  in  chil- 
dren than  the  diffuse  variety,  and  is  localized  at  the  epiphyseal  junction  of 
long  bones.  It  more  often  occurs  at  the  lower  end  of  the  femur.  It  com- 
mences in  the  succulent  tissues  connected  with  the  ossifying  process  of  the 
epiphyseal  cartilage,  and  involves  the  cancellous  tissue  of  the  epiphysis.  It 
progresses  toward  suppuration,  and  a  cavity  forms  containing  pus,  giving  rise 
to  an  abscess  of  bone.  The  pus  may  from  this  point  pass  into  the  neighbor- 
ing joint  or  along  the  shaft  or  to  the  medulla,  where  the  inflammation  spreads 
as  a  diffuse  osteomyelitis.     The  epiphysis  may  become  detached. 

The  CAU.SES  of  epiphysitis  are  injury,  exposure  to  cold,  an  exanthem,  or 
infection  from  an  existing  suppurative  focus.  The  new-formed  vessels  in  the 
ossifying  cartilage  are  susceptible  of  such  changes  by  injury,  cold,  and  other 
conditions  that  leucocytes  adhere  to  their  walls.  If  any  infective  materials 
are  floating  in  the  circulation,  it  is  more  liable  to  find  lodgement  in  these 
vessels  than  in  any  other. 

The  SY3IPT0MS  are  usually  very  pronounced.  Fever,  pain,  and  exhaus- 
tion follow  rapidly.  The  pain,  which  is  the  most  marked  early  symptom,  is 
of  a  gnawing,  boring  character,  while  the  pus  is  confined  by  dense  structures, 
and  relief  comes  only  when  the  pus  passes  out  into  yielding  tissues,  as  through 
the  periosteum  or  into  the  joint.  The  position  of  the  limb  is  semi-flexed, 
which  in  some  degree  relieves  tension.  Exhaustion  necessarily  follows  as  a 
result  of  the  fever,  pain,  and  disturbance  of  nutrition. 

The  conditions  of  greatest  importance  in  diagnosis  are  as  follows :  In 
the  early  stage,  when  there  may  be  no  swelling  of  the  part  nor  of  the  joint, 
by  careful  manipulation  a  marked  tenderness  will  be  found  at  the  seat  of 
disease.  This  point  of  acute  tenderness  is  very  characteristic.  When  the 
parts  are  swollen  by  the  approach  of  the  pus  to  the  surface  and  the  joint  is 
involved,  attention  must  be  chiefly  given  to  the  early  history  in  order  to 
exclude  rheumatism  and  periostitis. 

Case. — A  boy,  age  ten  years,  had  continued  gnawing  pain  below  knee,  moderate 
fever,  loss  of  sleep  except  under  the  influence  of  opiates ;  knee  not  swollen,  but 


DISEASES  OF  BONE.  543 

flexed.  Symptoms  had  existed  more  than  a  month,  but  had  become  more  severe 
within  a  few  days,  He  was  suffering  acutely  on  admission  from  pain  in  left  knee ; 
temperature  102°  F.  There  was  considerable  swelling  about  the  inside  of  the  upper 
end  of  the  tibia,  where  there  was  marked  tenderness.  An  incision  at  this  point 
down  to  the  bone  showed  evidences  of  inflammation,  but  no  pus.  A  small  trephine 
was  applied  to  the  bone,  which  exposed  the  cancellated  tissue  infiltrated  with  pus, 
and  very  soft,  but  no  distinct  cavity.  The  wound  was  treated  antiseptically,  but 
subsequently  the  knee  became  involved  and  required  to  be  opened,  and  carious 
bone  was  removed  from  the  head  of  the  tibia.  Persistent  use  of  antiseptic  meas- 
ures locally  and  tonic  treatment  restored  the  patient  to  health  with  a  useful  limb. 

The  TREATMENT  IS  the  evacuation  of  the  pus  by  freely  opening  the  soft 
parts ;  if  pus  is  not  found,  the  bone  should  be  penetrated  and  the  abscess 
fully  exposed.  The  cavity  should  be  freed  of  any  necrotic  bone-tissue, 
cleansed,  and  completely  disinfected.  If  the  joint  is  involved  in  the  sup- 
puration, it  must  be  sufficiently  exposed  to  remove  all  the  pus  and  be  disin- 
fected and  drained.  In  cases  which  have  set  up  osteomyelitis  the  shaft  of 
the  bone  should  be  trephined  at  such  points  as  will  evacuate  the  pus,  and  fre- 
quent cleansing  and  disinfection  should  be  practised  to  prevent  septicaemia 
and  pyaemia.  In  extreme  cases  amputation  may  be  necessary  to  save  the  life 
of  the  patient. 

Such  authorities  as  Fayrer  and  Macnamara,  according  to  Owen,  are  strong  in 
urging  amputation  and  reamputation,  and  the  less  the  delay  in  resorting  to  the  ope- 
ration the  better.  "  After  rigors  (convulsions)  and  other  symptoms,  including 
pyaemia,  have  commenced,  by  far  the  best  prospect  is  to  remove  the  whole  bone." 

G-rowing  fever  has  been  described  as  occurring  in  children  of  from  seven 
to  fifteen  years.  The  pain  is  located  at  the  epiphyseal  lines ;  there  is  rapid 
growth  and  some  fever  at  times,  with  general  disturbance.  The  symptoms 
usually  subside  without  unfavorable  results,  but  osteomyelitis  may  occur  and 
exostoses  may  form.^ 

Acute  osteomyelitis,  or  diaphysitis,  is  a  suppurative  inflammation  of  the 
marrow  of  bone.  It  is  a  very  common  and  destructive  disease  of  childhood. 
It  has  its  origin  in  the  infection  of  the  medullary  structure  of  bone  by  pus- 
microbes.  Though  all  bones  are  liable  to  be  affected,  the  disease  more  often 
appears  in  the  shafts  of  the  long  bones,  and  especially  in  the  vicinity  of  the 
epiphyseal  extremities.  This  is  due  to  the  fact  that  at  these  points  the  active 
process  of  ossification  of  the  epiphyseal  cartilage  is  in  progress,  and  the  newly 
and  as  yet  imperfectly  formed  vessels  readily  admit  the  implantation  of  the 
microbes,  floating  in  the  blood,  on  their  walls.  The  inflammation  begins 
within  these  vessels,  and  spreads  with  the  leucocytes  into  the  medullary 
tissue.  The  large  veins  become  occluded  with  thrombi  which  become  infected 
by  pus-microbes,  followed  by  liquefaction  of  the  coagulated  blood.  From  this 
condition  may  result  abscesses,  or  necrosis  from  the  interruption  of  the  cir- 
culation, or  pyaemia  from  the  entrance  of  infective  matters  into  the  general 
circulation.  The  infection  gradually  extends  to  the  periosteum,  and  suppura- 
tive periostitis  ensues,  with  separation  of  the  periosteum  from  the  bone ;  or 
the  periosteum  may  yield  and  pus  enter  the  cellular  tissue,  causing  wide- 
spread cellulitis. 

The  origin  of  the  pus-microbes  which  cause  osteomyelitis  is  often  a  sup- 
purating wound,  but  they  may  enter  the  circulation  through  the  lungs  or  the 
intestinal  canal.  A  recent  injury,  as  a  fracture,  may  furnish  all  the  con- 
ditions necessary  for  the  lodgement  of  microbes  entering  the  circulation  from 
an  existing  wound.  The  infectious  diseases  of  childhood,  as  scarlet  fever, 
measles,  diphtheria,  and  typhoid  fever,  often  furnish  the  microbes  which  in- 
duce inflammation  of  the  medulla.  These  cases  are  not  generally  pyaemic, 
for  the  patients  usually  die  of  exhaustion. 

^  Srit.  Med.  Journ.,  April  14,  1888,  p.  320. 


544  LOCAL  DISEASES. 

Case  (Owen). — An  infant,  aged  four  weeks,  was  admitted  to  hospital  on  Feb-^ 
ruary  7th.  An  acute  abscess  involved  the  lower  third  of  the  left  thigh,  and  another 
was  present  above  the  ankle  of  the  same  limb.  There  were  also  two  small  subcuta- 
neous abscesses  in  the  palm  and  little  finger  of  the  left  hand.  These  abscesses  de- 
veloped a  few  days  later,  suppuration  occurring  in  cutaneous  sores  on  the  arm.  The 
abscesses  were  opened,  flushed,  and  drained,  but  the  child  died  two  days  afterward. 
The  post-mortem  examination  showed  that  the  abscess  above  the  knee  led  to  bare 
bone  at  the  diaphyseal  surface  of  the  lower  epiphyseal  cartilage  of  the  femur,  and 
the  end  of  the  diaphysis  was  in  a  condition  of  acute  osteomyelitis.  There  was  no 
actual  cavity  in  the  bone,  and  the  knee-joint  was  not  involved.  The  abscess  above 
the  ankle  led  to  bare  bone  at  the  tibial  diaphysis,  which  was  partially  necrosed  and 
surrounded  by  a  good  deal  of  new  bone.  The  ankle-joint  was  not  involved.  There 
was  a  similar  condition  of  the  sternal  ends  of  the  third  right  and  fourth  left  ribs 
and  of  the  spinal  ends  of  the  seventh  and  eighth  ribs,  in  each  case  the  end  of  the 
rib  being  neci'osed.  There  was  also  in  this  case  purulent  meningitis  affecting  the 
convexity  of  the  brain,  but  no  other  sign  of  pyaemia  was  present.^ 

The  frequent  occurrence  of  this  disease  after  exposure  to  the  effects  of 
cold,  as  prolonged  bathing  or  lying  on  the  ground  after  vigorous  exercise,  is 
explained  by  Senn  as  probably  due  to  the  congestion  which  takes  place  at 
these  nutritive  points,  where  resistance  is  least,  and  then  the  mural  implanta- 
tion of  microbes  circulating  in  the  blood.  The  disease  may  progress  with 
great  rapidity,  with  more  or  less  violent  symptoms,  or  it  may  proceed  slowly 
and  assume  a  chronic  form. 

DiajjJii/sitis,  or  osteomyelitis  of  the  shaft  of  the  bone,  in  its  acute  form 
is  ushered  in  by  a  chill,  followed  by  fever  ;  severe  pain,  but  not  well  local- 
ized ;  tenderness  at  the  point  of  most  acute  inflammatory  action  ;  swelling  is 
a  later  sign,  attended  by  a  dusky  redness  of  the  skin  as  the  pus  approaches 
the  surface  ;  swelling  of  the  neighboring  joint  and  synovitis  complicate  the 
case  at  an  early  period.  As  swelling  may  be  a  late  symptom,  the  fever  may 
be  mistaken  for  typhoid  fever.  The  swelling  of  the  joint  often  leads  to  the 
diagnosis  of  rheumatism.  In  later  stages  it  may  be  taken  for  cellulitis^ 
periostitis,  or  ostitis.     There  is  no  one  characteristic  symptom. 

Case  (Goltdammer). — Patient  had  been  suffering  ten  days  with  fever ;  pulse  110 
to  120  ;  tympanites  ;  dry  tongue  ;  bronchitis  ;  delirium  -,  was  diagnosed  as  typhoid 
fever.  On  close  examination  a  slight  swelling  with  tenderness  was  found  over 
lower  part  of  tibia,  which  proved  to  be  osteomyelitis. 

The  DIAGNOSIS  must  be  made  on  this  line  of  inquiry.  The  chill  and 
fever  are  soon  followed  by  pain,  which  is  deep-seated,  boring,  tearing,  and 
throbbing  in  the  affected  limb.  In  a  brief  period  a  careful  examination 
reveals  at  the  epiphyseal  junction  a  tenderness,  well  localized,  which  is  the 
focus  of  the  inflammation  ;  this  tenderness  becomes  more  and  more  marked, 
until  a  swelling  appears  which  indicates  the  approach  of  pus  to  the  surface. 

The  TREATMENT  should  be  prompt  and  decisive  when  the  diagnosis  is 
satisfactorily  made  out.  It  must  be  borne  in  mind  that  the  focus  of  inflam- 
mation is  in  the  interior  of  the  bone,  and  that  the  active  cause  is  the  pus- 
microbe.  Until  that  is  removed  the  suppurating  process  will  continue  its 
destructive  work.  It  becomes  the  imperative  duty  of  the  surgeon  to  expose 
this  focus,  to  thoroughly  disinfect  the  cavity,  and,  as  far  as  possible,  the 
adjacent  structures.  When  this  operation  is  rightly  performed,  the  change 
in  all  of  the  conditions  is  very  great ;  the  pain  subsides,  the  swelling  dimin- 
ishes, the  fever  falls,  and  the  patient  secures  sleep  and  much-needed  rest. 
But  the  great  value  of  this  treatment  is  the  arrest  of  a  destructive  inflamma- 
tion which  was  liable  to  terminate  in  pyasmia,  necrosis,  suppuration  in  the 
nearest  joint,  and  possibly  in  loss  of  limb  and  even  of  life. 

1  Lancet,  May  5,  1894. 


DISEASES  OF  BONE.  545 

Case  (Pitts). — An  infant,  aged  six  weeks,  was  admitted  to  hospital  on  Jan.  5th. 
In  this  case  the  disease  followed  a  few  days  after  inflammation  and  suppuration  in 
some  cutaneous  sores.  There  was  an  acute  abscess  above  the  left  clavicle,  and 
another  above  the  left  knee.  On  opening  the  former  abscess  the  entire  diaphysis  of 
the  clavicle  came  away  as  a  sequestrum,  Avhich  lay  loose  in  the  abscess-cavity.  The 
femoral  abscess  led  to  a  cavity  in  the  region  of  the  epiphyseal  cartilage,  which  con- 
tained a  small  sequestrum.  The  knee-joint  and  shoulder-joint  were  not  involved. 
The  child  died  five  days  afterward.  The  necropsy  revealed  necrosis  of  the  acromial 
end  of  the  right  clavicle,  suppuration  in  the  acromio-clavicular  joint,  and  necrosis 
of  the  sternal  end  of  the  fourth  rib  on  the  right  side  and  of  the  spinal  end  of  the 
eighth  rib  on  the  same  side.     Subpleural  abscesses  were  found  in  each  case.^ 

There  may  be  no  guide  to  the  seat  of  the  disease  but  tenderness  on 
pressure.  At  that  point,  or  as  near  it  as  the  vessels  and  nerves  will  admit, 
an  incision  should  be  made  down  to  the  muscles ;  these  should  be  separated 
and  the  periosteum  exposed.  Usually  the  deeper  tissues  give  marked  evi- 
dence of  inflammation,  but  even  that  condition  may  not  exist,  and  on 
exposing  the  periosteum  there  may  be  no  appearance  of  disease  other  than 
congestion.  This  fact  should  not  deter  the  operator  fi-om  proceeding  to  open 
the  bone.  A  small  trephine  may  be  used,  but  a  semicircular  chisel  is  to  be 
preferred.  The  opening  is  to  be  in  the  direction  of  the  centre  of  the  bone. 
When  the  medulla  is  reached,  if  pus  has  not  formed,  the  tissues  will  be  con- 
gested and  soft,  and  blood  and  serum  will  be  discharged.  If  an  abscess 
exists,  there  will  be  a  free  flow  of  pus. 

As  the  object  of  exposing  the  cavity  is  to  remove  all  of  the  diseased 
tissue,  it  may  be  necessary  to  enlarge  the  opening,  which  should  be  in  the 
direction  of  the  axis  of  the  bone.  If  the  inflammation  involves  a  large  ex- 
tent of  bone,  it  is  better  to  make  several  openings  rather  than  a  single  one. 
When  the  cavity  is  sufficiently  exposed,  all  of  the  diseased  tissue  should  be 
removed  with  a  sharp  spoon  ;  the  cavity  should  be  irrigated  with  a  sublimate 
solution  (1  :  5000)  ;  peroxide  of  hydrogen  or  a  solution  of  chloride  of  zinc 
(10  per  cent.)  should  be  applied  to  all  the  surfaces  ;  the  cavity  should  then 
be  packed  with  strips  of  iodoform  gauze  and  the  parts  covered  with  anti- 
septic dressings.  The  limb  should  be  fixed  in  a  comfortable  position,  which 
favors  the  circulation.  The  dressings  should  be  repeated,  and  the  cavity 
cleansed  by  irrigations  with  warm  boracic-  or  carbolic-acid  solutions  or  perox- 
ide of  hydrogen.  If  the  temperature  indicates  an  extension  of  the  sup- 
purating process,  the  parts  involved  must  be  exposed  and  treated  as  indi- 
cated. If  the  operation  is  delayed  until  the  suppuration  is  extensive, 
incisions  should  be  made  at  such  points  as  will  freely  evacuate  the  pus  rather 
than  by  one  long  incision.  The  treatment  should  then  be  conducted  on  the 
lines  already  given. 

Necrosis  is  one  of  the  later  complications  of  the  severer  forms  of  osteo- 
myelitis. The  most  important  feature  in  the  treatment  is  to  maintain,  as  far 
as  possible,  an  aseptic  condition  of  the  entire  cavity,  and  not  to  attempt 
removal  of  the  dead  bone  until  it  has  become  so  far  detached  that  it  can  be 
removed  without  damage  to  the  living  bone.  Frequent  trials  with  a  probe 
may  be  made  through  the  openings  to  the  dead  bone  to  determine  whether  it 
is  loose.  If  the  involucrum  is  large,  the  granulations  may  so  enclose  the 
dead  mass  as  to  make  it  quite  difficult  to  detect  actual  separations  without 
force.  When  the  sequestrum  moves  in  its  place  on  pressure  with  the  probe, 
it  will  probably  be  found  necessary  to  enlarge  the  opening  in  the  bone 
(cloacfe)  to  make  it  possible  to  withdraw  it  from  the  involucrum.  If  this 
enlarged  opening  does  not  give  sufficient  space,  the  bridge  between  two  or 
more  cloacae  may  be  removed  with  rongeur  forceps  or  chisel,  always  in  the 
direction  of  the  shaft. 

1  Lancet,  May  5,  1894. 
35 


546  LOCAL  DISEASES. 

Necrosis  of  the  entire  diaphysis  sometimes  occurs  by  the  extension  of 
the  destructive  process.  The  management  of  these  cases  is  beset  with 
difficuhies.  The  conditions  may  be  such,  when  the  patient  is  first  seen,  as  to 
raise  the  question  of  immediate  removal  of  the  necrosed  bone  or  even  of 
amputation.  If  the  sequestrum  is  loose  and  the  patient  is  failing,  removal 
may  be  at  once  effected,  though  the  new  bone  is  imperfect.  If  it  is  not 
loose,  the  effort  must  first  be  made  to  secure  complete  evacuation  of  the  pus 
and  cleansing  and  disinfection  of  the  cavity.  Usually  improvement  follows, 
and  an  operation  may  be  delayed.  Failing  to  secure  a  better  condition, 
sequestrotomy  or  amputation  may  be  necessary  as  an  extreme  measure.  The 
former  operation  is  to  be  selected  if  there  is  an  even  chance  of  recovery,  the 
latter  being  a  last  resort. 

In  general,  two  features  in  the  treatment  are  of  great  importance— viz.  :-- 
1.  If  possible,  the  dead  bone  should  not  be  removed  until  the  involucrum  is 
sufficiently  formed  to  sustain  the  limb  ;  2.  The  epiphysis  should  be  preserved 
in  order  to  prevent  subsequent  shortening. 

The  chief  danger  to  be  apprehended  in  these  cases  is  the  exhaustion  of 
the  patient  by  septicaemia,  owing  to  the  necessary  presence  of  a  large  amount 
of  septic  matter. 

Case  (Masterman).^ — A  girl,  aged  eleven  years,  had  a  rigor  with  high  fever, 
nausea,  headache  ;  no  history  of  injury  ;  no  complaint  of  pain  in  the  limbs.  Diag- 
nosis was  an  ordinary  case  of  rigor.  On  the  second  day  there  was  fever,  vomiting, 
and  redness  along  the  right  leg.  Diagnosis  was  commencing  erysipelas.  Eight  days 
after  the  temperature  was  103°  F. ;  joints  stiff  and  painful,  especially  the  wrists  and 
elbows ;  right  leg  was  swollen,  but  redness  was  gone  :  there  was  fluctuation  over 
the  inner  surface  of  the  tibia,  extending  four  inches  up  the  leg  from  the  malleolus  ; 
the  skin  was  white,  but  not  tense.  On  incision  pus  escaped,  and  the  tibia  was  found 
bare  over  a  surface  of  two  inches.  Symptoms  became  worse,  being  marked  by  rigors 
and  sweats ;  the  joints  became  more  swollen  and  painful,  and  pyaemia  terminated 
the  life  of  the  child  on  the  seventeenth  day  from  the  attack. 

To  guard  against  this  danger,  as  free  exit  of  pus  must  be  secured  as  pos- 
sible, and  thorough  antiseptic  irrigation  of  the  entire  necrosed  surfaces  and 
the  cavity  in  which  the  dead  bone  is  encased.  At  the  same  time,  the  patient 
must  be  surrounded  with  the  best  hygienic  conditions,  and  be  sustained  by 
proper  food  and  tonic  remedies.  Should  chills  and  perspirations  indicate  a 
pyaemic  state,  the  chief  reliance  must  be  on  large  doses  of  quinine  and  alco- 
holic stimulants.  The  amount  and  kind  of  stimulants  which  are  given  must 
be  determined  by  the  conditions  in  each  case,  as  age,  severity  of  the  symp- 
toms, and  susceptibility  of  patient ;  but  it  must  be  remembered  that  children 
suffering  from  this  affection  are  remarkably  tolerant  of  alcoholic  stimulants. 
Should  the  case  progress  favorably,  the  new  bone  will  form  under  the  raised 
periosteum,  and  gradually  become  so  thick  and  firm  as  to  be  capable  of  sus- 
taining the  limb.  At  this  time  the  necrosed  shaft  is  usually  found  to  have 
separated  from  the  epiphyses  sufiiciently  to  be  removed  without  damage  to 
the  involucrum.  The  exact  time  of  separation  can  scarcely  be  approximately 
fixed.  In  general,  it  may  be  stated  that  small  bones,  as  the  phalanges,  may 
separate  in  four  or  five  weeks ;  superficial  masses  of  the  long  bones  may 
separate  in  seven  or  eight  weeks ;  while  the  entire  shaft  may  require  three 
to  six,  or  even  eight,  months. 

The  question  of  operation  must  depend  largely  upon  the  fact  that  the 
sequestrum  is  loose.  The  date  should  be  fixed  according  to  the  condition  of 
the  patient.  If  the  health  is  improving,  there  is  no  haste.  But,  having  de- 
cided to  remove  the  dead  mass,  all  necessary  antiseptic  precautions  should  be 

'  Lancet,  March  30,  1895,  p.  804. 


DISEASES  OF  BONE.  547 

taken.  The  elastic  bandage  should  be  applied  at  some  distance  above  the 
point  of  incision  after  the  limb  has  been  elevated  for  a  few  minutes. 

The  elastic  bandage  should  not  be  applied  from  the  toes  or  fingers,  as  it 
might  force  pus  beyond  the  diseased  area.  Senn  advises  applying  the  band- 
age at  a  point  above,  where  the  muscles  are  large,  in  order  to  protect  the 
nerves  from  undue  pressure,  as.  he  has  known  it  to  cause  temporary  paralysis. 

The  incision  should  be  in  one  of  the  fistulous  openings,  unless  important 
vessels  or  nerves  are  likely  to  be  involved,  and  should  be  in  the  direction 
of  the  fibres  of  the  muscles.  In  following  this  rule  great  care  should  be 
taken  to  avoid  injury  to  nerves  and  artei'ies  which  may  be  in  close  proximity 
to  sinuses,  as  the  radials  in  the  arm  and  the  popliteal  vessels  and  nerves. 
When  the  incision  reaches  the  muscles,  it  is  better  to  separate  parts  with  the 
handle  of  the  scalpel  down  to  the  bone. 

When  the  bone  is  exposed  great  care  must  be  exercised  in  enlarging  the 
opening  in  the  involucrum.  The  chisel  should  be  carefully  employed  to  en- 
large the  opening  in  the  direction  of  the  long  axis  of  the  shaft,  the  limb 
meantime  being  placed  on  a  firm  surface,  so  as  to  avoid  the  possibility  of 
breaking  the  new  bone,  which  is  very  hard  and  brittle.  When  the  cavity  in 
which  the  sequestrum  lies  is  fully  exposed,  the  shaft  should  be  gently  de- 
tached from  the  healthy  bone  at  each  end,  and  from  the  granulations  which 
enclose  it,  and  then  lifted  out  of  its  bed.  The  cavity  should  be  thoroughly 
curetted  to  remove  all  granulations,  washed  with  a  sublimate  solution  (1 :  5000), 
and  dried  with  an  antiseptic  sponge. 

The  healing  of  these  wounds  is  greatly  retarded  by  their  unyielding  walls, 
and  hence  many  efforts  have  been  made  to  facilitate  the  process.  The  most 
simple  is  that  of  Schede,  who  closed  the  soft  parts  with  sutures,  and  allowed 
the  cavity  to  fill  with  blood  ;  the  blood-clot  organized,  and  thus  the  process 
of  healing  was  greatly  promoted.  Careful  antiseptic  methods  were  employed 
in  dressing  the  wounds.  Senn  fills  the  cavity  with  decalcified  bone-chips  and 
sutures  the  periosteum  and  soft  parts  over  the  cavity. 

Senn  states  that  the  decalcified  bone-chips  are  preserved  in  an  alcoholic  solution 
of  corrosive  sublimate  (1  :  500)  or  a  solution  of  iodoform  in  sulphuric  ether.  The 
implantation  is  made  before  the  removal  of  the  constrictor,  in  order  that  after  this 
is  done  sufficient  blood  will  escape  to  fill  the  spaces  between  the  chips,  and  thus 
serve  the  useful  purpose  of  a  temporary  cement-substance.  After  the  surface  has 
been  dusted  over  lightly  with  iodoform  the  chips,  which  have  been  washed  previ- 
ously in  an  antiseptic  solution,  are  dried  upon  a  gauze  compress,  and  are  then  poured 
into  the  cavity  until  this  is  packed  with  them  as  far  as  the  periosteum.  The  peri- 
osteum is  then  sutured  over  the  surface  of  the  bone-chips. 

Chronic  circumscribed  osteomyelitis  differs  from  the  acute  form  in  the 
comparative  mildness  of  the  symptoms  and  its  slow  progress.  It  may  con- 
tinue for  a  long  period  with  no  more  marked  symptom  than  an  aching  pain  at 
night,  and  even  this  may  not  be  noticed  in  young  children.  On  this  account 
it  is  a  disease  which  is  very  liable  to  be  long  overlooked  in  cases  where  it  is 
marked  by  great  chronicity. 

In  the  progress  of  the  disease  there  is  usually  much  condensation  of  the 
bone  surrounding  the  abscess.  In  very  young  children,  however,  the  pus  may 
come  to  the  surface  with  very  little  disturbance,  or  it  may  extend  as  in  diffuse 
osteomyelitis.  Occasionally  neglected  cases  are  seen  where  feeble  children 
have  many  sinuses  leading  to  dead  bone. 

Case. — A  girl,  aged  ten  years,  received  a  blow  on  the  left  knee,  from  which  she 
seemed  to  recover ;  two  or  three  weeks  after  the  knee  and  the  lower  part  of  the 
femur  began  to  swell ;  the  pain  was  not  severe,  and  the  fever  was  slight.  At  length 
fluctuation  was  detected,  and  on  opening  the  abscess  above  the  knee  and  at  the  inner 
side  of  the  femur,  a  large  amount  of  pus  was  discharged.     The  bone  was  enlarged, 


548  LOCAL  DISEASES. 

and  the  probe  entered  a  small  sinus  leading  to  the  centre  of  the  shaft.  This  was 
enlarged,  and  a  cavity  was  found,  involving  the  epiphysis,  and  containing  a  small 
sequestrum.  A  similar  abscess  of  the  upper  extremity  of  the  left  humerus  formed 
soon  after,  and  on  opening  it  carious  bone  was  removed.    She  made  a  good  recovery. 

The  TREATMENT  whlch  Hiost  immediately  effects  relief  is  incision,  expos- 
ure of  the  bone,  and  trephining.  The  true  guide  to  the  focus  of  disease  is 
tenderness.  If  great  care  is  taken  to  make  out  this  point,  it  is  very  certain 
to  indicate  the  precise  place  for  the  incision.  There  should  be  no  hesitation 
in  exposing  the  bone  by  incision  and  in  opening  the  bone  by  trephine  or  chisel, 
for  the  failure  to  find  pus  by  no  means  renders  the  operation  useless.  Not 
infrequently  the  cancellous  tissue  is  simply  very  red,  with,  perhaps,  a  serous 
infiltration  and  a  few  drops  of  pus.  But  the  relief  is  uniformly  great,  as  the 
tension  is  removed,  and  the  inflammatory  process  is  much  relieved  and  modi- 
fied. In  many  instances  an  early  operation  prevents  the  pus  from  finding  its 
way  into  a  joint.  The  disease  does  not  always  become  located  in  the  epiph- 
ysis, but  occasionally  appears  in  the  shaft,  when  the  operation  must  be 
made  in  that  region,  the  precise  point  being  where  the  tip  of  the  finger  elicits 
evidence  of  the  most  tenderness.  The  cavity  should  always  be  thoroughly 
scraped,  disinfected,  and  drained,  and  antiseptic  dressings  employed. 

Chronic  diffuse  osteomyelitis  occurs  most  often  in  poorly-nourished  and 
scrofulous  children,  and  is  caused  by  injuries,  colds,  and  infective  matters 
from  suppurating  foci.  The  exact  point  of  commencement  is  not  always 
apparent,  but  the  first  evidences  of  trouble  appear  usually  at  the  epiphysis, 
unless  the  disease  results  from  periostitis.  It  may,  however,  be  met  with  in 
the  jaw,  ribs,  pelvis,  and  other  bones  when  there  is  a  tubercular  condition. 

The  SYMPTOMS  are  frequently  very  obscure  and  the  actual  evidence  of 
disease  of  the  bone  is  limited  to  pain  in  the  part  at  irregular  intervals.  But 
at  length  swelling  of  the  tissues  at  the  seat  of  pain,  and,  finally,  the  escape  of 
pus  and  the  formation  of  sinuses  leading  to  bone,  prove  the  existence  of  dif- 
fuse osteomyelitis.  The  destruction  of  bone  may  be  very  great,  involving 
sometimes  the  separation  of  an  epiphysis  or  necrosis  of  the  shaft,  or  even  of 
both.     The  joints  may  become  involved,  with  the  formation  of  pus. 

The  PROGRESS  of  the  case  is  very  slow,  and  the  sequestra  are  frequently 
surrounded  with  soft  and  imperfectly-formed  new  bone.  Attempts  to  remove 
sequestra  by  opening  the  new  bone  may  result  in  breaking  it  up,  when  there 
is  likely  to  be  a  tedious  effort  at  repair.  Even  when  the  new  bone  appears 
to  be  firm  the  disease  extends  in  spite  of  operations  for  the  evacuation  of 
pus,  the  cleaning  out  of  sinuses  and  abscesses,  and  the  removal  of  sequestra. 

Case. — A  boy,  aged  five  years,  fell,  striking  on  the  left  elbow.  The  bruise  was 
soon  recovered  from,  but  in  a  month  following  there  were  pain  and  SAvelling  of  the 
injured  elbow,  extending  to  the  upper  part  of  the  arm.  It  was  tense,  and  fluctua- 
tion was  detected  above  the  joint  on  the  inner  side ;  a  puncture  evacuated  a 
quantity  of  pus.  The  bone  was  uncovered  for  a  distance  of  three  inches.  The 
child  was  in  feeble  condition,  but  still  able  to  run  about  and  play.  The  arm  seemed 
to  improve  for  a  time,  but  subsequently  the  elbow-joint  became  involved  ;  pus  was 
discharged  through  an  incision,  but  there  was  no  destruction  of  cartilage.  After  a 
period  of  apparent  recovery  the  arm  again  became  swollen,  with  pain  and  fever. 
Deep-seated  fluctuation  was  detected,  and  on  incision  a  large  amount  of  pus 
escaped.  The  shaft  of  the  bone  was  uncovered,  the  periosteum  was  greatly  thick- 
ened, and  there  were  evidences  of  the  formation  of  new  bone.  After  a  period  of 
four  months  the  central  portion  of  the  shaft  separated  and  was  removed.  The  child 
recovered,  with  a  much  enlarged  humerus. 

This  form  of  osteomyelitis  may  result  in  sclerosis  of  the  bone,  with  ob- 
literation of  much  of  the  medulla  and  general  enlargement  of  the  shaft.  At 
points  along  the  shaft  there  may  be  necrosis  of  small  masses,  enclosed  by 


DISEASES  OF  BONE.  549 

the  new  bone.  Again,  the  inflammation  may  be  a  rarefying  process,  tlie  bone 
becoming  enlarged,  soft,  and  filled  witb  granulations.  With  careful  treat- 
ment the  patient  may  recover  and  regain  a  useful  limb.  In  a  large  number 
of  these  cases  the  tubercular  condition  is  recognized. 

The  TREATMENT  of  this  disease  should  always  be  very  conservative,  for 
recoveries  take  place  under  the  most  unfavorable  conditions.  It  must  always 
be  borne  in  mind  that  these  patients  are  probably  tuberculous,  and  are  cer- 
tainly feebly  constituted.  Every  necessary  means  should,  therefore,  be 
employed  to  improve  the  general  health.  The  local  treatment  is  to  be  con- 
ducted on  the  same  principles  as  that  already  given.  If  there  are  signs  of 
the  formation  of  pus,  incisions  miist  be  made,  and,  if  necessary,  the  bone 
must  be  opened  and  all  cavities  scraped  and  disinfected.  All  necrotic  tis- 
su^es  must  be  removed,  however  extensive  may  be  the  operation.  In  tuber- 
culous cases  the  exposed  cavities  must  be  thoroughly  curetted. 

Tuberculosis  of  Bone. — Children  recognized  as  scrofulous  or  strumous  are 
very  liable  to  develop  tuberculosis  of  bone.  It  has  been  known  in  its  various 
forms  as  abscess,  osteomyelitis,  spina  ventosa,  hip  disease,  spinal  caries,  etc. 
The  disease  results  from  the  escape  of  the  tubercle  bacilli  from  lymphatic 
glands  or  the  lungs,  where  they  have  already  formed  foci,  into  the  general 
circulation,  and  their  lodgement  in  the  tissues  of  the  bone.  It  is  not.  there- 
fore, a  primary  disease  in  the  individual,  but  is  due  to  the  emigration  of 
the  microbe,  already  fixed  in  other  and  more  favored  situations,  to  the  osseous 
structures.  The  process  of  infection  is  as  follows :  The  bacillus  of  this 
afi'ected  tissue  enters  the  circulation,  and  is  arrested  in  a  minute  artery,  where 
it  becomes  attached  to  the  wall ;  a  thrombus  now  forms  around  it,  which 
finally  completely  obstructs  the  vessel ;  a  focus  of  infection  is  thus  created 
and  a  pathological  process  commenced.  This  results  in  decalcification 
or  osteoporosis,  while  the  disease  continues.  It  may  terminate  by  progres- 
sive invasion  of  healthy  tissues,  or  osteosclerosis  of  the  surrounding  bone 
may  occur  as  the  process  subsides,  and  thus  the  focus  will  be  eifectuall}'  en- 
closed. 

The  localization  of  the  tubercle  bacilli  is  at  the  centre  of  active  growth, 
and  hence  they  are  found  in  the  medullary  tissue  of  the  cancellated  struc- 
tures in  the  vicinity  of  the  epiphyseal  cartilages.  The  newly-formed  vessels 
are  imperfect  and  irregular,  and  furnish  conditions  favorable  for  intercepting 
any  particle  floating  in  the  current  of  blood.  Tubercle  is  therefore  most 
often  found  in  the  vertebrae,  the  carpal  and  tarsal  bones,  and  the  epiphyseal 
extremities  of  the  long  bones.  It  is  rare  that  there  is  a  single  focus;  fre- 
quently two  or  more  appear  in  the  same  part,  and  occasionally  the  opposite 
limb  becomes  involved. 

The  granulation  process  set  up  in  the  infected  part  is  not  unlike  that  in 
the  glands,  and  may  terminate  in  caseation  and  subsequent  liquefaction,  or 
suppuration  owing  to  the  presence  of  pathogenic  germs.  Konig  recognizes 
four  principal  groups:  1.  The  granulating  focus;  2.  The  tubercular  necro- 
sis ;  3.  The  tuberculous  infarct ;  4.  Diffuse  tuberculous  osteomyelitis. 

1.  The  granulating  focus  exists  as  a  small  cavity  the  size  of  a  pea  or  a 
hazelnut,  and  may  contain  living  embryonal  tissues,  or  this  may  have  been 
destroyed  by  necrosis  and  caseation,  and  the  cavity  contain  cheesy  material  or 
tuberculous  pus. 

2.  If  the  infected  area  is  of  considerable  size  or  larger  than  a  hazelnut, 
the  vessels  surrounding  it  become  obstructed  and  necrosis  of  bone  results. 
In  this  case  a  sequestrum  will  be  found  in  the  cavity,  the  size,  color,  and 
porosity  of  which  will  depend  upon  the  rapidity  of  the  inflammatory  changes. 

3.  The  tuberculous  infarct  is  a  wedge-shaped  sequestrum,  due  to  the 
formation  of  an    embolism    containing;    tubercle   bacilli   in   a   branch  of  the 


550  LOCAL  DISEASES. 

nutrient  artery.     The  base  of  this  necrosed  bone  may  involve  a  joint,  and 
may  escape  detection. 

4.  The  diifuse  form  of  tuberculous  osteomyelitis  is  a  rapidly-spreading 
inflammation  of  bone  characterized  by  the  presence  of  the  tubercle  bacilli. 
It  closely  resembles  acute  suppurative  osteomyelitis,  and  is  liable  to  prove 
fatal  by  the  exhaustion  which  it  produces. 

The  DIAGNOSIS  of  tuberculosis  of  bone  is  frequently  very  difficult,  as  the 
general  symptoms  often  do  not  indicate  the  extent,  or  even  the  presence,  of 
the  disease.  An  apparent  condition  of  health  is  not  incompatible  with  ex- 
tensive osteo-tuberculosis.  But  Senn  states  that  "  in  95  out  of  every  100  cases 
chronic  inflammation  in  bone  means  tuberculosis."  The  earliest  symptom 
which  may  readily  be  recognized  is  a  daily  rise  of  evening  temperature, 
even  if  not  more  than  half  a  degree,  continuing  for  weeks.  Careful  search 
should  be  made,  in  a  suspicious  case  having  this  symptom,  for  tubercular  dis- 
ease of  bone.  A  second  important  symptom  is  progressive  anaemia.  Pain, 
though  a  constant  symptom,  is  very  variable  in  intensity,  depending  chiefly 
upon  the  severity  of  the  inflammation.  Its  value  must  be  estimated  in  each 
individual  case.  Tenderness  at  the  point  of  infection  is  always  present,  and 
when  carefully  tested  is  reliable  in  localizing  the  focus  of  disease.  Swelling- 
does  not  appear  until  the  pressure  of  the  contents  of  the  cavity  begins  to 
afi"ect  the  external  wall,  as  in  spina  ventosa,  or  in  the  progress  of  the  disease 
the  walls  have  been  perforated,  when  a  soft  semi-fluctuating  swelling  is 
found.  A  dusky  redness  of  the  skin  now  marks  the  focus  of  disease,  and  at 
length  the  skin  yields  to  the  pressure,  an  irregular  opening  forms,  and  the 
contents  of  the  abscess  escape.  The  limb  undergoes  marked  atrophy  as  the 
disease  progresses. 

The  differential  diagnosis  depends  upon  the  discovery  of  the  tubercle 
bacilli.  The  focus  can  be  explored,  for  the  purpose  of  extracting  its  con- 
tents, with  a  needle  or  with  a  hypodermic  syringe,  as  the  bone  is  quite  soft. 
The  needle  should  be  inserted  with  a  rotary  motion.  It  will  also  determine 
the  density  of  bone  and  the  size  of  the  abscess-cavity,  besides  withdrawing 
its  contents. 

The  PROGNOSIS  depends  upon  the  location  of  the  infected  part,  the  prog- 
ress of  the  disease,  and  the  condition  of  the  patient.  In  general,  the  prog- 
nosis is  good  when  the  focus  of  disease  is  accessible,  the  progress  slow,  and 
the  patient  is  in  fair  health.  It  may  be  possible  to  remove  the  infectious 
material,  and  by  a  change  of  climate  restore  the  general  health  of  the 
patient.  If,  however,  the  diseased  focus  is  inaccessible,  the  prognosis  is 
more  doubtful,  and  the  danger  is  increased  if  pus-microbes  gain  access  to  the 
abscess.  It  must  be  remembered  that  a  child  who  has  once  suffered  from 
tuberculosis  of  bone  is  liable  to  future  attacks. 

The  TREATMENT  is  general  and  local.  It  is  of  the  first  importance  to  im- 
prove the  health  of  the  child  by  suitable  medicines,  as  iron,  quinine,  phos- 
phorus, arsenic,  strychnine,  and  cod-liver  oil,  and  hygienic  measures,  as  pure 
air,  nutritious  food,  and  bathing.  Removal  of  the  patient  to  the  mountains 
or  seashore  at  proper  seasons  of  the  year  has  a  most  marked  influence  on  the 
progress  of  the  disease,  especially  if  the  child  is  a  resident  of  the  city.  The 
local  treatment  depends  upon  the  stage  of  the  disease  and  the  accessibility 
of  the  part  affected. 

The  local  treatment  should  first  consist  in  the  removal  of  all  sources  of 
irritation  and  in  securing  complete  rest  of  the  tissues  involved.  The  immo- 
bilization of  a  limb,  its  elevation  and  rest,  and  the  removal  of  pressure,  are 
the  immediate  measures  requiring  attention.  Destruction  of  the  tuber- 
cular infection  at  the  focus  of  disease  should  be  attempted  as  early  as  possi- 
ble.   In  this  procedure  every  necessary  antiseptic  precaution  should  be  taken 


DISEASES  OF  BONE.  551 

to  prevent  the  entrance  of  pus-microbes  into  the  cavity,  for  the  violent  in- 
flammation which  they  excite  has  hitherto  proved  a  most  dangerous  incident 
in  the  progress  of  the  case.  Two  methods  are  recommended  :  Ignipuncture  ^ 
consists  in  the  insertion  of  the  needle-point  of  a  Paquelin  cautery  heated  to 
a  dull-red  heat.  It  should  penetrate  slowly,  being  frequently  withdrawn  and 
heated  again.  When  it  enters  the  cavity,  the  resistance  suddenly  diminishes. 
The  results  obtained  are — free  drainage  of  the  cavity,  the  destruction  of 
some  portion  of  its  contents,  and  the  excitement  of  a  plastic  inflammation 
which  tends  to  limit  the  infection.  Through  the  track  of  the  needle  iodo- 
form solutions  may  be  applied  to  the  focus  of  disease.  This  treatment  is 
adapted  to  foci  in  the  epiphyses  of  long  bones  and  in  the  carpus  and  tarsus. 
Pain  is  usually  relieved  and  a  healthy  process  of  cicatrization  established. 
But  the  removal  of  the  tuberculous  collection  by  incision  is  the  most  effective 
method  of  relief.  This  consists  in  exposing  the  cavity  by  dissection,  perfora- 
tion of  the  bone  by  chisel  or  trephine,  removing  the  contents,  and  curetting 
the  walls.  This  operation  is  most  successful  when  performed  early  and 
before  caseation  has  occurred.  The  limb  should  be  rendered  bloodless  by  the 
elastic  bandage,  that  the  cavity  may  be  thoroughly  examined.  Care  should 
be  taken  to  discover  every  possible  collection  of  tubercle,  explorations  being 
made  for  any  foci  adjacent  by  means  of  a  perforator,  and  the  search  should 
not  cease  until  healthy  bone  is  reached.  In  some  instances  it  may  be  well  to 
use  the  point  of  the  cautery  in  doubtful  places  to  destroy  any  infective 
material  and  excite  healthy  reparative  action. 

The  dressing  consists  in  thoroughly  cleansing  the  cavity  with  an  anti- 
septic solution  and  packing  it  with  iodoform  gauze.  Senn  '^  advises  to  pack 
the  cavity  with  decalcified  bone-chips  and  to  suture  the  periosteum  over  it, 
draining  with  a  few  threads  of  catgut.  This  treatment  he  regards  as  import- 
ant in  the  prevention  of  a  local  recurrence  and  general  infection. 

He  states  that  "  if  all  the  infected  tissues  have  been  removed,  and  no  infection 
with  pus-microbes  has  taken  place  during  or  after  the  operation,  the  wound  unites 
under  one  dressing  in  from  one  to  two  weeks,  and  the  definitive  healing  of  the 
cavity  is  completed  in  the  course  of  three  to  six  weeks,  according  to  the  condition 
and  age  of  the  patient  and  the  size  of  the  cavity."  Should  suppuration  follow,  a 
secondary  implantation  can  be  made,  when  the  cavity  is  made  thoroughly  aseptic. 

it  sometimes  becomes  necessary  to  remove  portions  of  the  shaft  of  long 
bones,  and  when  the  carpus  and  tarsus  are  involved  entire  bones  may  require 
extirpation.  In  extensive  osteomyelitis  amputation  may  be  the  only  suc- 
cessful method  of  saving  the  patient. 

Acute  suppurative  arthritis  ^  is  now  recognized  as  a  not  infrequent  disease 
of  very  early  infancy.  It  has  its  origin  generally  in  the  epiphyses  of  the 
long  bones  and  penetrates  rapidly  into  the  joint,  destroying  the  cancellated 
structure  of  the  bone,  and  perforating  the  joint  surface.  It  may  follow  an 
injury  or  an  exanthem,  but  the  exciting  cause  is  often  unknown.  "Wright 
has  seen  a  case  which  gave  some  evidence  that  the  onset  of  the  disease  oc- 
curred in  utero.  The  age  of  the  child  is  quite  characteristic.  Though  the 
disease  may  appear  in  older  children,  by  far  the  lai'ger  number  affected  are 
under  two  years  of  age.  The  joint  swells  rapidly,  and  this  swelling  may 
involve  the  entire  limb ;  other  joints  sometimes  swell,  and  for  a  time  it  may 
be  impossible  to  determine  the  final  location  of  the  disease ;  one  joint,  how- 
ever, soon  beconies  chiefly  involved  and  the  swelling  subsides  in  the  other 
joints.  The  hip  is,  perhaps,  more  frequently  affected  than  the  knee,  but  it  is 
more  often  distinctly  recognized  in  the  latter  joint. 

^  Eichet.  ^  Principles  of  Surgery. 

^T.  Smith,  Brit.  Med.  Journ.,  Jan.,  1885. 


552  LOCAL  DISEASES. 

The  TREATMENT  consists  in  the  prompt  evacuation  of  the  pus  by  incision 
and  drainage.  The  first  operation  should  be  searching,  and  such  incisions 
should  be  made  as  will  not  only  drain  the  abscess  at  the  time,  but  will  enable 
the  remotest  recesses  to  be  cleansed  and  disinfected  at  every  dressing.  It 
may  happen  that  necrotic  bone  will  be  found,  and  in  that  case  all  such 
materials  must  be  removed,  but  with  great  care  in  order  to  avoid  the  injury 
of  livina;  bone. 


CHAPTER   V. 

DISEASES  OF  THE  JOINTS. 

The  diseases  of  the  joints  of  children  diflfer  from  the  same  diseases  in 
adults  only  in  certain  peculiarities  depending  chiefly  upon  differences  in  the 
maturity  of  the  tissues  involved.  In  the  child  the  immature  epiphyses  of 
the  long  bones,  the  succulent  cartilages  and  synovial  membranes  of  the  joints, 
afford  all  the  conditions  most  favorable  for  the  development  of  inflammatory 
affections.  Injuries  give  rise  to  congestions  over  larger  areas,  and  the  vessels 
of  these  tissues  become  thereby  enfeebled.  These  conditions  favor  the 
lodgement  of  infective  particles  in  the  circulation,  and  thus  centres  of  sup- 
puration are  more  readily  established.  The  tubercle  bacilli  from  existing 
foci  become  implanted  on  the  walls  of  the  large  and  congested  vessels  and 
set  up  active  disease.  Even  in  the  absence  of  traumatism  the  growing  tis- 
sues of  the  joint  are  supplied  with  new-formed .  vessels  which  are  extremely 
liable  to  intercept  the  tubercle  bacilli.  Tuberculosis  of  the  joints,  whether 
as  a  primary  or  secondary  disease,  is  therefore  far  more  frequent  in  children 
than  in  adults,  and  constitutes  the  prevailing  form  of  joint  diseases  in  the 
young.  The  liability  of  the  epiphyses,  as  well  as  the  joints  themselves,  to 
be  the  original  centres  of  diseased  action  renders  the  exact  diagnosis  of  joint 
affections  more  difiicult  in  children  than  in  adults. 

Acute  serous  synovitis  in  the  child,  except  when  due  to  injury  or  rheu- 
matism, is  a  comparatively  rare  affection.  The  part  swells  quickly  ;  effusion 
follows  ;  the  pain  is  severe  and  the  fever  high.  The  acute  symptoms  are  not 
as  readily  subdued  as  in  the  adult,  and  suppuration  is  vei'y  liable  to  super- 
*  vene,  with  ulceration  of  cartilages  and  destruction  of  the  soft  structures.  In 
very  mild  cases  dropsical  effusions  may  distend  the  joint  and  require  treat- 
ment. 

The  treatment  of  the  early  stages  should  be  absolute  rest  of  the  limb  in 
a  comfortable  position,  which  will  be  semiflexed.  The  limb  is  best  sup- 
ported on  an  angular  splint,  but  in  its  absence  it  may  be  flexed  over  a  firm 
pillow.  It  is  also  useful  to  attach  a  weight  of  one  to  three  pounds  to  the 
foot  in  the  manner  usually  employed  in  fractures,  which  relieves  pain  by 
slightly  separating  the  joint  surfaces.  Cold  applications  in  the  form  of  an 
ice-poultice  or  an  ice-bag  are  very  important,  but  they  must  be  continued 
without  any  intermission.  The  first  effect  of  the  cold  is  often  painful,  but 
when  the  cold  penetrates  the  joint  the  pain  subsides.  The  effect  of  the  cold 
should  be  carefully  watched,  and  if  the  pain  continues,  and  especially  if  it  is 
increased  by  the  cold,  the  application  should  be  removed.  Evaporating 
lotions  may  be  substituted.  When  the  inflammation  subsides  efforts  should 
be  made  persistently  to  restore  the  functions  of  the  joints  if  they  have  been 
impaired.     Passive  motion,  after  the  application  of  cloths  wrung  out  of  hot 


DISEASES  OF  THE  JOINTS.  553 

water,  is  most  useful.     If  fluid  accumulates  passively  in  the  joint,  small  and 
repeated  blisters,  with  compression,  is  the  best  treatment. 

Acute  suppurative  synovitis  is  marked  by  a  higher  grade  of  severe 
symptoms.  The  pain  is  greater,  the  fever  higher,  and  the  patient  shows 
marked  loss  of  flesh.  When  the  evidences  of  the  presence  of  pus  are  recog- 
nized, incisions  for  its  evacuation  should  be  promptly  made.  Before  the 
period  of  antisepsis  such  incisions  were  delayed  until  the  purulent  collection 
so  distended  the  soft  tissues  as  to  threaten  spontaneous  opening.  In  such 
cases  the  infiltration  of  tissues  was  very  great,  and  often  destructive.  With 
the  proper  employment  of  antiseptic  preparations  not  only  no  harm  comes  by 
the  exposure  of  the  cavity  of  the  abscess  by  incision,  but,  on  the  contrary, 
great  relief  follows,  and  frequently  the  process  of  recovery  dates  from  the 
operation.  To  accomplish  all  the  good  possible  the  pus  must  be  thoroughly 
evacuated,  and  the  joint  must  be  treated  as  an  abscess-cavity — viz.  disinfec- 
tion must  be  thorough,  the  removal  of  necrotic  tissues  carefully  efi"ected,  the 
drainage  complete,  and  antiseptic  dressings  properly  applied.  The  subse- 
quent treatment  must  be  governed  by  the  developments  as  they  occur  in  the 
progress  of  the  case. 

Case. — A  boy,  ao;ed  one  year,  has  suffered  five  weeks  from  tenderness,  pain,  and, 
finally,  swelling  of  left  hip  ;  has  emaciated  rapidly ;  all  movements  of  left  thigh 
cause  screaming.  Child  fell  from  arms  of  nurse  a  few  days  before  first  symptoms. 
Fluctuation  was  apparent,  and  an  exploratory  operation  was  performed,  evacuating 
a  large  amount  of  pus.  The  head  of  the  femur  was  found  separated  and  was  re- 
moved, with  much  broken-down  bone-structure.  The  cavity  was  cleared  of  all 
diseased  tissues  and  well  drained.  Improvement  followed,  and  the  child  eventually 
recovered  with  a  fairly  good  limb,  but  with  some  shortening. 

The  tubercular  affections  of  the  joints  of  children  are  usually  of  a  chronic 
character.  They  are  recognized  under  several  titles,  as  chronic  or  fungous 
arthritis,  strumous  arthritis,  and  tumor  albus. 

The  disease  may  begin  in  the  synovial  membrane  or  in  the  extremity  of 
the  bone  entering  into  the  joint.  When  the^infection  locates  in  the  synovial 
membrane  the  tubercle  bacilli  are  derived  from  the  circulation.  Several 
varieties  of  tubercular  synovitis  have  been  described,  but  clinically  two  are 
noticeable.  The  tubercle-nodule  first  appears  in  the  synovial  membrane 
and  spreads  over  that  structure ;  as  granulation  progresses  one  of  two  pecu- 
liarities will  be  noticeable  in  this  fungous  synovitis:  1,  the  membrane  may 
hecome  pulpy  throughout  without  eff"usion,  giving  the  true  tumor  cdhus,  or 
white  swelling,  with  its  characteristic  deformity  of  the  joint,  and  later  back- 
ward and  outward  dislocation  of  the  tibia  ;  2,  or  there  may  be  an  efi"usion  into 
the  joint  without  deformity,  and  suppuration  may  follow,  terminating  in 
destruction  of  the  granulations  and  perforations  of  the  capsules.  In  the 
primary  osteal  form  the  joint  becomes  involved  by  the  extension  of  the  dis- 
ease through  the  epiphysis.  The  disease  may  therefore  progress  for  a 
considerable  period  without  any  unusual  symptoms  at  the  joint. 

The  CAUSE  of  the  disease  in  the  vast  majority  of  cases  is  some  form  of 
injury,  often  very  slight,  for  severe  injuries  protect  the  joint  by  the  severe 
inflammation  which  follows. 

The  DIAGNOSIS  between  a  primary  osteal  and  a  primary  synovial  tuber- 
culosis of  the  joint  is  often  difficult.  The  former  is  four  times  as  frequent 
as  the  latter  at  the  knee,  hip,  and  elbow.  The  most  reliable  symptom  of 
osteal  tuberculosis  is  the  presence  of  tender  points  beyond  the  joint.  If  the 
disease  is  synovial,  the  symptoms  depend  upon  the  form  of  inflammation. 
If  it  is  plastic  and  without  effusion  (^caries  sicca),  the  progress  is  slow,  and  is 
detected  by  the  pain,  gradual  stiffening  of  the  joint,  and  slight  roughness  of 
the  joint-surfaces.     Or  there  may  be  effusion  into  the  joint,  which  then  be- 


554  LOCAL  DISEASES. 

comes  gradually  distended,  with  distinct  fluctuation.  Finally,  the  granula- 
tions may  become  of  lai'ge  size,  so  as  to  distend  the  joint  like  an  effusion, 
and  may  involve  the  tissues  around  the  joint  until  it  assumes  a  spindle  shape, 
while  the  skin  becomes  dense  and  white,  foi'ming  the  true  white  swelling. 
The  seeming  fluctuation  is  deceptive,  as  will  appear  on  using  a  hypodermic 
needle.  Pain  is  variable  and  not  reliable.  Deformity  occurs  only  when  the 
tissues  of  the  joint  are  weakened  or  destroyed. 

The  PROGNOSIS  of  joint  tuberculosis  is  favorable.  Its  curability  depends 
upon  the  intensity  of  the  infection  and  the  resistance  of  the  patient.  It 
may  terminate  in  recovery  where  the  infection  is  limited  and  the  patient  is  in 
good  condition,  but  the  joint  is  liable  to  be  impaired  in  motion.  The  other 
forms  are  amenable  to,  and  largely  curable  by,  surgical  treatment. 

The  TREATMENT  of  tuberculosis  of  the  joints,  when  undertaken  at  an 
early  period,  should  consist  in  immobilizing  the  part  and  improvement  of  the 
general  health.  Plaster  of  Paris  is  for  most  joints  a  useful  appliance,  and 
the  limb  should  be  fixed  in  such  position  as  will  render  it  most  serviceable 
should  ankylosis  occur.  If  the  joint  is  distended  with  fluid,  antiseptic 
aspiration  should  be  performed,  followed  by  pressure,  to  prevent  a  return  of 
the  efi'usion.  Injections  of  iodoform  have  been  successfully  vised  in  the  form 
of  an  ethereal  solution,  1  part  to  20;  or  in  glycerin  and  alcohol;  or  in 
glycerin,  water,  and  mucilage  of  gum  arabic,  making  a  10  per  cent,  solution. 
If  the  disease  afi'ects  only  the  synovial  membrane,  and  not  the  bone,  excision 
of  the  diseased  structures  (arthrectomy)  is  the  proper  method  of  radical 
treatment.  The  opening  of  the  joint  must  be  by  an  incision  which  com- 
pletely exposes  every  part  and  recess.  If  the  bone  is  involved,  the  operation 
must  extend  to  the  curetting  of  all  the  foci  in  the  joint-surfaces  of  the 
bones,  and,  if  necessary,  to  a  removal  with  the  saw  of  the  articular  ends  of 
the  bones.  In  all  these  operations  every  particle  of  tuberculous  material 
must  be  scrupulously  removed. 

The-  Shoulder-joint. 

The  shoulder-Joint  is  liable  to  inflammation  from  injury,  or  the  extension 
of  the  disease  from  neighboring  parts,  or  tuberculosis.  It  may  become  sec- 
ondarily aff"ected  when  other  joints  are  involved  or  after  exanthems. 

The  simple  acute  form  of  inflammation  is  extremely  rare.  The  shoulder 
rapidly  enlarges,  forming  on  the  anterior  part  a  globular  tumor,  painful  on 
pressure  or  when  the  arm  is  moved.  The  temperature  is  not  high  if  the 
shoulder  only  is  involved. 

The  TREATMENT  must  consist  in  supporting  the  arm  in  a  sling  so  adjusted 
as  to  secure  quiet  to  the  joint,  without  pressure  of  the  joint-surfaces  together 
or  dragging.  Evaporating  lotions  are  the  most  useful  as  well  as  convenient 
applications.  The  inflammation  usually  subsides  within  a  few  days,  and 
leaves  no  other  complications  than  a  stiff"ness  which  is  soon  overcome. 

The  tubercular  form  of  inflammation  of  the  shoulder-joint  in  children  is 
also  rarely  met  with.  It  may  first  appear  as  a  synovitis,  but  often  the  bone 
is  primarily  aff"ected.  It  progresses  as  a  chronic  disease  usually,  but  tends  to 
ultimate  suppuration  and  the  formation  of  sinuses,  through  which  dead  bone 
can  be  detected. 

The  early  treatment  consists  in  placing  the  joint  at  perfect  rest.  If 
pus  forms,  evacuation,  by  free  incision  and  the  removal  of  dead  bone,  must  be 
promptly  effected.  The  cavity  should  be  curetted  and  all  diseased  structures 
cut  away.  If  the  head  of  the  humerus  is  seriously  involved,  excision  may 
be  necessary.  The  general  health  must  be  sustained  by  improving  the  sur- 
roundings of  the  patient  and  the  judicious  employment  of  tonics. 


DISEASES   OF  THE  JOINTS.  555 

Case. — A  girl,  aged  three  years,  began  to  show  symptoms  of  disease  of  the  left 
shoulder-joint.  At  first  there  were  only  stiffness  and  pain  on  moving  the  arm,  espe- 
cially forward  over  the  chest ;  her  general  health  was  impaired  :  at  times  there  was 
some  fever.  The  arm  was  fixed  by  a  pasteboard  splint  applied  to  the  flexed  elbow 
and  held  in  position  by  a  sling.  Oleate  of  mercury  was  applied.  At  the  end  of 
four  months  fluctuation  was  discovered  at  the  inner  edge  of  the  insertion  of  the 
deltoid,  and  on  opening  the  swelling  curdy  material  was  discharged.  On  explora- 
tion the  probe  passed  upward  to  the  joint,  but  no  bare  bone  was  detected.  After 
several  weeks  of  treatment  the  joint  was  laid  open  and  the  head  of  the  humerus  was 
found  partially  destroyed.  The  bone  was  excised  at  the  anatomical  neck,  after  which 
recovery  progressed  favorably.  The  subsequent  history  of  the  child  showed  a  resto- 
ration of  most  of  the  functions  of  the  arm. 

The  Elbow-joint. 

The  elhoio-joint  is  liable  to  the  same  forms  of  inflammation  as  the  shoulder, 
but,  being  of  more  complicated  structure,  the  results  are  liable  to  be  crippling 
to  the  functions  of  the  forearm.  Synovitis  may  result  from  the  ordinary 
causes  which  produce  it  in  other  joints,  and  should  be  treated  by  rest  in  the 
semiflexed  position,  the  part  being  supported  by  a  well-padded  pasteboard 
angular  splint. 

If  the  afi"ection  of  the  joint  assumes  the  chronic  form,  the  original  focus 
of  inflammation  was  probably  located  in  one  of  the  condyles  of  the  humerus. 
The  limb  becomes  fixed  in  a  flexed  position,  and  the  tissues  infiltrated.  The 
enlargement  of  the  joint  assumes  a  spindle  shape,  finally  fluctuates,  and  on 
opening  the  abscess  pus,  mixed  with  curdy,  cheesy  masses,  is  discharged.  The 
cartilage  is  often  found  removed  and  the  bones  carious. 

If  the  case  comes  under  treatment  in  the  early  stage  of  the  disease,  the 
joint  must  be  fixed  in  a  flexed  position  by  an  angular  splint.  Local  appli- 
cations are  of  little  service.  Tonics,  nourishing  food,  and  good  air  are  of  im- 
portance with  reference  to  the  final  results.  When  the  presence  of  pus  is 
determined  operative  interference  is  imperative.  Incision  should  be  made  at 
the  point  of  fluctuation,  and  then  the  joint  should  be  thoroughly  explored. 
It  is  often  possible,  by  careful  exploration  through  longitudinal  incisions  on 
the  external  and  internal  aspects  of  the  joint,  so  to  remove  diseased  tissues 
and  to  curette  carious  bone-surfaces  as  to  leave  the  joint  free  from  diseased 
structures,  and  in  a  condition  for  recovery  with  a  comparatively  useful  joint. 
If,  however,  the  disease  of  the  bones  of  the  joint  involves  the  epiphyses,  ex- 
cision must  be  practised.  The  lateral  incisions  are  the  best  adapted  to  pre- 
serve the  soft  structures  of  the  joint  from  impairment.  In  the  enucleation 
of  the  diseased  bone  the  periosteum  should  be  preserved.  Frequently  this 
membrane  will  be  found  very  dense  and  easily  separated  from  the  bone. 
While  it  is  important  to  remove  all  of  the  necrotic  bone,  care  should  be  taken 
not  to  sacriflce  any  more  of  the  joint  extremities  than  is  absolutely  necessary. 
At  as  early  a  period  as  possible  passive  motion  should  be  commenced  in  order 
to  recover  as  much  flexion  as  possible. 

Case. — A  boy,  aged  four  years,  injured  the  right  elbow-joint  by  a  fall  six  months 
previously.  There  was  moderate  swelling,  which  soon  subsided.  On  being  lifted 
by  the  right  hand  he  complained  of  pain  ;  the  joint  became  tender  :  swelling  slowly 
increased.  When  first  seen  the  elbow  was  largely  swollen,  very  sensitive  on  slight 
movement,  and  crepitus  was  discovered.  An  incision  was  made  along  the  external 
margin  of  the  elbow,  giving  escape  to  pus  and  some  curd-like  masses.  The  external 
condyle  of  the  humerus  was  uncovered,  and  the  olecranon  was  also  involved  on  its 
joint-surface.  A  second  longitudinal  incision  over  the  internal  condyle  exposed  the 
carious  condition  of  that  bone.  The  periosteum  was  raised  and  the  joint-ends  of 
the  humerus  exposed.  A  small  portion  of  the  bone  was  removed  from  each  condyle 
with  a  fine  narrow  saw,  the  wound  cleared  of  some  fragments  of  tissue,  and  anti- 
septically  dressed.  Recovery  followed  slowly,  and  by  persistent  efforts  flexion  was 
secured  to  the  extent  of  enabling  the  patient  to  feed  himself  with  that  hand. 


556 


LOCAL  DISEASES. 


The  Wrist-joint. 

The  icrist-jolnt  is  rarely  the  seat  of  simple  s3'novitis.  When  affected,  a 
well-packled  splint  should  be  applied  to  the  dorsum  of  the  forearm  and  hand, 
and  the  forearm  must  be  supported  in  a  sling  which  includes  the  hand.  Evap- 
orating lotions  seem  often  to  relieve  the  inflammation  in  some  degree,  but 
they  ai-e  troublesome  dressings  to  maintain.  By  maintaining  complete  rest 
the  inflammation  usually  subsides  slowly,  but  is  likely  to  leave  some  stiffening 
of  the  joint,  which  may  be  overcome  by  gentle  passive  motion. 

The  tubercular  form  of  disease  is  liable  to  be  serious,  as  the  inflammation 
often  involves  the  carpal  joints.  The  swelling  occurs  slowly,  and  is  not  as 
strictly  limited  to  the  wrist-joint  as  synovitis ;  it  finally  assumes  a  baggy  or 
cedematous  condition,  often  involving  the  entire  carpal  region.  Finally,  rough- 
ness of  the  wrist-joint,  and  perhaps  of  some  of  the  neighboring  carpal  joints, 
is  detected,  showing  a  disorganization  of  the  joint-structures.  Complete  rest 
to  the  wrist  and  carpus  must  be  secured  and  maintained  by  well-padded  ante- 
rior and  posterior  splints,  and  the  general  health  improved  by  tonics  and  nutri- 
tion. Pus  must  be  evacuated  by  incision  when  detected,  and  the  wound  well 
drained.  If  the  disease  involves  the  bones  of  the  wrist  or  of  the  carpus, 
excision  must  be  performed.  This  operation  should  be  performed  with  great 
care,  in  order  to  preserve  the  parts  in  such  relations  as  to  secure  a  useful 
limb,  and  still  all  of  the  tuberculous  tissues  must  be  removed.  If  the  dis- 
ease is  intelligently  treated  from  its  first  inception,  no  other  excision  may 
become  necessary  than  the  removal  of  the  joint-end  of  the  radius.  In  this 
case  the  movements  of  the  joint  may  be  very  well  preserved.  But  usually 
the  carpus  is  also  involved,  and  then  the  operation  becomes  much  more  com- 
plicated.    The  approved  methods  of  operation  are  as  follows  : 

(a)  Lister's  excision  of  the  entire  wrist  consists  of  a  series  of  operations,  each 
of  which  must  be  executed  with  scrupulous  care,  as  follows :  Break  down  adhesions 
of  tendons  by  freely  moving  all  the  articulations  of  the  hand  -,  commence  the  first 

incision    at   the   middle   of  the   dorsal 
Fig-.  168.  aspect  of  the  radius,  A  (Fig.  168),  on  a 

level  with  the  styloid  process ;  carry  it 
toward  the  inner  side  of  the  metacarpo- 
phalangeal articulation  of  the  thumb, 
running  parallel  in  this  course  to  the 
extensor  secundi  internodii ;  on  reach- 
ing the  line  of  the  radial  border  of  the 
second  metacarpal  bone  carry  it  down- 
ward longitudinally  half  the  length 
of  the  bone,  the  radial  artery  lying 
farther  to  the  outer  side  of  the  limb ; 
detach  the  soft  parts  from  the  bone  at 
the  radial  side  of  the  incision,  the  knife 
being  guided  by  the  thumb-nail ;  divide 
the  tendon  of  the  extensor  carpi  radialis 
longior  at  its  insertion  into  the  base  of 
the  second  metacarpal  bone,  and  raise 
it  along  with  that  of  the  extensor  carpi 
radialis  brevier  previously  cut  across, 
and  the  extensor  secundi  internodii, 
while  the  radial  is  thrust  somewhat  out- 
ward :  sepai'ate  the  trapezium  from  the 
rest  of  the  cai"pus  by  cutting  forceps  ap- 
plied in  the  line  with  the  longitudinal 
part  of  the  incision  ;  leaving  the  trape- 
zium in  position  until  the  rest  of  the  carpus  is  taken  away,  dissect  the  soft  parts 
on  the  ulnar  side  of  the  incision  from  the  carpus  as  far  as  convenient,  the  hand 


mm'(^'' 


Excision  of  wrist:  A,  Lister's  radial  incision; 
B,  Lister's  ulnar  incision ;  C,  Oilier ;  D, 
Boeckel. 


DISEASES  OF  THE  JOINTS.  557 

being  bent  back  to  relax  the  extensor  tendons  of  the  fingers ;  commence  the  second 
incision,  B  (Fig.  168),  on  the  palmar  surface,  at  least  two  inches  above  the  end  of 
the  ulna,  immediately  anterior  to  the  bone,  and  carry  it  downward  between  the 
bone  and  flexor  carpi  ulnaris,  and  on  in  a  straight  line  as  far  as  the  middle  of  the 
fifth  metacarpal  bone  on  its  palmar  aspect :  raise  the  dorsal  lip,  cut  the  extensor 
carpi  ulnaris  at  its  insertion  into  the  fifth  metacarpal  bone,  and  dissect  it  from 
its  groove  in  the  ulna  without  isolating  it  from  the  integuments :  separate  the 
extensors  of  the  fingers  from  the  carpus,  and  divide  the  dorsal  and  internal  lateral 
ligaments  of  the  wrist-joint ;  leave  the  connections  of  the  tendons  with  the  radius 
undisturbed  ;  now  clear  the  anterior  surface  of  the  ulna  by  cutting  toward  the  bone, 
avoiding  the  artery  and  nerve  ;  open  the  articulation  of  the  pisiform  bone,  and  sepa- 
rate the  flexor  tendons  from  the  carpus,  the  hand  being  depressed  to  relax  them  ; 
clip  through  the  base  of  the  process  of  the  unciform  bone  with  pliers,  but  avoid 
carrying  the  knife  farther  down  the  hand  than  the  bases  of  the  metacarpal  bones  ; 
divide  the  anterior  ligament  of  the  wrist-joint,  separate  the  carpus  from  the  meta- 
carpus with  cutting  pliers,  and  extract  the  carpus  with  sequestrum  forceps  through 
the  ulnar  incision,  dividing  any  ligamentous  attachments ;  the  articular  ends  of  the 
radius  and  ulna  may  be  protruded  at  the  ulnar  incision  and  excised  ;  divide  the 
ulna  obliquely  with  a  small  saw  so  as  to  take  away  the  cartilage-covered  rounded 
part  over  which  the  radius  sweeps  while  the  base  of  the  styloid  process  is  retained ; 
clear  the  radius  sufficiently  to  remove  the  articular  surface ;  if  the  caries  is  slight, 
remove  a  thin  slice  without  disturbing  the  tendons  in  their  grooves  on  the  back  of 
the  bone  ;  clip  away  the  articular  facet  of  the  ulna  with  bone  forceps  applied  longi- 
tudinally ;  if  the  caries  is  extensive,  remove  freely  all  the  diseased  bone  with  pliers 
and  gouge  ;  examine  the  metacarpal  bones  and  excise  the  articular  surfaces  only 
if  they  are  sound,  and  more  extensively  if  diseased ;  next  seize  the  trapezium  with 
strong  forceps,  and  dissect  it  out  without  cutting  the  tendon  of  the  flexor  carpi 
radialis,  and  excise  the  end  of  the  metacarpal  bone  ;  clip  off'  the  articular  facet  of 
the  pisiform  bone,  and,  if  sound,  leave  the  remainder  in  position ;  close  the  radial 
incision  firmly  throughout  with  sutures,  and  also  the  end  of  the  ulnar  incision,  but 
the  middle  must  be  kept  open  by  pieces  of  lint  introduced  lightly  to  give  support 
to  the  extensor  tendons  and  afford  free  escape  of  discharges. 

(6)  In  Boeckel's  operation  the  incision  may  be  made  from  the  middle  of  the 
ulnar  border  of  the  metacarpal  bone  of  the  index  finger  upward  to  the  middle  of 
the  dorsal  surface  of  the  epiphyses  of  the  radius,  D  (Fig.  1-68),  crossing  to  the  ulnar 
side  of  the  extensor  carpi  ulnaris  at  its  insertion  into  the  base  of  the  third  metacar- 
pal bone,  and  dividing  the  dorsal  ligament  of  the  carpus  between  the  tendons  of  the 
long  extensor  of  the  thumb  and  the  extensor  indicis :  the  soft  parts  being  raised 
through  the  incision  by  careful  manipulation  of  the  hand,  the  carpal  bones  may  be 
removed,  one  by  one,  by  dividing  the  ligaments  which  bind  them  together  and  to 
other  bones. 

(c)  Oilier  makes  an  incision,  C  (Fig.  168).  from  an  inch  below  the  styloid  pro- 
cess of  the  radius  upward  along  the  external  border  of  that  bone,  to  a  sufficient  ex- 
tent ;  a  branch  of  the  radial  nerve  being  preserved,  the  extensor  tendons  of  the 
thumb  are  exposed  and  drawn  aside  and  the  insertion  of  the  superior  longus  ex- 
posed. AVith  the  periosteum  denude  the  end  of  the  radius  and  bend  the  carpus 
forcibly  inward,  dislocating  the  head  of  the  radius  outward.  After  separating  the 
fibrous  attachments  excise  the  requisite  amount.  The  end  of  the  ulna  may  be 
reached  through  the  same  wound,  or  an  incision  along  the  inner  border  will 
expose  it. 

The  after-treatment  must  be  pursued  with  due  recognition  of  the  fact 
that  the  new  joint  at  the  wrist  is  produced  by  an  approximation  of  the  bones 
of  the  forearm  and  of  the  metacarpus,  partly  by  shortening  of  the  limb  and 
partly  by  the  growth  of  new  bone  from  the  divided  ends  ;  with  proper  care 
perfect  symmetry  of  the  hand  can  always  be  ensured  ;  for  as  the  radius  and 
ulna  above  and  the  metacarpus  below  are  divided  in  parallel  lines,  the  shrink- 
ing of  the  new  material  between  them  draws  the  hand  equally  upward  toward 
the  forearm  ;  the  surgeon  should  aim  to  maintain  flexibility  of  the  fingers  by 
frequently  moving  them,  and  at  the  same  time  to  procure  firmness  of  the 
wrist  by  keeping  it  securely  fixed  during  the  process  of  consolidation.     These 


558  LOCAL  DISEASES. 

indications  are  met  by  placing  the  limb  on  Lister's  splint  (Fig.  169),  which 
consists  of  an  obtuse-angled  piece  of  thick  cork  attached  to  a  splint,  with  a 
cross-bar  of  cork  attached  to  the  under  surface  about  the  level  of  the  knuckle  ; 

Fig.  169. 


Haud  after  excision  ol'  wrist,  laid  in  splint. 

on  the  spUnt  the  hand  lies  semi-flexed,  its  natural  position,  the  fingers  mid- 
way between  the  extremes  of  flexion  and  extension  into  which  it  is  necessary 
to  bring  them  in  the  daily  passive  movements ;  the  thumb  is  to  be  kept  from 
the  index  finger  by  a  pad  of  cotton  maintained  between  them  ;  flexion  and 
extension  of  the  fingers  should  be  commenced  on  the  second  day  whether 
inflammation  has  subsided  or  not,  and  continued  daily,  each  finger  being 
flexed  and  extended  to  the  fullest  degree  possible  in  health,  care  being  taken 
that  the  metacarpal  bone  concerned  is  held  steady ;  pronation  and  supination 
must  not  be  neglected,  and  as  the  wrist  acquires  firmness  flexion  and  exten- 
sion, adduction  and  abduction,  should  be  occasionally  encouraged ;  passive 
motion  must  be  continued  until  there  is  no  longer  a  tendency  to  contract  ad- 
hesions. 

The  Hip-joint. 

The  hip-Joint  is  liable  to  all  the  forms  of  disease  peculiar  to  other  joints, 
but  in  a  very  difi"erent  ratio. 

Simple  synovitis,  uncomplicated  by  other  afiections,  is  rare  and  difficult 
of  correct  diagnosis.  It  is  most  apparent  when  it  immediately  follows  an 
injury.  It  soon  subsides  with  rest  and  extension  of  the  limb,  the  only  treat- 
ment applicable. 

The  acnte  siipjmrative  forms  of  inflammation  of  the  hip-joint  are  epi- 
physeal in  origin  and  run  the  course  of  osteomyelitis.  The  joint  becomes 
secondarily  aff"ected.  The  swelling  is  considerable,  the  pain  severe,  especially 
on  moving  the  limb,  and  the  temperature  high. 

The  TREATMENT  consists  in  extension  of  the  limb  by  a  weight  at  the  foot, 
perfect  rest,  and,  when  pus  is  detected,  free  incision.  It  often  happens  that 
necrotic  bone  is  discovered,  which  must  be  removed,  even  to  the  extent  of 
excision  of  the  entire  head  and  neck  of  the  femur,  if  necessary,  in  order  to 
leave  the  cavity  free  from  dead  structures.  Recovery  usually  follows,  and  a 
useful  limb  is  often  secured.  Convalescence  is  always  prolonged  according 
to  the  extent  of  damage  done  to  the  bone  and  the  general  health  of  the 
patient.  The  joint  must  be  protected  from  motion  by  the  hip-splint,  or  by 
extension  while  the  patient  is  confined  to  the  recumbent  position,  until  the 
consolidation  of  the  cavity  is  well  advanced,  and  then  movements  must  be 
restricted  for  a  considerable  period.  Usually  the  patient  should  be  confined 
in  bed,  with  extension  at  the  foot,  until  the  wound  is  granulating,  when 
he  can  resume  the  hip-splint. 

The  tuhercular  form  of  hip  disease  is  by  far  the  most  common,  and 
demands  the  most  intelligent  care  on  the  part  of  the  practitioner.     It  was 


DISEASES  OF  THE  JOINTS.  559 

formerly  one  of  the  most  painful  and  destructive  surgical  diseases  of  child- 
hood, but  at  the  present  time  it  has  become  amenable  to  treatment,  so  that 
it  may  not  only  be  rendered  comparatively  free  from  pain,  but  recovery  may 
be  secured  with  a  useful  limb.  In  a  total  of  277  cases,  142  were  males  and 
135  were  females  ;  9  were  over  fourteen  years  of  age,  and  261  were  under 
that  age.  Sex  is  therefore  unimportant  as  a  factor  in  the  liability  to  the 
disease,  but  it  is  peculiarly  a  disease  of  childhood.  Tubercular  hip  disease, 
therefore,  should  be  thoroughly  understood  by  the  practitioner. 

The  disease  may  commence  in  the  synovial  membrane,  or  in  the  acetabu- 
lum, or  in  the  head  of  the  femur.  It  is  more  frequently  of  osteal  origin, 
and  extends  to  the  joint  secondarily  through  the  epiphysis.  Four  forms  of 
tubercular  synovitis  have  been  recognized,  the  difference  depending  upon  the 
formation  of  the  granulation  tissue.  It  is,  however,  difficult  to  distinguish 
the  special  form  of  the  disease  at  an  early  period,  nor  is  it  of  practical  im- 
portance, as  the  treatment  of  the  several  forms  does  not  differ.  In  all  cases 
the  progress  of  the  affection,  when  of  synovial  origin,  is  more  liable  to  be 
acute  than  when  of  osteal  origin. 

The  SY3IPT0MS  of  both  synovial  and  osteal  tuberculosis  of  the  hip 
depend  upon  the  progress  of  the  disease.  It  usually  follows  an  injury  to 
the  hip.  If  the  inflammation  is  acute,  it  is  attended  with  great  intolerance 
of  movements  of  the  limbs,  fever,  swelling  of  the  hip,  emaciation,  and  dis- 
turbed sleep  owing  to  the  spasms  of  the  muscles  at  night.  Pus  forms  at  an 
early  period,  with  great  tumefaction  of  the  region  of  the  hip.  In  the  sub- 
acute form  all  of  the  preceding  symptoms  are  less  marked.  The  pain  does  not 
prevent  the  child  from  playing,  and  is  often  referred  to  the  inside  of  the 
knee ;  the  starting  of  the  limb  at  night  is  less  constant ;  the  flexion  is  less 
restrained,  but  cannot  be  carried  to  an  extreme  degree ;  the  swelling  conies 
on  slowly,  and  many  months  may  elapse  before  the  child  finally  ceases  to 
use  the  limb.  But  the  diseases  may  be  more  chronic  still,  especially  when 
of  osteal  origin.  It  frequently  happens  that  there  is  a  long  period  of  slowly 
progressing  trouble  at  the  hip  which  escapes  the  attention  of  even  the  physi- 
cian. The  pain  is  so  slight  and  occasional  that  it  is  never  complained  of; 
very  often  it  is  at  the  knee,  and  may  follow  a  fall  on  that  part,  thus  the  more 
readily  deceiving  the  attendant ;  the  patient  does  not  give  up  active  exer- 
cise, and  there  is  nothing  to  indicate  any  affection  at  the  hip.  It  is  only 
after  a  long  period  that  the  symptoms  become  so  pronounced  as  to  attract 
notice  to  the  actual  spot.  The  practitioner  cannot  be  too  careful  in  these 
cases,  for  on  a  correct  diagnosis  will  depend  the  recovery  of  the  patient  with 
a  useful  limb. 

The  DIAGNOSIS  of  hip  disease  is  liable  to  great  errors.  If  seen  at  an 
early  stage,  when  the  disease  is  of  a  chronic  form  and  the  symptoms  slight, 
it  has  been  mistaken  for  an  affection  of  the  knee,  of  the  sacro-iliac  joint,  for 
chronic  rheumatism,  rickets,  and  hysteria.  In  advanced  stages,  when  the 
swelling  is  great,  it  has  been  treated  as  acute  rhevimatism,  periostitis  of  tro- 
chanter, abscess  of  glandular,  psoas,  gluteal,  or  iliac  origin,  and  other  dis- 
eases. 

Pain  is  a  most  uncertain  and  often  misleading  symptom.  The  patient 
may  vaguely  admit  that  he  has  pain,  but  he  often  refers  it  to  other  places 
than  the  hip.  These  pains  are  often  called  "growing  pains."  They  may  be 
in  the  region  of  the  pelvis,  down  the  thigh,  at  the  knee  or  the  ankle.  They 
sometimes  remain  so  persistently  at  the  knee  that  the  disease  has  been  located 
in  that  joint,  and  applications  have  been  made  to  the  knee  for  its  relief. 
Efforts  to  elicit  symptoms  of  pain  in  the  joint  by  pressure  over  the  trochan- 
ter or  on  the  foot  generally  fails ;  it  is  only  by  extreme  abduction  or  adduc- 
tion that  the  patient  gives  evidence  of  being  injured.     Disturbed  sleep,  from 


560 


LOCAL  DISEASES. 


starting  of  the  limb,  is  sometimes  a  symptom  which  attracts  little  atten- 
tion. Lameness  is  also  present,  but  often  it  is  so  slight  that  neither  the 
patient  nor  immediate  relatives  recognize  its  existence  for  a  considerable 
time.  It  is,  however,  significant  of  impairment  of  the  movements  at  the 
hip-joint.  At  length  it  becomes  apparent,  owing  to  permanent  flexion  of  the 
thigh  and  the  eifort  of  the  patient  to  avoid  the  jar  caused  by  stepping  on 
the"  heel.  The  swelling  occurs  later  and  is  a  most  important  factor  in  the 
diagnosis.  It  may  appear  very  early  in  front,  and  then  indicates  distention 
of  the  capsule  with  fluid.  This,  with  accompanying  symptoms,  points  unmis- 
takably to  the  hip-joint  as  the  seat  of  trouble.  Later  the  tissues  around 
the  joint  become  involved,  and  finally  the  capsule  ruptures,  when  the  swell- 
ing becomes  most  marked  behind  the  trochanter. 

The  attitude  of  the  patient  should  be  carefully  studied.  Place  him  on 
the  back,  and,  grasping  the  leg  below  the  knee,  slowly  flex  each  thigh  on 
the  body.  The  unaffected  joint  will  permit  the  thigh  to  be  pressed  down 
firmly  upon  the  abdomen  (Fig.  170),  but  when  an  effort  is  made  to  flex  in  a 

Fig.  170. 


Sound  thigh  flexed  on  abdomen  for  ascertaining  exact  amount  of  deformity. 

similar  manner  the  opposite  thigh,  the  joint  of  which  is  aff"ected,  the  flexion, 
even  in  the  earliest  stages  of  disease,  is  suddenly  arrested,  and  the  child 
resists  all  further  attempts  at  flexion.  A  very  simple  method  of  making 
this  test  is  to  request  the  child  to  touch  his  nose  to  his  knee  ;  he  accomplishes 
the  feat  readily  with  the  healthy  limb,  but  fails  with  the  diseased  limb  or 
succeeds  with  difficulty,  though  he  makes  great  efforts  to  effect  the  object. 
This  is  one  of  the  most  reliable  evidences  of  hip  disease,  and  can  readily  be 
made.  A  second  test  of  a  similar  kind  should  be  made  at  the  same  time.  If 
the  patient  lies  on  a  smooth,  hard  surface,  and  his  spine  rests  on  it,  the  flexion 

Fig.  171. 


Limh  brought  down,  but  loin  arched  (Owen). 


of  the  thigh,  caused  by  the  fixation  of  the  joint,  will  at  once  elevate  the  knee 
of  the  affected  limb.  If,  now,  the  knee  is  pressed  down  so  as  to  touch 
the  surface,  the  spine  becomes  arched  (Fig.  171),  owing  to  the  fixation  of 
the  hip-joint.     The  same  test  can  also  he  applied  by  placing  the  patient  in 


DISEASES   OF  THE  JOINTS. 


561 


Fig.  172. 


a  prone  position  and  slowly  elevating  the  leg,  seizing  it  at  the  ankle.     The 
healthy  limb  will  move  readily  to  the  fullest  extent 
backward,  while    the    affected   limb    admits   of   but 
limited  backward  motion. 

Atrophy  of  the  limb  is  a  very  early  sign  of  hip 
disease.  The  points  of  measurement  are  the  middle 
of  the  upper  thirds  of  both  the  thigh  and  leg.  At 
these  points  we  measure  the  muscles  at  their  largest 
development.  If  there  is  atrophy  of  the  limb  which 
is  suspected,  the  fact  is  of  value  only  in  connection 
with  the  other  signs  and  symptoms.  Of  more  im- 
portance in  diagnosis  is  the  wasting  of  the  muscles 
of  the  affected  part.  The  hip  assumes  a  flattened 
appearance,  and  the  usually  well-marked  trans- 
verse (Fig.  172)  gluteal  fold  disappears  or  takes  an 
oblique  direction  downward  and  outward.  As  the 
disease  advances  the  symptoms  and  appearances  be- 
come more  marked  and  significant.  In  the  first  stage 
the  limb  emaciates,  and  the  thigh  becomes  flexed ;  in 
the  second  stage  the  limb  is  abducted  and  rotated 
outward ;  and  in  the  third  stage  it  is  adducted  and 
rests  on  the  other  thigh. 

Sayre  explains  the  pathological  conditions  as  fol- 
lows :  The  cavity  of  the  joint  becomes  distended 
with  fluid,  and  the  affected  limb  is  slowly  abducted 
and  apparently  lengthened ;  subsequently  suppura- 
tion occurs  in  the  joint,  the  capsule  ruptures,  and 
the  limb  becomes  adducted,  and  it  appears  to  have 
undergone  a  process  of  shortening.  These  differences  in  length  are,  how- 
ever, only  apparent,  owing  to  an  inclination  of  the  pelvis. 

Owen  remarks:  "As  soon  as  the  pelvis  is  brought  square  with  the  spine  and 
the  lumbar  vertebrae  are  all  flat  upon  the  table,  the  amount  of  deformity  may  be 
accurately  determined.  Apparent  shortening  is  then  explained,  and  a  limb  which 
hitherto  might  have  been  considered  to  be  in  good  position  may  be  found  of  normal 

Fig.  173. 


Advanced  hip-joint  disease. 


>1 


J 


I  I  I 

n! 
FA 


\ 


length,  but  flexed  and  greatly  adducted.  The  schemes  represent  (a)  pelvis  and 
lower  extremities  in  every  respect  normal  ;  (b)  disease  of  the  left  hip-joint,  tilting 
of  the  pelvis,  the  left  limb  being  apparently  shortened,  but  in  the  normal  line  ;  (c) 
shows  how,  by  the  squaring  of  the  pelvis,  the  limb  has  been  brought  down  and 
found  greatly  adducted.  yet  of  normal  length  :  (d)  represents  disease  of  the  left 
joint,  the  pelvis  having  been  tilted  (possibly  dropping  from  want  of  the  accustomed 
support),  so  that  the  left  extremity  seems  increased  in  length,  though  still  in  normal 
36 


562  LOCAL  DISEASES. 

parallelism.  But  on  bringing  the  transverse  line  of  the  iliac  crests  at  right  angles 
with  the  spinal  column,  as  in  (e),  the  left  limb  is  found  of  normal  length,  but 
greatly  abducted. 

"  the  position  of  the  limb,  therefore,  marks  three  stages  in  the  progress  of  the 
disease,  and  becomes  a  valuable  diagnostic  sign  :  viz.  1,  there  is  simple  flexion, 
with  perhaps  slight  abduction  and  outward  rotation  ;  2,  flexion  with  marked  rota- 
tion outward,  and  abduction  with  apparent  lengthening  ;  3,  flexion,  rotation  inward, 
adduction  and  apparent  shortening." 

As  the  case  progresses  the  hip  becomes  flattened  and  the  gluteal  fold  is 
lost  or  becomes  very  oblique.  The  patient  suflPers  at  night  from  starting 
pains,  and  during  the  day  maintains  the  limb  in  a  fixed  position,  partly  by 
muscular  force  and  partly  by  the  thickening  of  tissues.  The  pain  varies 
much  ;  it  may  be  absent  in  severe  cases  or  intermittent,  and  is  liable  to 
change  from  one  locality  to  another  as  to  the  thigh,  knee,  leg,  and  feet.  Its 
diagnostic  value  is  very  slight.  Finally,  the  child  assumes  a  perfectly  quiet 
position,  and  resists  every  effort  to  move  the  limb.  This  peculiarity  marks 
the  last  stages  of  the  disease.  The  swelling,  which  was  at  first  most  marked 
in  front  of  the  thigh,  now  becomes  prominent  over  the  trochanter,  and  indi- 
cates suppuration  in  the  joint.  The  abscess  at  length  opens,  usually  behind 
and  below  the  trochanter,  and  afterward  at  other  points,  following  the  course 
of  the  muscles.  On  moving  the  limb,  grating  may  now  be  felt  if  the  joint  is 
destroyed,  owing  to  the  escape  of  the  pus,  which  by  distention  prevented 
the  head  of  the  femur  from  free  contact  with  the  acetabulum.  From  this 
time  the  limb  remains  permanently  flexed  and  adducted. 

In  cases  which  have  progressed  uninterruptedly  the  head  of  the  femur 
may  be  destroyed  or  may  escape  from  the  acetabulum.  During  this  period 
of  suppuration  the  health  of  the  patient  deteriorates ;  there  is  septicaemia, 
and  often  pyaemia  ;  emaciation  increases,  and  the  larger  number  die  of  ex- 
haustion if  the  disease  is  allowed  t)o  pursue  its  course  to  its  termination.  Those 
who  survive  the  natural  processes  are  doomed  to  have  a  crippled  limb  for  life. 

The  PROGNOSIS  of  hip  disease  under  intelligent  treatment  is  extremely 
favorable.  It  can  be  arrested  in  the  early  stages  by  modern  methods  of  treat- 
ment, and  the  general  health  preserved.  In  the  later  stages  it  can  be  ren- 
dered painless  and  the  patient  can  be  protected  from  loss  of  health.  Finally, 
in  the  most  advanced  and  unfavorable  cases  when  first  brought  under  treat- 
ment life  may  be  preserved  and  a  comparatively  useful  limb  secured. 

The  TREATMENT  of  hip  disease  is  now  based  on  rational  principles,  and 
can  be  successfully  carried  out  by  every  practitioner.  At  every  stage  of  the 
case  the  result  aimed  at  in  this  treatment  is  the  protection  of  the  diseased 
structures  from  injury  and  the  promotion  of  the  health  of  the  patient.  These 
conditions  are  not  secured  by  rest  in  bed.  It  is  true  that  rest  will  prevent  the 
shock  and  impact  of  walking,  but  it  will  not  save  the  joint  from  the  injury 
caused  by  the  spasm  of  the  muscles  and  the  movements  of  the  limb.  Proper 
protection  can  only  be  secured  by  such  traction  of  the  limb  as  will  relieve  all 
pressure  of  the  head  of  the  femur  on  the  joint-surfaces.  This  can  be  effected 
by  the  weight  and  pulley  when  the  patient  is  confined  to  his  bed,  and  by  the 
hip-splint  when  he  is  allowed  to  move  about. 

The  employment  of  these  appliances  should  not  be  delayed  after  the  diag- 
nosis of  hip-joint  disease  is  made,  nor  should  they  be  intermitted  until  the 
cure  has  been  perfected.  In  the  early  periods  of  a  very  chronic  case  it  will 
be  difiicult  to  persuade  the  patient  and  friends  to  submit  to  this  plan  of  treat- 
ment. But  the  practitioner  will  be  culpable  who  does  not  firmly  insist  upon 
the  application  of  well-adjusted  and  efiieient  apparatus.  The  period  during 
which  the  hip-splint  will  be  required,  even  in  the  most  favorable  cases,  will 
exceed  a  year,  and  more  often  eighteen  months  or  two  years. 


DISEASES  OF  THE  JOINTS. 


563 


The  importance  of  the  hip-splint  in  tubercular  disease  of  the  joint  cannot 
be  over-estimated.  It  enables  the  patient  to  take  the  necessary  amount  of 
exercise  in  the  open  air  to  preserve  his  general  health,  while  the  affected  joint 
is  placed  in  a  condition  of  rest  from  its  ordinary  functions.  Frequently  the 
child  is  enabled  to  resume  many  of  those  sports  in  the  open  air  which  give  zest 
to  exercise  and  are  essential  to  health.  There  is  no  single  device  in  practical 
surgery  which  more  exactly  meets  all  its  indications  than  the  ordinary  hip- 
splint.  It  is  doubtful  if  in  the  whole  realm  of  inventions  a  greater  service 
has  been  rendered  to  an  individual  class  of  patients  than  this  splint  has  ren- 
dered to  those  afflicted  with  hip  disease.  It  has  not  only  rescued  vast  num- 
bers of  children  from  a  prolonged  and  painful  sickness  and  a  lingering  death, 
but  it  has  saved  them  from  pain  and  suffering.  When,  therefore,  the  disease 
is  recognized  as  involving  the  structures  entering  into  the  hip-joint,  whether 
as  a  synovitis  or  an  osteomyelitis,  this  treatment  should  be  commenced.  It 
is  generally  better  to  employ,  for  a  time,  extension  of  the  limb  while  the 
patient  is  in  bed  before  permanent  apparatus  is  applied.  The  patient  should 
accordingly  be  placed  in  the  recumbent  position,  with  a  weight  at  the  foot  to 
make  such  extension  as  will  counteract  muscular  contraction.  The  rubber 
plaster  should  be  selected,  and  cut  in  strips  about  an  inch  and  a  half  wide  and 
of  sufficient  length  to  extend  to  the  middle  of  the  thigh  and  form  a  loop  below 

Fig.  174. 


Bed  for  extension. 

the  foot.  The  bed  should  be  firm,  the  foot  being  elevated  slightly  (Fig.  174) 
and  the  surface  smooth.  The  weight  need  not  exceed  four  to  six  pounds. 
At  first  the  extension  should  be  in  the  direction  of  the  flexed  thigh,  but  grad- 
ually it  should  assume  the  straight  position.  Usually  great  relief  to  all  of 
the  symptoms  follows  the  use  of  the  weight.  This  is  due  to  the  traction  of 
the  muscles  of  the  thigh,  which  prevents  the  undue  pressure  of  the  head  of 
the  femur  on  the  joint  attending  their  spasmodic  contraction. 

But  confinement  to  the  bed  soon  impairs  the  patient's  health,  and  hence 
the  necessity  of  supplying  an  apparatus  at  an  early  period  which  enables  him 
to  take  proper  exercise,  while  it  protects  the  joint  from  injury.  The  hip-splint 
meets  every  indication  now  present.    The  following  is  a  description  of  the  splint : 

The  splint  (Fig.  175)  extends  from  the  sole  to  the  crest  of  the  ilium,  where  it  is 
connected  to  a  pelvic  band  by  a  joint  allowing  flexion  and  extension,  abduction  and 
adduction,  but  properly  regulated.  Extension  is  made  by  means  of  adhesive  plaster 
applied  to  the  leg  and  attached  by  buckles  to  the  two  ends  of  a  leather  strap  fastened 
to  the  foot-piece  ;  counter-extension  is  made  by  means  of  two  perineal  pads  fastened  to 
the  pelvic  band  with  straps  and  buckles  ;  at  the  knee-joint  is  a  movable  ci'oss-piece  for 
attaching  a  leather  cap  to  steady  and  support  the  knee  ;  at  the  bottom  of  the  instru- 
ment is  a  foot-piece  with  a  leather  sole  attached,  to  prevent  jar  in  Avalking  :  a  leather 
strap,  passing  under  the  foot  through  apertures  in  the  foot-piece,  turns  up  an  end  on 
each  side  of  the  ankle,  and  fastens  to  buckles  in  adhesive  strips,  which  prepare  as 
follows :  Cut  two  pieces  of  strong  plaster,  to  reach  from  the  middle  of  the  thigh 
nearly  to  the  ankle  and  two  inches  wide ;  attach  a  strong  saddler's  buckle  to  the 


564 


LOCAL  DISEASES. 


lower  end  of  each  ;  apply  the  plasters  against  the  lateral  aspects  of  the  leg,  begin- 
ning about  two  inches  above  the  internal  and  external  malleoli  with  the  ends  hav- 
ing' the  buckles  attached  ;  a  few  turns  of  roller  bandage  are  then  made  around  the 
ankle,  just  under  the  lower  ends  of  the  straps,  to  protect  the  flesh  under  the  buckles, 
and  then  continued  over  the  strips  on  the  whole  limb.  The  patient  should  be  laid  on 
his  back,  and  great  care  ought  to  be  taken  that  the  pelvis  is  not  inclined  forward  by- 
contractions  of  the  flexor  muscles ;  should  this  be  the  case,  elevate  the  leg  until  the 
lumbar  vertebrae  come  near  the  couch  and  the  spinal  column  assumes  its  normal 
shape  ;  the  instrument  is  then  applied.  The  pelvic  band  ought  to  be  loose  enough 
to  allow  the  pelvis  to  move  freely  in  it ;  the  anterior  superior  spine  of  the  ilium 
ought  to  be  above  the  pelvic  band  (Fig.  176) ;  in  applying  the  ankle-straps  leave  a  little 


Fig.  175. 


Fig.  176. 


Hip-splint. 


Hip-splint  applied. 


space  between  the  foot  and  the  foot-piece,  so  that  in  standing  or  walking  the  weight 
of  the  patient  does  not  rest  on  the  leg,  but  on  the  instrument ;  the  perineal  straps 
must  be  so  adjusted  that  the  patient  sits  firmly  and  comfortably  upon  them  ;  when  the 
apparatus  is  adjusted  tighten  the  perineal  straps  until  the  patient  gives  evidence  that 
the  strain  is  suSicient.  The  attendant  should  be  instructed  to  keep  all  the  straps  as 
tense  as  the  patient  will  bear  without  complaint. 

The  hip-splint,  properly  adjusted,  should  be  entirely  comfortable,  and  should 
enable  the  patient  to  walk  with  comparative  ease.  In  ordinary  cases  of  hip  dis- 
ease of  osteal  origin  the  splint  must  be  worn  for  eighteen  months  to  two  years. 

Case. — J.  C ,  a  boy,  aged  nine  years,  strumous,  developed  tubercular  epiph- 
ysitis of  the  neck  of  the  femur.  When  first  seen  the  left  leg  was  flexed  and  slightly 
abducted;  the  pain  constant;  sleep  was  disturbed ;  there  was  marked  emaciation. 
The  hip-splint  was  applied,  and  he  soon  began  to  walk  freely  ;  the  pain  disappeared, 
and  he  began  to  take  on  flesh.  He  wore  the  splint  twenty  months,  and  during  the 
time  took  active  exercise.  Latterly  he  played  games  of  ball.  All  signs  and  symp- 
toms of  hip  disease  meantime  disappeared. 

The  removal  of  the  splint  must  be  undertaken  with  great  care,  and  only 
after  all  of  the  symptoms  have  disappeared  for  a  considerable  period.  To 
determine  the  condition  of  the  joint,  the  limb  should  be  flexed,  abducted, 
adducted,  percussed,  and  rotated.  The  motions,  especially  flexion,  will  not 
be  as  free  as  are  those  of  the  healthy  limb,  but  they  will  not  be  painful  as 


DISEASES  OF  THE  JOINTS.  565 

formerly.  The  splint  should  for  a  time  be  removed  only  at  niglit,  to  be 
resumed  in  the  morning  before  rising.  Then  it  may  be  omitted  while  the 
patient  i*emains  in  the  house,  and  applied  if  he  walks  out,  to  prevent  acci- 
dent. Finally,  if  the  case  progresses  well,  the  intervals  of  use  of  the  splint 
may  be  lengthened.  If  at  any  time  there  is  a  recurrence  of  symptoms,  the 
splint  must  be  resumed  for  a  time. 

Abscess  is  likely  to  appear  in  the  progress  of  the  disease,  and  there  has 
been  much  discussion  as  to  the  propriety  of  evacuating  the  pus.  It  is  held 
that  if  the  abscess  is  not  disturbed  it  will  be  harmless,  and  may  be  absorbed, 
while  if  the  cavity  is  opened,  profuse  suppuration  is  liable  to  be  established, 
greatly  to  the  detriment  of  the  patient.  Such  reasoning  is  fallacious,  in  that, 
first,  there  is  danger  that  the  retained  pus  will  infect  the  system  as  it  invades 
new  areas  of  cellular  tissue ;  and,  second,  the  pus  can  be  evacuated  without 
endangering  increased  suppuration.  The  rule  of  practice  should  be  to  freely 
open  abscesses  which  arise  in  the  course  of  hip-joint  disease,  taking  all  need- 
ful antiseptic  precautions.  The  result  of  such  treatment  is  always  beneficial, 
and  in  some  instances  is  followed  by  immediate  improvement. 

Case. — A.  B ,  a  lady,  twenty  years  old,  had  been  under  treatment  for  hip 

disease  one  year,  during  which  she  wore  the  usual  hip-splint.  An  abscess  appeared 
four  months  before  admission  to  the  hospital,  but  it  was  not  opened.  It  was  now 
of  large  size,  being  most  prominent  behind  the  trochanter.  She  was  greatly  ema- 
ciated, had  fever  with  irregular  chills  and  sweats,  and  a  rapid,  feeble  pulse.  An 
anaesthetic  was  given  on  two  occasions  for  an  operation,  but  in  both  instances  the 
heart  failed,  her  face  became  purple  and  the  respiration  greatly  embarrassed.  A 
third  attempt  was  preceded  by  securing  partial  intoxication  wdth  whiskey.  The 
patient  took  an  ounce  of  whiskey  in  half  a  pint  of  hot  milk  every  hour,  commencing 
at  eight  o'clock  in  the  morning.  At  twelve  o'clock  she  was  talking  foolishly  ;  her 
e3'es  were  suifused,  her  pulse  quiet  at  96  beats  per  minute,  her  skin  warm  and 
natural,  and  her  respirations  full.  She  required  but  little  of  the  anaesthetic,  and 
during  the  operation  her  pulse  continued  at  96,  without  showing  any  signs  of 
weakness,  and  the  respirations  remained  unchanged.  A  large  amount  of  pus  was 
evacuated.  The  head  of  the  femur  had  separated,  and  was  removed,  with  much 
disintegrated  bone.  The  general  condition  of  the  patient  improved  rapidly,  and  she 
made  a  good  recovery. 

The  abscess  may  not  communicate  with  the  joint,  and  in  that  case  the 
cavity  should  be  thoroughly  curetted  and  packed  with  antiseptic  gauze. 
The  healing  of  the  abscess-cavity  generally  progresses  favorably.  If  how- 
ever, the  abscess  is  connected  with  the  joint  or  with  diseased  bone,  the 
operation  should  extend  to  the  removal  of  all  dead  structures,  even  to  the 
extent  of  excision  of  the  head  of  the  femur. 

Aspiration  of  the  distended  capsule  may  be  practised  in  the  early  stage 
of  effusion.  This  condition  is  marked  by  a  swelling  over  the  joint  and  that 
feeling  of  elasticity  which  is  due  to  the  tense  capsule.  It  is  safer  to  make 
the  puncture  behind  the  trochanter  than  in  front.  Aspiration  to  remove  a 
purulent  collection  during  the  progress  of  hip-joint  disease  is  a  waste  of  time. 
If  the  indications  are  that  the  head  of  the  bone  is  seriously  involved, 
excision  will  be  required.  An  exploratory  operation  to  determine  the  extent 
of  the  destruction  of  tissues  should  be  deliberately  undertaken,  provision 
having  been  made  to  excise  the  necrotic  bone. 

The  extent  of  the  resection  should  depend  upon  the  amount  of  disease ; 
if  limited  to  the  head,  that  part  alone  should  be  removed  ;  if  the  neck  is 
carious,  the  trochanter  may  still  be  preserved  ;  but  if  the  latter  is  involved, 
the  bone  must  be  divided  at  the  trochanter  minor. 

The  methods  of  operating  are  numerous,  but  the  single  incision,  with  sub- 
periosteal removal  of  the  bone,  most  nearly  meets  the  anatomical  indication 
of  the  part. 


566 


LOCAL  DISEASES. 


Several  arteries  are  distributed  to  this  region — viz.  the  gluteal,  sciatic, 
obturator,  and  circumflex,  the  only  one  which  approaches  the  line  of  the 
incision  near  enough  to  be  incised  before  dividing  into  branches  of  distribu- 
tion too  small  to  give  rise  to  noticeable  hemorrhage  is  a  twig  of  the  internal 
circumflex,  which  at  one-eighth  to  one-fourth  of  an  inch  from  the  insertion 
of  the  obturator  externus  breaks  up  into  its  terminal  divisions ;.  this  branch 

may  be  avoided  by  keeping  the  point  of 
Fig.  177.  the  knife  well  against  the  bone,  and  divid- 

,.. -.^  ing  the  tendon  of  the  obturator  externus 

muscle  in  the  digital  fossa. 

Excision  is  as  follows :  The  patient  lying 
on  the  sound  side,  with  a  strons;  knife  com- 
mence an  incision,  A  (Fig.  177).  at  a  point 
midway  between  the  anterior  inferior  spinous 
process  of  the  ilium  and  the  top  of  the  great 
trochanter ;  carry  it  in  a  curved  line  over  the 
ilium  in  contact  with  the  bone,  across  to  the 
top  of  the  great  trochanter ;  extend  it  not  di- 
rectly over  the  centre  of  the  trochanter,  but 
midway  between  the  centre  and  its  posterior 
border ;  complete  it  by  carrying  the  knife  for- 
ward and  inward,  making  the  whole  length  of 
the  incision  four  to  six  or  eight  inches,  accord- 
ing to  the  size  of  the  thigh  :  if  the  periosteum 
has  not  been  divided  by  the  first  incision, 
carry  the  point  of  the  knife  along  the  same 
line  a  second  or  third  time  :  an  assistant  sepa- 
rating the  wound  Avith  the  fingers  or  retractors, 
the  great  trochanter,  b  (Fig.  l~i<),  is  exposed  ; 
with  a  narrow,  thick  knife  make  an  incision 
through  the  periosteum  only  at  right  angles 
with  the  first  at  a  point  an  inch  or  an  inch  and 
a  half  below  the  top  of  the  great  trochanter, 
opposite  or  a  little  above  the  lesser  trochanter, 
and  extend  it  as  far  as  possible  around  the  bone,  making  sure  that  the  periosteum 
is  freely  divided ;  at  the  junction  of  the  two  incisions  of  the  periosteum  introduce 

the  blade  of  the  periosteal  elevator,  and  grad- 
ually peel  up  the  periosteum  from  either  side 
with  its  fibrous  attachments  until  the  digital 
fossa  has  been  reached  :  with  the  point  of  the 
knife  applied  to  the  bone  divide  the  attach- 
ments of  the  rotator  muscle,  and  continue  to 
elevate  the  periosteum,  carefully  avoiding 
rupturing  it  at  any  point :  when  the  perios- 
teum is  removed  as  far  as  necessary,  adduct 
the  limb  slightly,  depress  the  lower  end  of 
the  femur  sufficiently  to  allow  the  head  of  the 
bone  to  be  lifted  out  only  so  far  as  is  requi- 
site to  permit  its  removal  with  the  saw,  g ; 
divide  the  bone  just  above  the  trochanter 
minor  and  remove  the  fragment :  if  the  head 
of  the  bone  cannot  be  raised  before  division 
on  account  of  the  involucrum,  saw  the  bone 
first  and  then  remove  the  head ;  if  the  shaft 
at  the  point  of  section  is  necrosed,  expose 
and  exsect  more  ;  examine  the  acetabulum, 
and  if  found  diseased  remove  all  dead  bone  ; 
if  perforated,  the  internal  periosteum  will  be 
found  peeled  oS",  making  a  kind  of  cavity  be- 
hind the  acetabulum,  and  all  diseased  bone 
Passing  chain-saw.  must  be  very  carefully  chipped  ofi"  down  to 


Excision  of  the  hip :  A,  Sayre  ;  B,  Oilier. 


DISEASES  OF  THE  JOINTS.  567 

the  point  where  the  periosteum  is  reflected  from  sound  bone.  Every  part  of  the 
wound  and  all  sinuses  must  be  thoroughly  cleaned  of  particles  of  bone  and  false 
membrane. 

For  some  time  after  the  operation  the  patient  must  remain  in  bed.  and 
extension  of  the  leg  by  a  weight  should  be  continued,  and  not  omitted  until 
the  hip-splint  is  resumed.  As  soon,  however,  as  the  wound  has  healed  suffi- 
ciently to  allow  him  to  move  about  and  without  discomfort,  the  patient 
should  resume  his  splint  and  continue  to  wear  it  until  the  tissues  of  the 
joint  are  consolidated.  The  amount  of  shortening  which  follows  is  very 
variable.  Primai'ily,  it  depends  upon  the  extent  of  the  bone  removed,  but 
this  does  not  affect  it  so  greatly  as  does  the  treatment.  If  a  suitable  degree 
of  extension  of  the  limb  is  maintained,  two  important  changes  occur — viz. 
first,  the  femur  continues  to  lengthen  by  the  natural  growth  of  the  bone  at 
the  lower  epiphysis ;  and,  second,  the  new  structures  which  form  at  the  seat 
of  excision  are  extensive,  and,  becoming  firmly  attached  to  the  bone,  main- 
tain it  in  good  position.  It  is  ver}'  important,  therefore,  to  maintain  exten- 
sion, first,  by  a  weight  during  the  confinement  of  the  patient  to  the  recum- 
bent position,  and  when  he  is  able  to  resume  the  splint,  that  should  be  faith- 
fully employed  until  the  wound  is  firmly  closed  and  perfected.  The  wound 
sometimes  reopens  and  small  fragments  of  bone  are  discharged  ;  this  reopen- 
ing is  occasionally  due  to  an  injury  of  the  new  tissues  of  the  abscess- 
cavity. 

As  recovery  progresses  the  question  of  mobility  of  the  limb  becomes 
important.  The  tendency  of  the  cicatrization  of  the  new-formed  tissues  is 
to  immobilize  the  upper  end  of  the  femur.  If  no  effort  is  made  to  prevent 
this  contraction  and  consolidation,  immobility  will  become  complete,  and 
ankylosis  at  the  hip  will  result.  It  is  desirable,  therefore,  to  commence 
slight  passive  motion  at  an  early  period,  and  gradually  increase  the  mobility. 
If  the  limb  has  been  shortened  by  excision  of  the  head  of  the  femur,  a 
proper  shoe  should  be  applied. 

The  Knee-joint. 

The  large  extent  of  the  surfaces  of  the  knee-joint,  its  complicated  mechan- 
ism, and  its  exposed  position  render  it  peculiarly  liable  to  inflammatory  affec- 
tions. 

Acute  synovitis  is  caused  by  injury.  Its  diagnosis  is  readily  made,  as  the 
significance  of  the  swelling,  heat,  and  pain  is  at  once  appreciated. 

The  TREATMENT  should  be  absolute  rest,  the  limb  being  somewhat  flexed 
over  a  pillow,  and  applications  made  of  the  ice-bag  or  of  an  ice-poultice. 
The  disease  is  of  short  duration,  but  the  patient  must  resume  active  use  of 
the  joint  very  gradually. 

Chronic  synovitis,  with  the  large  collections  of  fluid  which  occur  in  the 
adult,  is  very  rarely  seen  in  the  child.  When  it  exi.sts  the  child  will  be 
found  to  be  in  impaired  health. 

The  TREATMENT  must  be  directed  to  improvement  of  the  health,  and  the 
application  of  such  measures  as  will  promote  absorption.  One  of  the  most 
simple  and  effective  methods  is  strapping.  The  straps  should  be  applied  in 
such  manner  as  to  compress  the  contents  of  its  cavity  firmly  against  the 
hard  tissues,  and  not  into  recesses  of  the  capsule.  This  is  effected  by  placing 
the  straps  alternately  above  and  below,  and  completing  the  process  by  apply- 
ing the  last  over  the  centre  of  the  joint.  They  should  not  meet  posteriorly, 
in  order  not  to  interrupt  the  circulation  in  that  region.  Painting  the  knee 
with  strong  iodine  frequently  is  sometimes  u,s'eful,  as  are  small  blisters,  often 
repeated. 


568  LOCAL  DISEASES. 

Tubercular  disease  of  the  knee  may  begin  in  the  synovial  or  bony  tissues, 
the  latter  being  to  the  former  in  the  proportion  of  3  to  1.  In  the  early 
stages  the  former  is  recognized  as  a  degeneration  of  the  synovial  membrane, 
cartilage,  and  the  bone-surfaces  through  a  process  of  granulation.  It  usually 
proceeds  slowly,  with  no  severe  symptoms.  The  destruction  of  tissue  is 
extensive.  In  the  early  stages  of  the  aflFection  two  conditions  may  be  found. 
In  one  there  is  little  or  no  eifusion  and  the  knee  is  pulpy,  owing  to  the 
amount  of  granulation  tissue.  The  joint-ends  of  the  bone  seem  to  be  en- 
larged, but  this  condition  is  due  to  the  dense  thickening  of  tissues  by  gran- 
ulations. This  is  the  "  white  swelling  "  of  early  writers,  and  is  followed  by 
such  deformities  as  flexion,  backward  dislocation,  outward  rotation.  In  the 
other  form  efi"usion  takes  place  without  deformity,  and  fluctuation  is  notice- 
able. If  the  disease  is  of  osteal  origin,  the  primary  swelling  is  not  so 
directly  in  the  line  of  the  joint,  but  in  the  vicinity  of  the  epiphysis  involved, 
and  tenderness  may  be  detected  on  this  line. 

The  PROGRESS  of  the  acute  disease  is  that  of  an  osteomyelitis,  the  joint 
becoming  involved  secondarily  by  the  penetration  of  the  pus  from  the  focus 
of  suppuration. 

The  SYMPTOMS  at  first  are  pain,  swelling,  and  tenderness,  well  localized. 
But  the  progress  may  be  slow  and  the  general  health  may  not  be  seriously 
disturbed  for  a  long  period.  When,  however,  pus  has  formed  in  considerable 
quantity,  and  is  penetrating  the  structures  of  the  joint,  there  will  usually  be 
an  accession  of  the  severe  symptoms,  as  fever,  loss  of  flesh,  and  rigors,  fol- 
lowed by  perspirations. 

The  PROGNOSIS  will  depend  upon  the  stage  and  progress  of  the  disease. 
In  the  early  period  with  complete  rest  of  the  joint,  with  a  well-applied  plas- 
ter-of-Paris  dressing  extending  from  the  toes  to  the  hip,  and  with  tonic 
treatment,  the  disease  may  sometimes  be  arrested.  But  there  is  frequently  a 
certain  danger  of  deformity  remaining,  and  a  liability  to  a  renewal  of  the 
disease.  If  the  disease  is  advanced,  perfect  results  are  more  likely  to  be 
secured  when  the  tuberculous  tissues  are  completely  removed.  In  these 
conditions  operative  procedures,  by  which  the  infective  material  is  destroyed 
or  removed,  offer  the  best  chance  of  permanent  recovery. 

When  the  knee-joint  is  filled  with  fluid,  aspiration  will  relieve  the  dis- 
tention, and  to  that  extent  prove  useful.  A  more  radical  treatment  is  the 
injection  into  the  cavity,  after  its  evacuation,  of  an  ethereal  solution  of  iodo- 
form. For  this  purpose  a  trocar  may  be  used  both  to  withdraw  the  fluid  and 
to  inject  the  iodoform.  Before  the  iodoform  is  injected,  it  is  well  to  wash  out 
the  cavity  with  a  boric-acid  solution.  It  may  be  necessary  to  inject  the 
iodoform  several  times   at  intervals  of  a  week  or  more. 

Arthrectomy  is  a  much  more  useful  operation  where  the  synovial  mem- 
brane is  extensively  diseased.  It  consists  in  completely  exposing  the  inte- 
rior of  the  joint,  and  with  the  forceps  and  scissors  cutting  away  all  diseased 
tissues.  The  joint  may  be  exposed  by  making  a  flap  convex  downward  or 
convex  upward,  or  by  a  transverse  incision  over  the  centre  of  the  patella, 
and  sawing  through  that  bone,  but  uniting  it,  after  the  joint  is  cleared,  by 
wire  or  even  by  silk  ligatures.  Too  much  care  cannot  be  taken  to  excise 
every  particle  of  tuberculous  structure,  and  hence  the  operation,  if  well  per- 
formed, will  be  tedious.  If  small  cavities  in  the  cartilage  and  bone  are 
filled  with  tubercle,  they  should  be  thoroughly  scraped  with  a  sharp 
spoon. 

If  the  tuberculous  cavities  are  found  to  involve  the  articular  ends  of  the 
bones,  excision  becomes  necessary,  and  may  be  successfully  performed  by 
one  familiar  with  operative  procedures.  The  most  useful  operation  is  as 
follows : 


DISEASES   OF  THE  JOINTS. 


569 


Fig.  179. 


The  leg  being  slightly  flexed  on  the  thigh,  make  a  curved  incision,  commencing 
at  the  insertion  of  the  internal  lateral  ligament  into  the  inner  condyle  of  the  femur, 
and  passing  just  below  the  lower  extremity  of  the 
patella,  terminate  it  at  the  same  point  on  the  external 
aspect  of  the  joint ;  the  lateral  incisions  should  not  be 
made  lower  than  the  insertion  of  the  lateral  ligaments, 
to  avoid  division  of  the  articular  arteries ;  remove 
all  diseased  and  degenerated  tissues ;  reflect  flap  up- 
ward (Fig.  179) ;  remove  the  patella  if  diseased  ;  if  not, 
leave  it  undisturbed  and  divide  the  lateral  and 
interarticular  ligaments  ;  pass  a  fold  of  cloth  through 
the  joint,  and  draw  it  firmly  under  the  extremity  of 
the  bone  to  be  sawn,  thus  completely  isolating  the  soft 
parts  behind  ;  apply  the  saw  first  to  the  extremity  of 
the  femur,  and  then-  to  the  articular  head  of  the  tibia. 
The  bones  must  be  maintained  in  apposition  by  two 
or  three  silver  wires,  which  should  now  be  introduced 
into  the  anterior  part  of  the  tibia  and  femur,  and,  when 
sufiiciently  twisted,  cut  off  and  the  ends  turned  down 
between  the  bones. 

The  dressings  should  be  antiseptic — viz.  layers 
of  iodoform  gauze  next  to  the  wound,  then  gauze 
bandages    treated    with   bichloride  solution,  next  Excision  of  knee, 

borated  cotton  firmly  bound  by  gauze  bandages, 

and  last  gypsum  bandages  sufficient  to  immobilize  the  knee.  The  more 
superficial  dressings  should  extend  from  the  hip  to  the  ankle.  The  limb 
should  now  be  placed  in  a  sling.  The  dressings  should  not  be  changed, 
except  to  remove  the  drain-tube,  for  several  weeks.  The  wires  are  allowed 
to  remain. 


The  Ankle-joint. 

Synovitis  of  the  ankle-joint  results  from  that  form  of  injury  known  as  a 
"  sprain."  This  is  due  to  the  sudden  turning  of  the  foot  when  planted  on  a 
rounded  body,  as  a  stone  or  stick.  A  strain  of  the  ankle  may  occur  when 
the  foot  is  caught  and  the  child  falls,  as  at  play.  The  pain  on  attempting  to 
walk  is  more  or  less  severe,  and  the  joint  at  once  swells  from  the  efi"usion 
which  results  from  the  rupture  of  tissues. 

Owen  states  that  "  in  this  stretching  the  synovial  membrane  also  pai'ticipates, 
and  a  considerable  amount,  if  not  of  blood,  at  least  of  altered  synovia,  is  quickly 
poured  into  the  interior  of  the  joint." 

The  important  features  of  the  treatment  are  complete  rest  and  the 
early  application  of  hot  water.  To  carry  out  this  treatment  satisfactorily 
the  child  should  first  be  confined  to  the  bed,  with  the  foot  elevated.  The 
leg,  nearly  to  the  knee,  should  at  once  be  placed  in  hot  water  of  a  tempera- 
tvire  as  high  as  can  be  borne.  After  a  submersion  of  half  an  hour  the 
ankle  should  be  wrapped  with  three  or  four  layers  of  flannel  wrung  out  of 
water  as  hot  as  the  child  will  tolerate,  and  covered  with  oiled  silk  to  retain 
heat  and  moisture.  These  dressings  should  be  renewed  every  three  or  four 
hours,  or  the  heat  may  be  maintained  by  a  hot-water  bag  or  hot-water  bot- 
tles, especially  at  night.  After  this  treatment  has  been  continued  for  one 
day,  the  dressings  should  be  changed  for  hot  camphorated  oil.  The  swell- 
ing usually  rapidly  subsides,  and  then  adhesive  strips  should  be  applied 
to  the  entire  ankle,  and  retained  two  or  three  weeks  or  until  the  cure  is 
complete. 


570 


LOCAL  DISEASES. 


Fig.  180. 


Gentle  but  very  firm  rubbing  of  the  foot,  ankle,  and  leg,  with  the  hand 
softened  with  vaseline  or  oil,  will  be  very  useful 
in  restoring  the  functions  of  the  joint.  The 
child  may  begin  to  move  about  on  crutches 
when  action  gives  no  pain,  but  actual  attempts 
to  walk  must  be  delayed  until  the  joint  has 
so  far  recovered  that  the  weight  can  be  readily 
borne. 

Tubercular  disease  of  the  ankle  is  chronic 
in  its  character,  and,  like  this  aiFection  in  other 
joints,  is  often  obscure  at  its  origin.  The  pain 
is  slight,  the  swelling  limited,  and  the  lame- 
ness unnoticed.  At  length  the  puffiness  about 
the  posterior  and  inner  part  of  the  ankle  be- 
comes noticeable  (Fig.  180),  lameness  increases, 
and  the  pain  prevents  the  free  use  of  the  foot. 
The  disease  usually  commences  in  the  synovial 
membrane,  but  it  is  frequently  complicated  with 
tuberculous  affections  of  the  tarsal  bones.  As 
the  disease  progresses  the  swelling  increases, 
until  the  joint  has  a  peculiar  tuberose  or 
spindle-shaped  appearance.  The  foot  assumes 
a  position  of  extension,  unless  the  tarsus  is 
involved,  when  the  whole  foot  and  ankle  be- 
come a  swollen  mass,  with  the  foot  at  right  angles  to  the  leg.  The  disease 
often  extends,  also,  along  the  sheaths  of  tendons,  giving  rise  to  swelling  in 
the  lower  part  of  the  leg,  the  dorsum  of  the  foot,  and  even  the  plantar 
region,  though  the  plantar  fascia  maintains  the  arch  of  the  foot. 

The  TREATMENT,  in  the  early  stages,  is  proper  fixation  of  the  joint.  This 
is  readily  and  effectually  accomplished  by  the  plaster-of-Paris  bandage.  In 
its  first  application  care  must  be  taken  to  protect  the  limb  by  covering  it  with 
so  much  cotton  batting  that  the  plaster  will  not  produce  irritation  of  the 
skin.  It  is  especially  important  to  envelop  the  swollen  ankle  with  a  large 
amount  of  the  cotton,  in  order  that  the  bandages  may  be  applied  very  tightly 
for  the  purpose  of  securing  as  much  pressure  as  possible.  Compression  is  an 
important  feature  in  the  treatment,  and  the  cotton,  while  protecting  the  skin, 
has  an  elasticity  which  is  highly  beneficial.  When  the  plaster  dressing  is 
well  applied,  the  child  can  move  about  on  crutches,  keeping  his  diseased  foot 
from  the  ground. 

Sayre  very  properly  attaches  great  importance  to  extension  in  the  treatment  of 

Fig.  181. 


Tubercular  disease  of  the  ankle. 


Sayre's  steel  brace. 


Apparatus  applied. 


DISEASES  OF  THE  JOINTS. 


571 


ankle-joint  disease,  and  has  devised  an  ingenious  apparatus  for  that  purpose  :  The 
steel  brace  is  applied  (Fig.  181)  as  follows :  Cut  adhesive  plaster  in  strips  about  one 
inch  in  width,  and  long  enough  to  reach  from  the  ankle  to  near  the  tubercle  of  the 
tibia,  and  placed  all  around  the  limb :  secure  the  plaster  in  its  position,  to  within 
an  inch  of  its  upper  extremity,  by  a  well-adjusted  roller,  as  seen  in  Fig.  181  :  fix 
the  instrument  and  secure  the  foot  firmly  by  a  number  of  strips  of  adhesive  plaster. 
In  applying  the  gypsum  brace  the  foot,  held  at  a  right  angle,  is  wound  with 
plaster  from  the  base  of  the  nail  of  the  great  toe  as  far  as  the  disease  extends,  and 
from  above  the  ankle  almost  to  the  knee.  The  bracket  is  placed  in  position  and 
bound  down  by  repeated  turns  of  the  plastered  bandage,  taking  care  that  the  foot  is 
still  at  right  angles  ;  the  whole  is  neatly  covered  with  fresh  bandage. 

If  the  case  progress  unfavorably,  pus  forms  and  makes  its  appearance  at 
the  inner  or  outer  side  of  the  joint.  The  treatment  should  now  be  changed. 
The  pus  should  be  evacuated  by  incision  and  the  joint  thoroughly  examined. 
If  the  abscess  does  not  communicate  with  the  joint,  the  plaster  bandage 
should  be  renewed,  and  a  window  should  be  cut  in  it  over  the  opening,  so  as 
to  allow  the  escape  of  pus  and  the  use  of  proper  dressings.  If,  however,  the 
synovial  membrane  is  pulpy  and  the  cartilage  disintegrated,  the  joints  should 
be  exposed  and  all  injured  tissues  removed.  Although  arthrectomy  does  not 
usually  succeed  at  the  ankle  as  well  as  at  the  knee-joint,  it  is  worthy  of  trial. 
The  method  of  operating  is  not  unlike  that  of  excision. 

If  the  disease  has  also  seriously  damaged  the  bone,  as  well  as  the  soft 
structures  of  the  joint,  excision  must  be  performed.  The  operation  is  diffi- 
cult, and  the  results  are  not  always  favorable.  The  chief  difficulty  encoun- 
tered is  the  proper  exposure  of  the  parts  to  be  removed  without  injuring  im- 
portant structures.  It  is  necessary  to  avoid  dividing  the  tendons  of  the  mus- 
cles of  the  legs,  as  well  as  the  arteries  and  nerves.  Methods  of  operating, 
therefore,  which  involve  the  incision  of  such  structures  should  not  be 
adopted. 

The  operation  which  best  preserves  vessels,  nerves,  and  tendons,  as  well 
as  the  periosteum,  is  by  two  longitudinal  incisions,  one  over  the  external  and 
the  other  over  the  internal  malleolus,  and  extended  above  and  below  suf- 
ficiently to  give  free  access  to  all  of  the  diseased  bone.  All  transverse  in- 
cisions involving  the  vessels,  nerves,  and  tendons  should  be  avoided.  The 
limb  being  turned  on  the  inner  side  upon  a  firm  pillow,  make  an  incision  two 
or  three  inches  long  (B,  Fig.  182)  on  the  middle  of  the  fibula  down  to  the 

Fig.  182. 


Excision  of  ankle ;  outer  surface  (Treves). 


point  of  the  malleolus,  and  sufficiently  deep  to  divide  the  periosteum  ;  from 
the  extremity  of  the  malleolus  continue  the  incision  backward  around  the 


672 


LOCAL  DISEASES. 


malleolus,  an  inch,  merely  through  the  skin,  so  as  not  to  injure  the  tendons, 
and  3"et  permit  of  their  being  raised  from  behind  the  malleolus  ;  at  the 
point  where  the  bone  is  to  be  divided  separate  the  periosteum  with  the  raspa- 


FiG.  183. 


Excision  of  ankle ;  inner  surface  (Treves). 


torium,  and  turn  down  as  much  as  circumstances  will  permit ;  introduce  the 
point  of  the  index  finger  or  a  spatula  into  the  interosseous  space  to  protect 
the  soft  parts  during  the  act  of  sawing ;  incline  the  saw  slightly  toward  the 

joint,  so  that  the  part  to  be  removed  will  be 
external  at  the  point  of  division  ;  seizing  the 
upper  exti'emity  of  the  fragment  with  very 
strong  forceps,  separate  its  connections  with 
the  raspatorium  and  knife  when  necessary. 
Now  turn  the  foot  upon  the  external  surface, 
and  make  the  same  straight  incision  as  upon 
the  fibula,  and  a  transverse  one  at  its  lower  end 
{B,  Fig.  183)  ;  the  periosteum  is  more  easily  separated  than  from  the  fibula  ; 
saw  the  tibia  in  place  with  a  fine-bladed  saw.  It  may  be  possible,  after  the 
periosteum  has  been  separated  and  the  ligaments  incised,  to  gradually  dislo- 


184. 


Suspension-splint . 


J 


Fig.  185. 


Leg  suspended. 


cate  the  foot  outward  with  the  aid  of  the  knife,  and  remove  the  tibia  with 
the  saw.  To  gain  more  complete  access  in  many  cases  the  incisions  made 
along  the  centre  of  the  malleoli  may  be  extended  laterally  along  the  margins 
of  the  extremities  of  these  bones.     Or  the  same  result  may  be  attained  by 


DISEASES  OF  THE  JOINTS.  573 

extending  the  incisions  made  along  the  posterior  margins  of  the  tibia  and 
fibula  around  the  lower  and  anterior  margins  of  the  malleoli  (Figs.  182,  183). 
The  after-treatment  requires  the  protection  of  the  ankle  from  movements, 
with  free  drainage.  This  is  best  effected  by  apparatus  which  allows  suspen- 
sion of  the  limb.  A  convenient  method  of  suspending  the  limb  is  as  follows  : 
Make  a  splint  of  wood  or  metal  fitted  to  the  anterior  surface  of  the  leg  and 
ankle  (Fig.  184),  with  rings  inserted  at  three  points  for  suspension  ;  in  its 
application  the  splint  is  well  padded  and  laid  on  the  front  part  of  the  leg 
and  the  limb  fixed  in  the  ordinary  bandage,  the  ankle  being  free  (Fig.  185) ; 
or  the  gypsum  bandage  may  be  applied  over  the  splint  and  around  the  leg,  a 
layer  of  old  flannel  being  first  adapted  to  the  leg  and  the  ankle  left  exposed. 

The  Tarsus. 

Synovitis  of  the  tarsal  joints  occurs  when  the  anterior  part  of  the  foot  is 
caught  and  the  leg  is  twisted  by  the  movements  of  the  body.  This  is  a 
"  sprain  of  the  foot."  The  injury  consists  in  the  tearing  of  the  ligaments 
of  these  joints  and  injuries  to  the  synovial  membranes.  The  tarsus  swells 
quickly  in  the  line  of  the  injured  joints,  and  is  very  painful  on  pressure  and 
on  moving  the  anterior  portion  of  the  foot. 

The  TREATMENT  should  be  the  same  as  that  given  for  similar  injuries 
of  the  ankle-joint — viz.  absolute  rest,  hot  water  at  first,  followed  by  strap- 
ping or  the  plaster-of-Paris  bandage. 

Tubercular  disease  of  the  tarsal  Joints  and  bones  of  children  is  always 
serious  as  regards  the  usefulness  of  the  limb.  When  the  tubercular  infec- 
tion has  once  entered  these  structures,  it  spreads  insidiously,  and  its  progress 
is  arrested  with  difficulty.  Not  infrequently  it  extends  to  the  joints  of  most 
of  the  tarsal  bones,  and  both  bones  and  joints  become  involved  in  the 
destructive  inflammation.  The  ankle-joint  is  also  often  invaded  by  a  pri- 
mary tubercular  disease  of  the  tarsus. 

The  SYMPTOMS  develop  after  an  injury,  and  at  first  consist  of  pain 
through  the  central  part  of  the  foot  in  walking,  with  swelling  in  the  form 
of  a  pufiiness  over  the  tarsus.  x\t  this  early  stage  the  precise  location  may 
sometimes  be  defined  with  considerable  accuracy  by  holding  the  heel  firmly 
with  one  hand,  while  with  the  other  the  anterior  part  of  the  foot  is  moved 
in  such  manner  as  to  compress  the  tarsal  joints,  with  friction  of  their  surfaces. 

The  early  treatment  should  be  that  of  a  sprain.  But  if  suppuration 
occurs,  a  carefully-planned  operation  should  be  performed,  having  for  its 
object  the  evacuation  of  pus  and  the  removal  of  dead  structures.  Great 
care  must  be  taken  to  avoid  injuring  tissues  not  affected,  for  the  joints  of  the 
tarsus  are  so  related  that  one  may  be  curetted  without  injuring  another.  No 
special  method  of  operation  can  be  given,  but,  as  a  rule,  it  is  important  not 
to  make  a  deep  transverse  incision  which  will  divide  the  tendons  of  the 
muscles  causing  dorsal  flexion  of  the  foot.  If  any  one  of  the  dorsal  bones 
is  carious,  it  should  be  carefully  dissected  from  its  fellows,  the  cavity 
thoroughly  cleansed  and  drained,  and  the  foot  supported  in  a  plaster-of-Paris 
bandage,  with  openings  that  will  allow  the  change  of  dressings. 

If  the  disease  invade  the  tarsus  so  generally  that  partial  excision  would 
be  satisfactory,  the  tarsal  bones,  excepting  the  caleaneum  and  astragalus, 
may  be  removed,  and  a  fairly  useful  extremity  may  result.  In  this  case  the 
incision  may  be  across  the  foot,  dividing  all  the  tissues  down  to  the  bone,  for 
dorsal  flexion  of  the  foot  will  not  be  an  important  function.  When  tendons 
are  thus  divided,  they  should  be  reunited  by  sutures.  The  support  of  the 
foot  can  best  be  secured  by  a  pasteboard  splint  applied  to  the  posterior  part 
of  the  leg  and  to  the  plantar  surface. 


574 


LOCAL  DISEASES. 


If  the  disease  still  progress,  a  Syme's  amputation  at  the  ankle-joint  must 
be  the  operation  of  final  resort.  Excisions  of  the  ankle  for  tubercular  disease 
do  not  always  progress  favorably.  The  infection  will  sometimes  escape  the 
most  thorough  search,  or  there  may  be  a  renewed  infection  from  foci  pre- 
existing in  the  system.  There  is  also  in  these  cases  a  constant  liability  to 
infection  with  pyogenic  microbes,  owing  to  the  susceptible  tissues  of  stru- 
mous children.  If  suppuration  continue  freely,  renewed  efi"orts  should  be 
made  to  remove  sources  of  septic  matters.  If,  however,  the  disease  continues 
to  progress,  it  may  finally  be  necessary  to  resort  to  amputation  at  the  joint. 

The  method  of  amputation  which  gives  the  most  favorable  results,  both 
in  the  prompt  recovery  of  the  patient  and  in  the  adaptation  of  a  stump  for 
an  artificial  limb,  is  Syme's.  Pirogofi"s  method,  which  some  recommend,  has 
two  disadvantages — viz.,  first,  the  fragment  of  bone  taken  from  the  os  calcis 
is  liable  to  necrose,  owing  to  the  failure  of  nutrition ;  and,  second,  the  stump 
is  not  as  well  adapted  to  an  artificial  foot,  owing  to  the  length  of  the  limb, 
which  brings  the  ankle-joint  too  near  the  surface  for  easy  progression. 

Symes  amputation  is  as  follows :  Place  the  foot  at  a  right  angle  to  the 
leg;  enter  the  knife  at  the  point  of  the  external  malleolus  (i^,  Fig.  182),  and 
carry  it  directly  across  the  sole  of  the  foot  to  a  point  opposite,  or  six  lines 
below  the  internal  malleolus  (i?,  Fig.  183)  ;  the  posterior  tibial  artery  divides 
beneath  the  internal  annular  ligament  into  the  internal  and  external  plantar 
arteries,  and  if  the  incision  extends  to  the  point  of  the  internal  malleolus,  the 


Fig.  186. 


Fig.  187. 


Syme's  amputation  of  the  foot :  anterior 
incision  and  disarticulation. 


Syme's  amputation  of  the  foot : 
cleaning  the  os  calcis. 


vessel  may  be  divided  ;  join  the  two  extremities  of  this  incision  by  an  anterior 
incision  in  a  direct  line  over  the  instep,  so  that  the  cicatrix  may  come  well  in 
front  (Fig.  186).     In  dissecting  the  posterior  flap,  place  the  fingers  of  the 


DISEASES  OF  THE  JOINTS.  575 

left  hand  upon  the  heel,  and  with  the  thumb  press  the  edge  of  the  flap 
firmly  backward,  cutting  between  the  nail  of  the  thumb  and  the  tuberosity 
of  the  OS  calcis  (Fig.  187),  so  as  to  avoid  lacerating  the  soft  parts  ;  the  tendo 
Achillis  is  exposed  and  divided.  Disarticulate  the  foot  and  saw  oif  the 
malleoli,  leave  the  articular  extremity  of  the  tibia  uninjured,  for  it  is  better 
not  to  interfere  with  the  bone  if  it  is  healthy. 

The  Foot. 

In  cases  of  disease  or  injuries  which  so  involve  the  anterior  part  of  the 
foot  as  to  render  amputation  necessary,  it  is  important  to  save  the  phalanges 
as  far  as  possible.  Of  these  it  must  be  remembered  that  the  great  toe  is  the 
most  useful  in  the  act  of  walking.  The  spring  and  elasticity  of  the  step  of 
the  patient  depends  more  on  this  toe  than  on  all  the  others  taken  together. 
This  toe  should  not,  therefore,  be  sacrificed  if  it  is  possible  to  preserve  even 
a  portion  of  the  phalanx.  While  the  other  toes  are  comparatively  less  use- 
ful in  the  preservation  of  a  good  step,  they  are  important  in  maintaining  the 
proper  breadth  of  foot. 

In  amputating  one  or  more  phalanges  the  flap  should  be  so  constructed 
as  to  bring  the  plantar  surface  over  the  stump,  so  that  this  dense  tissue  will 
receive  the  pressure  of  the  shoe,  and  the  impact  of  the  step  when  the  foot 
strikes  the  ground.  This  operation  requires  a  short  dorsal  and  a  long  plantar 
flap,  so  formed  that  the  cicatrix  is  on  the  dorsal  surface  rather  than  on  the 
end  of  the  stump. 


SEOTIO^nT   II. 
DISEASES   OF  THE   CEREBRO-SPINAL  SYSTEM. 


Diseases  of  the  brain  and  spinal  cord  are  less  frequent  than  those  of  the 
respiratory  and  digestive  systems,  and,  being  less  amenable  to  treatment,  they 
largely  increase  the  aggregate  of  deaths.  They  contrast  with  the  diseases  of 
the  other  systems  in  their  greater  relative  frequency  in  infancy  and  childhood 
than  in  adult  life.  This  is  explained,  as  regards  the  brain,  by  the  rapid  devel- 
opment and  active  molecular  change  in  this  organ  in  early  life,  its  great  im- 
pressibility by  the  emotions,  and  the  thinness  of  the  covering  which  protects- 
it  from  external  agencies. 

Some  of  the  most  important  of  the  diseases  of  the  cerebro-spinal  system 
are  peculiar  to  early  life,  as  tetanus  infantum  and  spina  bifida.  The  diseases 
of  this  system  also  contrast  with  other  local  affections  in  their  greater  obscur- 
ity, especially  in  their  commencement ;  for,  while  maladies  of  the  thorax  can 
be  readily  ascertained  by  auscultation  and  percussion,  or  those  of  the  abdo- 
men by  the  nature  of  the  evacuations  or  the  degree  of  tenderness  or  disten- 
tion, our  means  of  conducting  examination  through  the  bony  encasement  of  the 
cerebro-spinal  axis  are  meagre  and  unsatisfactory.  The  condition  of  the  brain 
and  spinal  cord  must  be  determined  chiefly  by  the  study  of  symptoms,  and 
not  by  direct  examination.  The  state  of  the  anterior  fontanelle  in  young  in- 
fants, however,  enables  us  to  determine  the  presence  or  absence  of  active  con- 
gestion of  the  brain.  If  there  be  an  excess  of  arterial  blood,  it  is  convex. 
Prominence  of  the  fontanelle  is  common  in  inflammatory  and  febrile  diseases,. 
and  is  a  sign  of  considerable  diagnostic  and  prognostic  value. 

Within  a  few  years  the  ophthalmoscope  has  been  employed  as  a  means  of 
diagnosis  in  cerebral  diseases,  and,  although  the  use  of  this  instrument  for 
such  purposes  is  but  recent,  enough  has  been  elicited  to  prove  its  value  as 
an  aid  in  determining  the  state  of  the  brain.  Prof.  H.  D.  Noyes  remarks  on 
this  subject:  ".  .  .  .  The  argument  for  making  ophthalmoscopic  examination 
in  all  cases  of  brain  disease  becomes  irresistible.  Indeed,  a  moment's  reflec- 
tion would  lead  to  this  conclusion  without  any  considerations  drawn  from 
pathology.  The  optic  nerve  is  only  an  outlying  portion  of  the  brain  ;  its 
extremity  is  fully  exposed  to  view.  Situated  within  about  two  inches  of  the 
brain,  it  is  the  only  nerve  in  the  body  which  we  can  inspect ;  it  contains  blood- 
vessels which  communicate  directly  with  the  intracranial  circulation.  We 
thus  come  into  relation  with  the  cerebrum  by  continuity  of  nerve-structure 
and  also  of  blood-vessels." 

Structural  changes  in  the  optic  nerve  and  retina  have  been  discovered  by 
means  of  the  ophthalmoscope  in  meningitis,  hydrocephalus,  phlebitis  of  the 
sinuses,  apoplexy,  etc.  Among  the  lesions  which  have  been  observed  by  this 
instrument  are  hyperaemia,  more  or  less  opacity  and  tumefaction  of  the  optic 
nerve,  engorgement  of  the  vessels  of  the  retina,  with  serous  or  sero-fibrinous 
exudation  and  ecchymotic  points.  In  certain  protracted  diseases,  as  chronic 
hydrocephalus,  in  which  dimness  or  loss  of  sight  occurs,  the  ophthalmoscope 
discloses  a  state  of  atrophy  of  the  optic  nerve.  Heretofore  this  instrument 
has  been  chiefly  employed  by  oculists,  but  as  it  comes  into  more  general  use 
576 


DISEASES   OF  THE  CEREBROSPINAL  SYSTEM.  577 

there  can  be  little  doubt  that  it  will  be  recognized  as  an  important  aid  in  the 
diagnosis  of  obscure  cerebral  diseases. 

Still,  with  all  possible  aid  to  diagnosis,  the  obscurity  which  attends  the 
invasion  of  many  of  the  cerebro-spinal  diseases  must  be  acknowledged.  To 
the  hasty  and  careless  physician  their  symptoms  are  often  deceptive.  Careful 
weighing  of  the  phenomena  and  thorough  and  pi'otracted  examination  are 
requisite  in  order  to  ensure  correct  diagnosis  and  proper  treatment.  Some 
of  the  cerebro-spinal  affections  are,  in  reality,  sequelae  of  other  diseases — as, 
for  example,  spurious  hydrocephalus — -and  some  are,  strictly  speaking,  only 
symptoms,  as  convulsions ;  but  on  account  of  their  importance,  and  because 
they  require  special  treatment,  it  is  proper  to  consider  them  as  diseases  jjer  se. 
The  brain  presents  certain  peculiarities  in  infancy  and  childhood.  In  the 
foetus,  while  the  other  organs  are  well  formed,  the  brain,  especially  its  cerebral 
portion,  is  still  diffluent,  and  at  birth  it  has  so  little  consistence  that  it  must 
be  handled  carefully  to  prevent  laceration.  This  softness  is  due  to  the  large 
proportion  of  water  which  it  contains.  The  following  analyses  show  the  com- 
position of  the  brain  in  three  periods  of  life : 

Infant.  Youth.  Adult. 

Albumen 7.00  10.20  9.40 

Cerebral  fats 3.45  5.30  6.10 

Phosphorus 0.80  1.65  1.80 

Osmazome,  salts 5.96  8.59  10.19 

Water 82.79  74.26  72.51 

At  birth  the  brain  has  a  nearly  uniform  white  color.  The  gray  substance, 
in  which  the  nervous  power  originates,  is  undeveloped.  The  date  of  its  ap- 
pearance corresponds  with  the  first  exhibition  of  emotion  or  intelligence,  and 
the  decided  gray  color  which  we  observe  in  the  brain  of  the  adult  does  not 
appear  until  the  age  of  full  mental  activity. 

In  the  new-born  the  brain  is  large  in  proportion  to  the  rest  of  the  body, 
and  its  growth  during  infancy  and  childhood  is  rapid.  Until  the  fifth  year, 
as  appears  from  the  observations  of  Dr.  Peacock,  its  weight  is  about  one- 
seventh  or  one-eighth  that  of  the  entire  system,  the  proportion  varying  some- 
what in  different  cases. 

The  brain  does  not  attain  its  full  size,  as  stated  by  Dr.  West,  at  the  age  of 
seven  years,  but,  according  to  Dr.  Peacock's  statistics,  it  continues  to  increase 
till  the  age  of  twenty-five  or  thirty,  although  its  growth  is  less  rapid  after  the 
age  of  seven  years  than  previously.  , 

The  membranous  covering  of  the  cerebro-spinal  axis  is  scarcely  less  inter- 
esting to  the  pathologist  than  the  axis  itself.  I  shall  speak  in  the  follow- 
ing pages  of  the  arachnoid  and  cavity  of  the  arachnoid  for  convenience  of 
description,  although  aware  of  the  fact  that  some  eminent  authorities,  as 
Virehow  and  Kolliker,  whose  opinions  in  reference  to  the  minute  anatomy 
of  the  system  always  command  attention,  if  not  assent,  believe  that  there 
is  no  arachnoid,  but  what  has  heretofore  been  called  by  this  name  is  on  the 
one  side  the  smooth  surface  of  the  dura  mater  and  on  the  other  of  the  pia 
mater. 

The  dura  mater  is  seldom  involved  in  the  diseases  of  early  life,  except  as 
it  is  affected  by  pressure,  while  the  pia  mater  and  arachnoid  are  the  seat  and 
source  of  some  of  the  most  important  diseases,  as  meningitis,  meningeal 
apoplexy,  etc. 

The  more  complicated  and  delicate  the  structure  of  an  organ,  the  more 
liable  it  is  to  errors  of  nutrition  and  growth.  There  is,  therefore,  no  organ 
which  is  so  liable  to  irregular  development  as  the  brain.  It  may  be  entirely 
wanting  or  it  may  be  partially  developed,  certain  portions  being  absent,  or, 
lastly,  its  growth  may  be  excessive,  constituting  hypertrophy. 
37 


578  LOCAL  DISEASES. 

CHAPTER  I. 

CONGESTION  OF  THE  BKAIN. 

Congestion  of  the  brain  is  not  peculiar  to  infancy  and  childhood,  but  it  is 
much  more  common  in  these  periods  of  life  than  subsequently.  This  is  due, 
in  a  great  measure,  to  the  fact  that  in  the  young  the  circulation  is  more 
readily  disturbed  by  moral  as  well  as  physical  causes  than  in  the  adult. 

Congestion  of  the  brain  is  occasionally  primary  ;  more  frequently  it  occurs 
as  a  concomitant  or  sequel  of  some  other  affection.  Diseases,  whether  con- 
stitutional or  local,  which  in  the  adult  have  no  appreciable  effect  on  the  vas- 
cularity of  the  brain  often  cause  in  the  child  a  decided  increase  of  blood  in 
this  organ. 

Causes. — Cerebral  congestion  is  of  two  kinds,  active  and  passive.  The 
former  results  from  a  cause  which  directly  affects  the  brain  and  increases  the 
flow  of  blood  toward  it,  or  from  a  cause  operating  primarily  on  the  heart  and 
increasing  the  frequency  and  force  of  its  systolic  movement ;  the  latter  is 
due  to  some  obstruction  in  the  course  of  the  circulation  or  to  feeble  propel- 
ling power  on  the  part  of  the  heart. 

Among  the  causes  which  most  frequently  produce  active  congestion  of 
the  brain  in  the  child  may  be  mentioned  blows  or  falls  on  the  head,  excessive 
fatigue  or  excitement,  heat,  dentition,  and  also  various  inflammatory  and 
febrile  affections,  especially  in  their  first  stages. 

Cerebral  symptoms  occurring  in  the  course  of  an  essential  fever  are  no 
doubt  often  due,  in  a  great  measui-e,  to  the  irritating  effect  on  the  brain  of 
the  specific  principle,  whatever  it  may  be,  circulating  in  the  blood.  Occur- 
ring in  inflammatory  diseases  which  are  located  elsewhere  than  within  the 
cranium,  they  are  often  attributed  to  functional  disturbance  of  the  brain. 
But  observations  show  that  symptoms  referable  to  the  brain,  arising  in  the 
commencement  of  the  essential  fevers  and  of  the  phlegmasise,  are  in  many 
instances  preceded  by,  and  are  therefore  doubtless  in  greater  or  less  degree 
dependent  on,  hyperaemia  of  this  organ. 

Difiicult  as  it  is  to  ascertain  the  state  of  the  brain  in  many  diseases  in 
which  it  is  involved,  we  may  determine  whether  or  not  there  be  congestion 
in  the  young  child  by  observing  the  anterior  fontanelle.  If  it  be  elevated  and 
tense  in  an  acute  disease,  hyperasmia  is  indicated.  Now,  it  is  often  unusu- 
ally prominent  in  fevers  and  inflammations,  especially  in  their  first  stages, 
when  cerebral  symptoms  are  present.  Its  elevation,  under  such  circum- 
stances, is  obviously  coincident  with  cerebral  congestion. 

The  acute  inflammations  which  are  most  likely  to  be  attended  by  cerebral 
congestion  are  those  of  the  mucous  surfaces  and  pneumonia.  Severe  coryza, 
tracheo-bronchitis,  entero-colitis,  and  colitis,  commencing  suddenly  with  great 
febrile  excitement,  are  frequently  accompanied  in  their  initial  stage  by  active 
congestion  of  the  cerebral  vessels.  Cases  like  the  following,  which  I  find  in 
my  note-book,  are  not  infrequent : 

An  infant,  four  months  old,  had  been  sick  about  two  days  with  coryza  and 
bronchitis  when  I  was  called  to  see  it;  the  pulse  numbered  156,  respiration  64;  it 
took  the  breast,  but  was  restless :  cough  frequent  and  dry :  bowels  moderately  relaxed. 
The  mucous  membrane  of  the  fauces  was  injected,  and  coarse  mucous  rales  were 
present  in  the  chest.  The  anterior  fontanelle  rose  above  the  level  of  the  cranium 
and  pulsated  forcibly.  Soon  after  convulsions  occurred,  which  were  relieved  by 
appi-opriate  measures,  and  on  the  following  day  the  fontanelle  had  subsided.  The 
patient  gradually  recovered  without  any  untoward  symptom. 


CONGESTION  OF  THE  BRAIN.  579 

Cerebral  congestion  and  convulsions  often  mark  the  initial  stage  of  active 
intestinal  phlegmasia.  This  is  especially  true  of  dysentery.  The  little 
patient,  perhaps  from  the  very  inception  of  the  colitis,  is  drowsy  ;  its  surface 
is  hot ;  pulse  full  and  rapid.  There  is  sudden  and  momentary  starting  or 
twitching  of  the  limbs.  The  anterior  fontanelle,  if  still  open,  is  elevated, 
and  it  is  not  till  the  lapse  of  several  hours  that  the  cause  of  these  symptoms 
is  apparent  from  the  occurrence  of  bloody  stools. 

The  causes  of  passive  congestion  of  the  brain  are  very  different  from 
those  of  the  active  form.  A  common  cause  is  obstruction  in  a  sinus  or  vein 
by  a  fibrinous  concretion  or  by  a  tumor  or  abscess  external  to  it. 

I  have  occasionally  met  cases  in  which  this  form  of  cerebral  congestion 
appeared  to  be  plainly  referable  to  obstruction  to  the  return  of  blood  from 
the  brain  by  the  pressure  of  bronchial  glands,  enlarged  by  hyperplasia  in 
tubercular  disease,  these  bodies  diminishing  by  external  pressure  the  calibre 
of  the  vena3  innominatae  or  the  descending  vena  cava.  Rilliet  and  Barthez 
have  called  attention  to  such  cases  in  the  clinical  history  of  tuberculosis. 
The  following  case  may  be  cited  as  an  example  ;  it  occurred  in  the  infants' 
service  of  the  New  York  Charity  Hospital : 

An  infant,  about  one  year  old,  affected  with  tuberculosis,  both  bronchial 
and  pulmonary,  was  observed  during  the  ten  days  preceding  its  death  to  bore 
the  pillow  with  its  head  almost  constantly,  so  as  to  wear  the  hair  from  the 
occiput.  The  movement  of  the  head  was  the  only  prominent  cerebral  symp- 
tom. Nothing  abnormal  was  noticed  in  the  appearance  of  the  eyes,  nor  was 
the  stomach  irritable.  A  spasmodic  cough  and  progressive  emaciation 
attracted  attention,  but  these  were  referable  to  the  tubercular  disease.  At 
the  autopsy  we  found  the  cerebral  sinuses,  veins,  and  capillaries  greatly  con- 
gested. On  tracing  the  veins  which  return  blood  from  the  brain,  an  inflamed 
and  enlarged  bronchial  gland  was  discovered  in  the  angle  formed  by  the  con- 
vergence of  the  right  and  left  venae  innominatae.  This  gland,  which  con- 
tained but  a  single  point  of  cheesy  degeneration,  had. attained  such  a  volume 
by  proliferation  of  its  cells  that  it  pressed  upon  both  vessels,  so  that  it  had 
obviously  retarded  the  circulation  in  each  and  given  rise  to  cerebral  conges- 
tion of  the  passive  form. 

Passive  congestion  often  occurs  in  the  infant  at  birth,  either  from  tedious- 
ness  of  the  labor  or  delay  in  the  expulsion  of  the  body  after  the  birth  of  the 
head.  If  it  be  simple  congestion,  and  not  congestion  with  hemorrhage,  it 
soon  passes  off.  Passive  congestion  of  the  brain  also  occurs  in  severe  parox- 
ysms of  whooping  cough,  in  which  return  of  blood  from  this  organ  is  tem- 
porarily retarded.  All  are  familiar  with  the  congestion  which  occurs  in 
parts  external  to  the  cranium  from  the  severity  of  the  cough,  producing 
epistaxis,  extravasations  under  the  conjunctiva,  etc.  The  extracranial  con- 
gestion obviously  indicates  the  presence  and  degree  of  congestion  within  the 
cranium. 

Those  who  practise  in  malarious  regions  sometimes  meet  cases  of  danger- 
ous passive  congestion  of  the  brain,  the  result  of  malaria,  occurring  especially 
in  the  cold  state  of  intermittent  fever.  In  these  cases  the  surface  is  pallid, 
its  temperature  reduced,  and  the  pulse  feeble.  The  blood,  leaving  the  pe- 
ripheral vessels,  collects  in  undue  quantity  in  the  internal  organs,  producing 
congestion  of  the  brain  as  well  as  of  the  thoracic  and  abdominal  viscera.  In 
the  child  with  malarial  disease,  in  whom  there  is  less  vigor  of  constitution 
than  in  the  adult,  death  sometimes  results  from  this  passive  congestion.  Two 
such  cases  have  occurred  in  my  practice,  although  in  this  latitude  the  malarial 
maladies  are  mild  in  comparison  with  the  type  which  they  present  in  many 
parts  of  the  United  States. 

Symptoms. — The  symptoms  of  active  congestion  of  the  brain  are  stupor, 


580  LOCAL  DISEASES. 

heat  of  head  and  headache,  throbbing  of  carotids,  restlessness  when  aroused, 
twitching  of  the  limbs,  and  perhaps  convulsions.  There  is  also  sometimes 
intolerance  of  light,  and  the  anterior  fontanelle,  if  open,  pulsates  strongly.  In 
passive  congestion  many  of  the  symptoms  are  the  same  as  in  the  active  form. 
Stupor,  twitching  of  the  limbs,  and  fretfulness  or  irritability  when  the  patient 
is  disturbed  are  common,  ordinarily  without  increase  of  temperature ;  the 
surface  may  indeed  be  cool,  and  the  face  is  not  flushed  nor  the  eyes  injected. 
The  strong  pulsation  and  elevation  of  the  anterior  fontanelle,  so  conspicuous 
in  active  congestion,  are — the  former  always,  the  latter  often — lacking. 
In  both  acute  and  passive  cerebral  congestion,  constipation  is  a  common 
symptom. 

In  many  cases  the  symptoms  of  congestion  of  the  brain  are  associated 
with  others  which  proceed  directly  from  the  cause  of  the  congestion,  but  it  is 
not  difficult,  unless  in  exceptional  instances,  to  determine  which  are  due  to 
the  congestion  and  which  to  the  antecedent  and  coexisting  pathological  state. 

ANATOMICAL  Characters. — In  active  congestion  there  is  an  excess  of 
arterial  blood  in  the  brain  and  its  membranes.  The  arteries,  to  their  minutest 
branches,  are  seen  to  be  full,  presenting  the  bright  hue  of  oxygenated  blood. 
In  passive  congestion  the  sinuses  and  veins  are  distended.  The  pia  mater, 
choroid  plexus,  and  the  vessels  of  the  brain  have  a  darker  appearance  than  in 
active  congestion.  In  both  forms  of  congestion,  unless  they  quickly  abate, 
other  anatomical  changes  soon  occur.  If  there  be  great  distention  of  the 
capillaries,  these  vessels  are  liable  to  give  way,  and  we  find  here  and  there 
little  patches  of  extravasated  blood.  In  other  cases  the  over-distention  is 
relieved  by  the  transudation  of  the  serous  portion  of  the  blood  through  the 
coats  of  the  vessels.  The  cephalo-rachidian  fluid  is  then  found  in  excess 
external  to  the  brain  and  in  the  ventricles. 

Progxosis. — The  duration  and  the  result  of  congestion  of  the  brain 
depend,  in  great  measure,  on  the  nature  of  the  cause.  If  the  cause  be 
trivial,  as  mental  excitement,  fatigue,  exposure  to  heat,  there  is  usually 
prompt  relief  if  the  condition  of  the  patient  be  understood  and  properly 
treated.  If  the  cause  be  general  or  constitutional,  as  one  of  the  essential 
fevers  or  whooping  cough,  or  if  it  be  local,  but  its  seat  external  to  the 
cranium,  the  prognosis,  so  far  as  the  congestion  is  concerned,  is  not  unfavor- 
able if  there  be  a  timely  and  judicious  use  of  remedies.  The  most  unfavor- 
able cases  are  those  in  which  the  cause  is  seated  in  the  encephalon  and  those 
in  which  there  is  some  obstructive  disease  in  the  course  of  the  circulation. 
Congestion  occurring  from  a  structural  change  within  the  cranium  is,  from 
the  nature  of  the  cause,  without  remedy  and  ordinarily  fatal.  Obstructive 
diseases  of  the  circulatory  system,  wherever  located,  being  for  the  most  part 
permanent,  give  rise,  as  a  rule,  to  incurable  congestion. 

Congestion  of  the  brain,  if  it  be  not  relieved  in  a  few  hours,  becomes 
less  and  less  amenable  to  treatment.  It  soon  passes  beyond  the  resources  of 
our  art  and  ends  in  coma  ;  it  is  seldom  protracted  beyond  a  few  days.  Extrav- 
asations of  blood,  common  in  active  congestion,  and  serous  effusion,  common 
in  the  passive  form,  diminish  the  chances  of  a  favorable  result. 

Treatment. — ^The  indication  for  treatment  in  active  congestion  is  plain. 
Measures  should  be  employed  which  produce  derivation  from  the  brain. 
Unless  there  be  an  asthenic  primary  affection,  in  the  course  of  which  the 
congestion  is  developed,  active  purgation  is  required.  A  saline  purgative  is 
ordinarily  preferable.  If  the  stomach  be  irritable,  there  is  no  better  purga- 
tive than  calomel.  In  all  cases  of  active  congestion,  whatever  the  cause, 
the  bowels  should  be  kept  open.  It  is  often  better  not  to  wait  for  the  tardy 
action  of  a  cathartic,  but  to  give  at  once  an  enema  of  soap  and  water  or  salt 
and  water.     External  derivative  agents  are  also  indicated.     A  warm  mustard 


INTRACRANIAL  HEMORRHAGE.  581 

foot-bat.li,  sinapisms  to  the  back  of  the  neck  or  chest  and  to  the  feet,  and 
cold  applications  to  the  head,  are  measures  which  should  never  be  neglected. 
In  many  cases  those  medicines  are  useful  which  reduce  the  contractile  power 
of  the  heart,  as  phenacetin. 

This  treatment,  if  employed  early,  will  relieve  the  congestion  in  a  large 
proportion  of  cases ;  but  if  there  be  no  improvement  and  if  the  child  be 
robust,  an  ice-cap  should  be  constantly  applied  to  the  head.  If  after  the 
lapse  of  some  hours  cerebral  symptoms  continue,  sanguineous  or  serous  effu- 
sion has  probably  occurred. 

The  treatment  appropriate  for  passi't-e  congestion  is  somewhat  different : 
cold  applications  to  the  head  and  those  of  a  derivative  nature  to  the  extremi- 
ties are  useful.  As  this  form  of  the  disease  is  not  primary,  but  is  dependent 
on  some  antecedent  pathological  state,  it  is  evident  that  it  can  only  be  treated 
successfully  by  removing  or  obviating  the  cause  as  far  as  possible.  But  the 
nature  of  the  various  obstructions  to  the  intracranial  circulation  is  such  that 
our  ability  to  accomplish  this  end  is  very  limited. 

If  the  cause  be  constitutional,  or  if  it  be  some  disease  in  the  neck  or 
chest,  it  may  sometimes  be  partially  or  even  wholly  removed,  but  if  seated 
within  the  cranium  it  is  beyond  our  control.  In  general,  it  may  be  said  that 
depletion  is  not  required  or  tolerated  in  passive  congestion,  and  stimulants 
are  often  needed. 


CHAPTER    II. 

INTEACEANIAL  HEMOEKHAGE   (MENINGEAL  HEMOEEHAGE, 
CEEEBEAL  HEMOEEHAGE). 

Hemorrhage  within  the  cranium  is  not  very  infrequent  in  infancy  and 
childhood,  and  there  is  no  part  of  the  encephalon,  whether  the  meninges  or 
brain,  in  which  it  does  not  sometimes  occur.  If  the  blood  be  extravasated 
upon  the  surface  of  the  brain  or  between  the  meninges,  the  disease  is  des- 
ignated by  writers  meningeal  apoplexy  ;  if  in  the  substance  of  the  brain, 
cerebral  apoplexy.  Extravasation  may  also  occur  in  one  of  the  lateral 
ventricles. 

Causes. — Apoplexy  is  usually  (there  is  an  exception)  preceded  by  con- 
gestion. If  the  congestion  increase  to  a  certain  degree,  the  distended  capil- 
laries give  way  and  extravasation  of  blood  results.  Therefore  the  causes  of 
congestion  which  have  been  enumerated  in  the  preceding  chapter  are,  in  great 
measure,  those  of  apoplexy.  Microscopic  examinations  have  demonstrated 
that  the  corpuscular  elements  of  the  blood  may  escape  from  capillaries  with- 
out rupture.  While,  therefore,  it  is  probable  that  intracranial  hemorrhage  in 
early  life  commonly  occurs  from  rupture,  its  occasional  occurrence  by 
diapedesis,  or  escape  of  blood  through  the  walls  of  the  capillaries,  must  be 
admitted. 

Intracranial  hemorrhage  is  not  infrequent  in  the  new-born.  It  results  in 
them  from  tediousness  of  the  birth  and  severity  of  the  labor-pains.  At  first 
there  is  extreme  congestion  of  the  meningeal  and  cerebral  vessels,  correspond- 
ing with  that  of  the  scalp  and  face.  This  congestion,  continuing,  soon  ends 
in  extravasation  of  blood.  In  some  of  these  cases  forceps  have  been  used  to 
effect  the  delivery,  but  it  is  doubtful  whether  the  use  of  instruments  mate- 
rially increases  the  congestion  or  the  amount  of  extravasation.  Certainly,  in 
a  large  proportion  of  intracranial  as  well  as  supracranial  hemorrhages  of  the 


582  LOCAL  DISEASES. 

new-born,  instruments  have  not  been  used.  An  additional  cause  of  the  hem- 
orrhage is,  in  some  instances,  the  use  of  ergot,  which,  by  producing  strong 
and  continuous  labor-pains,  interrupts  the  placental  circulation  and  increases 
the  congestion  of  the  foetal  veins  and  capillaries. 

In  infants  a  few  days  old  intracranial  hemorrhage  may  result  from  that 
rapid  and  fatal  disease,  tetanus  infantum.  The  hemorrhage  is  preceded  by 
intense  passive  congestion,  which  the  tetanic  rigidity  and  spasms  produce  by 
obstructing  respiration  and  circulation.  Few  cases  of  tetanus  infantum  occur 
without  more  or  less  extravasation  of  blood,  either  meningeal  or  cerebral. 
Another  cause  of  this  disease  is  obstruction  in  the  vessels  which  return  the 
blood  from  the  brain.  The  various  structural  changes  which  produce  this 
obstruction  in  different  cases  have  been  sufficiently  described  in  our  remarks 
on  cerebral  congestion. 

The  congestion  which  precedes  hemorrhage,  when  occurring  under  the 
conditions  described  above,  is  passive. 

Among  the  causes  which  produce  hemorrhage  through  the  intermediate 
state  of  active  congestion  may  be  mentioned  great  mental  excitement,  of 
which  M.  Legendre  relates  a  case,  and  lengthened  exposure  to  the  sun's  rays, 
an  example  of  which  Rilliet  and  Barthez  have  seen.  It  is  also  said  that 
compression  of  the  aorta  by  an  enlarged  liver  or  an  abdominal  tumor  has 
sometimes  produced  meningeal  or  cerebral  hemorrhage  by  causing  an  increased 
afflux  of  blood  to  the  head.  A  very  important  cause  of  cerebral  or  menin- 
geal hemorrhage  to  which  I  have  not  alluded  is  that  general  state  of  the 
circulatory  system  which  is  designated  by  the  term  purpura  hsemorrhagica. 
This  sometimes  results  from  the  antihygienic  conditions  in  which  the  child  is 
placed.  In  other  instances  it  results  from  some  antecedent  disease,  pro- 
tracted and  debilitating,  which  has  produced  a  profound  alteration  in  the 
state  of  the  blood  and  the  vessels.  The  capillaries  become  less  firm  and 
elastic  and  easily  give  way,  so  that  in  such  patients  ecchymotic  points  are 
ordinarily  found  in  different  parts  of  the  system.  The  diseases  which  occa- 
sionally end  in  this  hemorrhagic  diathesis  are  numerous.  I  have  known  it  to 
occur  after  measles,  scarlet  fever,  and  smallpox.  It  is  also  an  occasional 
sequel  of  chronic  diarrhoea  or  intermittent  and  typhoid  fevers,  and  of 
rachitis. 

Anatomical  Characters. — Hemorrhage  in  or  upon  the  brain  in  infancy 
and  childhood  differs  in  important  particulars  from  that  occurring  in  adult 
life.  In  the  adult,  and  more  so  as  life  advances,  the  arteries  become  less 
distensible  and  more  brittle,  so  that  when  hemorrhage  occurs  it  is  usually 
from  one  of  these  vessels.  In  early  life,  on  the  other  hand,  the  blood  does 
not  ordinarily  escape  from  an  artery,  but,  as  has  been  stated,  from  the  capil- 
laries. The  extravasation  is  not,  therefore,  so  rapid  and  violent,  and  is  not 
attended  by  such  laceration  and  injury  of  surrounding  parts  in  infancy  and 
childhood  as  at  a  subsequent  age.  In  the  adult  the  hemorrhage  commonly 
occurs  in  the  substance  of  the  brain.  The  flow  of  blood  from  the  ruptured 
artery  separates  the  brain-substance,  producing  a  cavity  in  which  a  clot 
forms.  This  constitutes  the  usual  form  of  apoplexy  in  the  adult.  In  the  first 
years  of  life,  on  the  contrary,  the  extravasation  is  commonly  from  the 
meninges,  and  the  symptoms  to  which  the  effused  fluid  gives  rise  are  for  the 
most  part  due  to  its  mechanical  effect.  Cases  of  hemoi'rhage  in  the  sub- 
stance of  the  brain  constitute  a  small  minority,  unless  during  the  days  imme- 
diately succeeding  birth.  In  early  life,  therefore,  on  account  of  its  greater 
frequency,  meningeal  hemorrhage  is  a  disease  of  more  importance  than  cere- 
bral, and  its  anatomical  character  should  be  carefully  studied. 

In  meningeal  hemorrhage  the  extravasation  may  be  between  the  cra- 
nium and  dura  mater,  upon  the  visceral  layer  of  the  arachnoid,  in  the  meshes 


INTRACRANIAL  HEMORRHAGE.  583 

of  the  pia  mater,  or  in  a  lateral  ventricle  from  rupture  of  the  capillaries  in 
the  choroid  plexus.  Much  the  most  common  seat  is  external  to  the  pia 
mater  in  the  so-called  cavity  of  the  arachnoid  ;  the  blood  escaping  in  this 
situation  spreads  uniformly  in  all  directions.  It  soon  separates  into  two  por- 
tions, the  solid  and  liquid.  The  solid  portion,  or  the  clot,  is  free  or  but 
slightly  attached  to  the  adjacent  membrane.  The  meninges  in  the  vicinity 
of  the  extravasated  blood  preserve  their  normal  appearance  or  are  but  slightly 
injected;  the  clot  gradually  becomes  extended  on  all  sides,  so  as  to  form  a 
lamina  at  the  seat  of  the  extravasation,  thinner  at  its  circumference  than 
centre,  and  at  first  of  a  dark-red  color.  The  color  gradually  fades,  and  the 
lamina,  becoming  smooth  and  polished  and  at  the  same  time  more  and  more 
attenuated,  finally  resembles  the  arachnoid  in  appearance.  Its  diameter 
varies  in  different  cases  from  a  few  lines  to  two  or  three  or  more  inches. 
M.  Tonnele  relates  two  observations  in  which  the  adventitious  membrane 
extended  over  the  superior  surface  of  both  hemispheres,  and  in  one  of  them 
also  over  the  falx  cerebri. 

The  extravasation  may  occur  at  any  part  of  the  surface  of  the  brain,  but 
its  usual  seat  is  the  vertex.  The  next  most  frequent  locality  is  the  base  of 
the  brain.  The  subsequent  history  of  the  delicate  membrane  into  which  the 
clot  is  gradually  transformed  is  interesting.  It  often  extends  so  as  to  cover 
more  space  than  was  occupied  by  the  extravasated  blood,  and  its  edges  are 
then  scarcely  distinguishable,  in  consequence  of  their  extreme  tenuity  and 
their  close  resemblance  to  the  arachnoid.  The  attachments  of  this  mem- 
brane, so  far  as  it  forms  any,  are  usually  to  the  parietal  surface  of  the  arach- 
noid. Sometimes  a  portion  of  the  membrane  is  attached,  while  the  rest  lies 
free,  bathed  on  either  side  by  the  liquid  portion  of  the  blood  which  still 
remains  from  the  extravasation.  According  to  M.  Legendre,  in  the  most 
favorable  cases  the  serum  is  absorbed,  and  the  membrane  which  has  resulted 
from  the  clot,  and  which  I  have  described,  becomes  intimately  adherent  to 
the  internal  surface  of  the  dura  mater.  It  forms  an  integral  part  of  this 
membrane,  and  there  only  remain  a  little  thickening  and  increased  opacity, 
indicating  the  seat  of  the  extravasation.     The  health  is  fully  re-established. 

But  the  result  in  other  cases  is  as  follows  :  The  serum  is  not  absorbed, 
and  the  newly-formed  membrane,  uniting  at  points  with  the  inner  surface  of 
the  dura  mater  or  its  arachnoidal  covering,  encloses  the  fluid  so  as  to  produce 
a  circumscribed  hydrocephalus. 

Sometimes  there  is  only  one  cyst ;  in  other  instances  the  membrane, 
especially  if  large,  unites  in  such  a  way  as  to  give  rise  to  more  cysts  than 
one.  The  size  of  the  cyst  varies  according  to  the  quantity  of  fluid,  which 
may  be  only  a  few  drachms  or  several  ounces.  Rilliet  and  Barthez  report  a 
case  in  which  there  was  a  pint  of  fluid  lying  over  each  hemisphere,  there 
being  two  cysts.  If  the  cranial  bones  are  not  united,  so  that  they  yield  to 
the  pressure,  the  size  of  the  cranium  is  increased,  and  if  the  extravasation 
be  confined  to  one  side,  an  inequality  results  and  the  symmetry  of  the  head 
is  destroyed.  The  fluid  which  causes  the  enlargement  of  the  head  in  such 
cases  is  in  part  the  serum  of  the  extravasated  blood  and  in  part  a  subsequent 
secretion. 

Various  writers  relate  cases  of  ventricular  hemorrhage.  Valleix  met  it 
in  an  infant  that  died  at  the  age  of  two  days.  In  the  Edinburgh  Journal 
of  Medicine  and  Surgery,  October,  1831,  an  interesting  case  is  related.  A 
boy,  nine  years  old,  died  of  hemorrhage  in  both  ventricles,  and  also  at  the 
base  of  the  brain  and  in  the  spinal  canal.  In  the  Nursery  and  Child's  Hos- 
pital of  this  city  the  post-mortem  examination  was  made  of  an  infant  who 
died  at  the  age  of  one  month.  In  the  posterior  eornu  of  the  left  lateral 
ventricle  were  two  clots,  elongated  and  black,  one  larger  than  the  other.     In 


584  LOCAL  DISEASES. 

the  corresponding  cornu  on  the  opposite  side  was  a  smaller  clot.  A  similar 
post-mortem  appearance  was  observed  at  the  autopsy  of  a  young  infant  that 
died  in  Charity  Hospital.  A  dark  crescentic  clot  lay  in  each  posterior  cornu. 
The  clot,  if  remaining  a  long  time,  undergoes  degeneration.  In  the  case  of 
an  adult  in  which  a  year  had  elapsed  after  the  extravasation  I  found  it  to 
contain  crystals  of  cholesterin  and  carbonate  of  lime. 

Cerebral  hemorrhage,  or  hemorrhage  in  the  substance  of  the  brain,  may 
occur  at  any  time  in  infancy  and  childhood.  The  blood  is  sometimes  extrav- 
asated  in  points  here  and  there  over  the  entire  organ  or  a  part  of  the  organ  ; 
in  other  cases  it  is  extravasated  in  one  or  perhaps  two  cavities,  as  in  the  ordi- 
nary form  of  apoplexy  in  the  adult.  In  the  first  form  of  cerebral  hemorrhage, 
or  that  in  which  the  blood  escapes  from  numerous  points  through  the  brain, 
there  is  evidently  little  laceration  or  injury  of  the  organ.  The  brain-sub- 
stance surrounding  the  hemorrhagic  points  sometimes  preserves  the  usual 
appearance.  It  is  white  and  firm.  In  other  cases  it  presents  a  reddish  or 
yellowish  appearance,  and  is  softened  to  the  depth  of  a  line  or  two.  If  the 
hemorrhage  occur  in  a  cavity,  as  in  apoplexy  of  adults,  the  nerve-fibres  are 
evidently  torn  and  separated  and  there  is  more  or  less  compression  of  the 
surrounding  brain-substance.  Unless  the  disease  be  of  long  standing,  the 
cavity  contains  a  dark  and  soft  clot  bathed  with  serum  which  has  a  reddish 
or  a  yellowish-red  appearance.  The  brain  in  the  immediate  vicinity  of  the 
cavity  is  sometimes  softened.  Rilliet  and  Barthez  state  that  they  have  seen 
8  cases  of  cerebral  hemorrhage  of  the  capillary  form  ;  10  cases  in  which  the 
hemorrhage  was  in  cavities  ;  and  in  2  of  the  18  both  forms  were  present.  In 
5  of  those  in  which  the  form  was  capillary  the  disease  was  limited  to  portions 
of  the  brain,  while  in  the  remaining  3  the  hemorrhagic  points  were  found  in 
nearly  every  part  of  the  brain. 

Apoplectic  cavities  are  seldom  seen  in  the  cerebellum,  and,  whether  the 
hemorrhage  be  capillary  or  in  a  cavity,  there  is  in  most  cases,  as  previously 
stated,  more  or  less  congestion  of  the  vessels  of  the  brain. 

The  proportion  of  cases  of  cerebral  to  other  forms  of  hemorrhage  is  be- 
lieved by  some  to  be  greater  in  the  new-born  than  at  any  other  period  of  life. 
Valleix  relates  4  cases  of  intracranial  hemorrhage  occurring  at  this  age,  2  of 
which  were  cerebral,  1  ventricular,  and  in  the  other  the  extravasation  was  in 
the  cavity  of  the  arachnoid.  Mignot  has  published  8  cases  occurring  in  the 
new-born,  in  2  of  which  the  hemorrhage  was  in  cavities  in  the  cerebrum  ;  in 
3,  in  the  lateral  ventricles ;  and  in  3,  external  to  the  brain.  If  the  same 
proportion  be  observed  in  other  statistics,  1  in  3  of  the  cases  of  intracranial 
hemorrhage  occurring  in  the  new-born  is  cerebral. 

Symptoms. — The  symptoms  in  intracranial  hemorrhage  are  not  uniform  ; 
they  vary  according  to  the  seat  as  well  as  the  quantity  of  the  efi'used  blood.' 
In  some  cases  the  extravasation  occurs  without  such  symptoms  as  would 
direct  attention  to  the  brain.  When  the  hemorrhage  occurs  at  the  time  of 
birth  in  consequence  of  strong  and  long-continued  labor-pains,  the  infant  is 
often  born  apparently  dead.  This  is  due  partly  to  the  hemorrhage,  partly  to 
the  great  congestion  of  the  brain  which  precedes  and  accompanies  the  hemor- 
rhage. Resuscitation  is  gradual  and  difficult.  The  infant's  features  are  livid 
and  perhaps  swollen  ;  its  respiration  is  gasping,  and  both  pulse  and  respira- 
tion are  slow.  Its  cry  is  feeble,  with  but  slight  movement  of  the  facial  mus- 
cles, and  the  lungs  are  but  pai'tially  inflated ;  the  eyelids  are  closed  and  the 
limbs  almost  motionless.  By  artificial  respiration  and  by  friction  the  pulse 
and  breathing  may  be  rendered  more  frequent,  but  the  latter  remains  irreg- 
ular and  gasping.  Finally,  the  limbs  grow  cold,  the  surface,  from  a  state  of 
lividity,  becomes  pallid,  and  death  occurs  in  profound  coma.  M.  Cruveilhier 
made  many  observations  at  the  Maternite  in  reference  to  the  death  of  new- 


INTRACRANIAL  HEMORRHAGE.  585 

born  infants,  and  lie  believes  that  one-third  of  those  who  die  in  birth  at  the 
full  period  die  of  apoplexy.  I  have  made  post-mortem  examinations  in  a  few 
cases  when  death  had  occurred  from  this  cause,  and  in  all  the  hemorrhage 
was  meningeal.  One  of  these  was  born  on  the  30th  of  December,  1864.  The 
birth  was  delayed  by  unusual  projection  of  the  promontory  of  the  sacrum, 
so  that  finally  the  application  of  forceps  was  necessary.  The  infant  was  ap- 
parently stillborn,  but  by  persistent  efforts  on  the  part  of  the  physician  who 
assisted  it  was  resuscitated  so  as  to  live  several  hours,  though  with  constant 
embarrassment  of  respiration  and  with  lividity.  At  the  autopsy  a  large  ex- 
travasation of  blood  was  found  in  the  cavity  of  the  arachnoid  over  a  consid- 
erable part  of  the  convexity  of  the  brain,  and  the  substance  of  the  brain  was 
deeply  congested. 

Apoplexy  in  the  new-born  does  not  always  terminate  fatally,  or,  when 
fatal,  in  the  sudden  manner  which  I  have  described.  Valleix  relates  the 
case  of  an  infant  who  died  of  pneumonia  at  the  age  of  three  and  a  half 
months.  Its  birth  had  been  protracted  and  difficult,  but  was  completed  with- 
out the  use  of  instruments.  It  had  had  during  its  entire  life  paralysis  of  the 
right  side.  At  the  autopsy  a  clot  was  found  near  the  base  of  the  right  thal- 
amus opticus,  evidently  existing  from  birth.  Around  the  clot  the  brain  was 
softened  to  the  depth  of  some  lines  and  was  of  a  bluish-red  color.  A  very 
similar  case  is  related  by  M.  Yernois.  An  infant  lived  forty-nine  days  with 
paralysis  of  the  left  side,  and  died  of  pneumonia.  At  the  autopsy  a  hemor- 
rhagic excavation  in  process  of  cicatrization  was  found  behind  the  right 
corpus  striatum  and  the  thalamus  opticus. 

Intracranial  hemorrhage  occurring  from  accidents  of  birth  is  generally 
attended  by  marked  symptoms,  such  as  have  been  described.  But  when  it 
occurs  subsequently  to  birth,  whether  in  infancy  or  childhood,  the  symptoms 
vary  greatly  in  different  cases  and  are  generally  obscure.  I  will  briefly  state 
the  symptoms  which  have  been  observed  in  both  the  cerebral  and  meningeal 
forms  of  this  disease.  First,  the  cerebral.  Sedillot  relates  the  case  of  a  child 
seven  and  a  half  years  old  whose  bare  head  had  been  exposed  several  hours 
to  the  sun's  rays.  Suddenly,  after  a  paroxysm  of  anger,  it  was  seized  with 
great  pain,  corresponding  with  the  posterior  and  inferior  fossae  of  the  cranium. 
It  uttered  piercing  cries  and  died  in  a  quarter  of  an  hour.  A  clot  was  found 
in  the  right  lobe  of  the  cerebellum.  Richard  Quinn  (Rilliet  and  Barthez) 
gives  the  history  of  a  boy,  nine  years  old,  who  in  playing  with  a  hoop  sud- 
denly stopped,  carried  his  hands  to  his  head,  and  fell  backward  unconscious. 
Three  or  four  hours  afterward,  when  examined,  he  was  found  pallid,  surface 
cool,  respiration  slow  and  at  times  stertorous,  pulse  50  to  60  per  minute  ; 
the  left  arm  was  flexed,  the  left  leg  paralyzed ;  the  right  leg  and  arm  con- 
vulsed;  right  pupil  strongly  dilated,  the  left  contracted.  He  died  seven 
hours  after  the  commencement  of  the  attack,  and  a  large  clot  was  found  in 
the  centrum  ovale  on  the  right  side. 

Pdlliet  and  Barthez  relate  the  following  case  from  Campbell :  A  boy  with 
good  previous  health  was  suddenly  seized  about  7  A.  M.  with  repeated  vomiting, 
followed  in  an  hour  and  a  half  by  violent  convulsions  ;  he  rolled  his  eyes  and 
uttered  inarticulate  cries  ;  pulse  frequent  and  hard  ;  pupils  contracted  ;  trunk 
and  lower  extremities  cool.  In  the  afternoon  he  presented  symptoms  of  com- 
pression of  the  brain,  such  as  dilatation  of  the  pupils,  frequent  and  feeble 
pulse.  Death  occurred  in  the  evening,  and  a  hemorrhagic  cavity  was  found 
occupying  the  right  middle  lobe  of  the  cerebrum.  Guibert  relates  a  case  of 
extravasation  in  the  superior  part  of  the  right  hemisphere  of  the  brain  in  a  boy 
fourteen  years  old.  The  principal  symptoms  were  feebleness  of  the  limbs, 
inability  to  walk,  cephalalgia,  involuntary  evacuations,  fever,  grinding  the 
teeth,  rigors  severe  and  prolonged,  lividity,  loss  of  intellectual  faculties,  dila- 


586  LOCAL  DISEASES. 

tation  of  the  pupils,  insensibility  to  light,  stertorous  respiration.  Death  oc- 
curred in  about  an  hour. 

Rilliet  and  Barthez  narrate  the  history  of  a  girl  two  years  old  who,  after 
an  attack  of  measles,  was  taken  with  convulsions  accompanied  with  fever  and 
prostration.  The  convulsive  movements  aflFected  especially  the  eyes  and  upper 
extremities ;  the  right  leg  was  immovable ;  the  left  pupil  dilated.  These 
symptoms  resulted  from  hemorrhage  in  the  corpus  striatum  and  opticus  thal- 
amus. The  same  authors  relate  also  the  case  of  a  girl  seven  years  old  who 
died  with  a  large  apoplectic  cavity  in  the  left  thalamus  opticus.  The  symp- 
toms were  headache,  convulsive  movements,  loss  of  consciousness,  delirium, 
vomiting,  constipation,  and  convergent  strabismus.  The  symptoms  nearly  dis- 
appeared, but  in  a  few  days  the  headache  returned,  with  strabismus  and  a 
slight  drawing  of  the  face  toward  the  left ;  on  the  twenty-seventh  day  con- 
vulsive movements  of  the  right  eye  were  observed,  with  paralysis  of  the  arm. 
Finally,  contraction  of  the  arms  occurred,  with  acceleration  of  pulse,  irregular 
breathing,  dilated  pupils,  paralysis,  and  retraction  of  the  head,  followed  by 
death  on  the  forty-eighth  day. 

These  cases,  and  those  from  Valleix  and  Vernois  which  have  been  related 
in  our  remarks  on  hemorrhage  of  the  new-born,  are  sufficient  to  show  the 
character  of  the  symptoms  in  that  form  of  cerebral  hemorrhage  in  which  the 
extravasated  blood  forms  a  cavity  in  the  interior  of  the  brain. 

If  the  amount  of  extravasation  be  large  and  the  substance  of  the  brain 
be  much  lacerated  and  compressed,  death  may  occur  almost  immediately,  and 
therefore  without  symptoms,  or  before  it  is  possible  to  determine  whether  or 
not  symptoms  are  present.  If  the  disease  be  not  so  speedily  fatal,  the  symp- 
toms, as  appears  from  the  above  cases,  are  headache,  confusion  of  thought,  or 
even  insensibility  ;  cries,  sometimes  piercing ;  cold  extremities,  pallor,  slow 
and  perhaps  stertorous  respiration  ;  convulsive  movements  followed  by  paral- 
ysis, or  convulsions  aifecting  one  or  more  limbs,  with  paralysis  of  others ;  pupils 
contracted  or  dilated,  sometimes  one  contracted  and  the  other  dilated ;  stra- 
bismus, rolling  of  eyes,  vomiting. 

These  symptoms  have  all  been  observed  in  different  cases,  but  they  are  not 
all  present  in  any  one  case.  Those  which  are  generally  present,  and  on  which 
we  mainly  rely  for  diagnosis,  are  headache,  convulsive  movements,  paralysis,, 
confusion  of  thought,  irregularity  in  the  pupils,  and  strabismus. 

In  the  capillary  form  of  cerebral  hemorrhage  there  is  usually  some  com- 
plication, so  that  it  is  not  easy  to  determine  how  far  symptoms  are  due  to  the 
hemorrhage  and  how  far  to  the  coexisting  pathological  state. 

There  are,  indeed,  but  few  published  observations  of  hemorrhage  in  the 
substance  of  the  brain  unaccompanied  with  meningeal  hemorrhage,  hemor- 
rhage into  a  ventricle,  or  some  other  distinct  disease  ;  but,  so  far  as  I  have  been 
able  to  ascertain  the  symptoms  referable  to  this  form  of  extravasation,  they 
are  as  follows  :  The  child  is  drowsy  ;  fretful  when  disturbed  ;  it  perhaps  moans. 
There  are  sometimes  slight  convulsive  movements  and  partial  paralysis.  If 
there  be  considerable  extravasation,  the  respiration  is  irregular  and  sighing. 
Death  occurs  in  coma,  occasionally  preceded  by  convulsions.  Taupin  relates 
the  case  of  a  child,  nine  years  old,  who  died  with  this  form  of  hemorrhage, 
accompanied  by  softening  of  the  brain.  The  disease  began  at  night  with  delir- 
ium, agitation,  and  piercing  cries.  In  the  morning  the  patient  lay  in  bed, 
drowsy,  not  complaining  of  pain  and  not  replying  to  questions  ;  piipils  dilated 
and  insensible  to  light ;  left  eye  half  open  during  sleep  and  its  axis  changed ; 
eyebrows  contracted  ;  face  pale  ;  mouth  open  ;  had  no  convulsions,  but  tran- 
sient stiffening  of  the  limbs,  during  which  the  thumbs  were  firmly  compressed 
by  the  fingers;  senses  unimpaired,  but  the  face  drawn  to  the  right;  deglu- 
tition difficult ;  pulse  small,  irregular,  and  feeble  ;  respiration  32,  sighing.    In 


INTBACBANIAL  HEMORRHAGE.  587 

the  evening  he  had  rigidity  of  the  limbs  and  back,  and  finally  was  taken  with 
general  convulsions,  in  which  he  died  at  eleven  o'clock.  The  hemorrhagic 
points  in  this  case  were  numerous.  K  boy  five  years  old,  whose  case  is  de- 
scribed by  Rilliet  and  Barthez,  died  of  this  disease,  pneumonia,  and  white 
softening  of  the  intestine.  During  the  last  five  days  there  were  cerebral  symp- 
toms, the  chief  of  which  were  drowsiness,  fretfulness  when  disturbed,  and 
moaning  without  apparent  cause.  Another  child,  whose  case  is  described  by 
Rilliet  and  Barthez,  died  at  the  age  of  four  years  with  cerebral  capillary  hem- 
orrhage, accompanied  by  yellow  softening.  Six  months  before  death  he  had 
general  convulsions,  followed  by  spasmodic  movements  of  the  left  side.  These 
subsided,  but  the  left  side  remained  feeble. 

In  meningeal  hemorrhage  there  are  often  convulsions,  general  or  par- 
tial—in some  patients  tonic,  in  others  clonic.  When  partial,  the  convulsive 
movements  may  only  occur  in  the  muscles  of  the  face  and  eyes.  With  the 
spasmodic  muscular  action  is  a  degree  of  drowsiness  with  irritability.  Paral- 
ysis, so  common  in  the  apoplexy  of  the  adult,  and  not  infrequent,  as  we  have 
seen,  in  the  cerebral  form  in  early  life,  is  sometimes,  but  not  ordinarily,  pres- 
ent in  meningeal  hemorrhage.  Instead  of  paralysis,  there  are  vomiting,  some 
febrile  action,  thirst,  and  loss  of  appetite.  The  symptoms  are  different,  how- 
ever, according  to  the  exact  seat  of  the  hemorrhagic  extravasation  and  the 
duration  of  the  disease.  If  the  extravasation  end  in  the  formation  of  a  cyst, 
the  symptoms  are  those  of  hydrocephalus.  The  following  condensed  history 
of  cases  which  I  have  selected  as  typical  will  give  us  a  clearer  idea  of  the  his- 
tory and  course  of  the  various  forms  of  meningeal  hemorrhage  than  can  be 
imparted  by  a  narration  of  symptoms : 

M.  Tonnele  relates  the  case  of  a  child  which  was  taken  with  faintness  and 
convulsive  movements.  On  the  following  day  the  trunk  and  inferior  extrem- 
ities became  rigid ;  deglutition  was  painful  ;  the  pupils  were  largely  dilated, 
immovable ;  face  pale ;  pulse  feeble  and  intermittent.  Death  occurred  the 
same  day.  The  dura  mater  was  distended.  A  layer  of  coagulated  blood  of 
great  thickness  extended  over  the  convexity  of  each  hemisphere.  The  veins 
ramifying  into  the  superior  portion  of  the  cerebrum  were  distended  with  coag- 
ulated blood.  The  hemorrhage  was  in  the  meshes  of  the  pia  mater.  Drs. 
Lombard  and  Panchard  of  Geneva  relate  a  somewhat  similar  case.  A  child 
thirteen  months  old  was  convalescing  from  inflammation  of  the  bronchial  and 
intestinal  mucous  surfaces  when  it  was  seized  with  general  convulsions  ;  the 
mouth  and  eyes  were  open  and  the  eyes  directed  upward  ;  pupils  contracted ; 
pulse  frequent  and  irregular.  The  convulsions  abated  somewhat,  but  soon 
reappeared  with  violence.  The  patient  became  insensible,  and  died  nineteen 
hours  after  the  commencement  of  cerebral  symptoms.  The  extravasated  blood 
covered  the  upper  surface  of  both  hemi.spheres.  From  the  above  eases  we  see 
the  symptoms  and  the  course  of  meningeal  hemorrhage  when  the  extrava- 
sation is  so  large  that  death  speedily  results.  In  protracted  cases  of  menin- 
geal hemorrhage  there  is  either  a  gradual  disappearance  of  symptoms  and 
return  to  health,  or,  circumscribed  hydrocephalus  occurring,  the  symptoms  of 
that  disease  arise. 

Diagnosis. — It  is  evident,  from  what  has  been  stated,  that  the  diagnosis 
of  intracranial  hemorrhage  is  attended  with  unusual  difficulty,  since  the 
symptoms  of  this  disease  occur  also  in  other  and  distinct  pathological  states. 
The  history  of  the  case,  and  especially  the  character  of  the  cause,  if  ascer- 
tained, will  aid  in  diagnosis.  If  there  have  been  an  obvious  determination 
of  blood  to  the  brain  or  some  known  obstruction  to  the  return  of  blood  from 
that  organ,  the  persistence  of  cerebral  symptoms  would  justify  us  in  con- 
cluding that  either  serous  or  sanguineous  effusion  had  supervened  on  a  state 
of  congestion.     The  points  of  differential  diagnosis  between   apoplexy  and 


588  LOCAL  DISEASES. 

meningitis  are  the  sudden  and  full  development  of  symptoms  in  one  case, 
the  gradual  commencement  and  gradual  increase  of  symptoms  in  the  other ; 
differences  also  of  symptoms  in  certain  respects ;  for  example,  as  regards 
fever,  constipation,  etc. 

There  is  one  symptom  in  cerebral  hemorrhage  which  is  of  great  diagnostic 
value — namely,  paralysis.  Its  presence  affords  strong  evidence  that  there  is 
extravasation  of  blood,  and  probably  in  a  cavity  of  the  substance  of  the  brain. 
If  the  extravasation  end  in  the  formation  of  a  cyst,  the  symptoms  and  appear- 
anqe  of  hydrocephalus,  vi^hich  after  a  time  arise,  throw  light  on  the  nature 
of  the  disease. 

Prognosis.  —  There  can  be  no  doubt  that  many  cases  of  intracranial 
hemorrhage  occur  and  terminate  favorably  without  the  nature  of  the  disease 
being  suspected.  In  such  cases  the  amount  of  extravasated  blood  is  small 
or  moderate.  In  several  published  cases  in  which  the  accuracy  of  the  diag- 
nosis was  shown  by  post-mortem  examinations,  the  patients  were  convalescing 
from  the  hemorrhage  when  they  succumbed  to  intercurrent  disease.  If, 
however,  the  amount  of  extravasated  blood  be  such  as  to  give  rise  to  those 
symptoms  which  have  been  described,  the  prognosis  is  unfavorable.  Recur- 
ring convulsions  and  persistent  stupor  from  which  it  is  difficult  to  arouse  the 
patient  are  unfavorable  symptoms.  If  the  convulsions  cease  and  conscious- 
ness return,  even  if  there  be  paralysis,  the  result  may  be  favorable. 

Treatment. — The  proper  treatment  in  intracranial  hemorrhage  depends 
on  the  state  of  the  patient,  the  time  which  has  elapsed  since  the  extravasa- 
tion, and  the  degree  of  it  as  shown  by  the  nature  and  severity  of  the  symp- 
toms. If,  as  is  often  the  case,  the  patient  be  robust  and  be  visited  soon  after 
the  commencement  of  the  attack,  cold  applications  should  be  made  to  the 
head,  mustard  to  the  back  of  the  neck  and  perhaps  chest,  and  derivation 
should  be  produced  by  mustard  pediluvia.  In  active  congestion  prompt  pur- 
gation by  salines  or  other  cathartics  is  sometimes  of  great  importance.  The 
object  of  such  treatment  is  to  relieve  congestion  of  the  cerebral  and  meningeal 
vessels,  and  thereby  prevent  further  extravasation  of  blood.  If  the  conges- 
tion be  active,  the  pulse  continue  full  and  frequent,  and  the  face  be  flushed, 
it  is  proper  in  many  cases  to  control  the  action  of  the  heart  by  a  sedative. 
For  this  purpose  the  tincture  of  aconite-root  may  be  given  in  doses  of  one 
drop  to  a  child  five  years  old,  repeated  in  three  hours,  or  a  more  prompt 
sedative,  as  phenacetin,  may  be  given.  If  the  stupor  or  convulsions  continue 
after  sufficient  time  have  elapsed  for  the  patient  to  receive  the  full  benefit 
of  the  above  remedies,  more  counter-irritation  is  required.  Cantharidal  col- 
lodion should  be  applied  behind  each  ear.  If  the  hemorrhage  occur  from 
passive  congestion  or  in  a  cachectic  state  of  system,  active  depressing  reme- 
dies should  not  be  employed.  External  derivatives  are  of  service,  as  well  as 
cool  applications  to  the  head,  and  we  should  attempt,  as  far  as  possible,  to 
remove  the  cause  of  the  congestion  and  hemorrhage.  If  it  depend  on  a 
cachectic  state,  tonic  or  other  remedies  calculated  to  relieve  this  state  are 
indicated.  The  hemorrhage  from  such  a  cause  is  usually  in  points  in  the 
substance  of  the  brain  or  in  moderate  quantity  over  the  surface  of  this  or2;an, 
and  by  a  timely  use  of  constitutional  remedies  possibly  we  may  prevent  further 
extravasation  of  blood  and  increase  the  chance  of  the  patient's  recovery. 

If  a  cyst  result  from  the  hemorrhagic  effusion,  the  treatment  which  is 
proper  is  that  described  in  the  chapter  on  Acquired  Hydrocephalus. 


CONGENITAL  HYDROCEPHALUS.  589 

CHAPTER    III. 

CONGENITAL     HYDROCEPHALUS. 

Congenital  hydrocephalus  consists  in  an  excess  of  the  cerebro-spinal 
fluid,  lying  either  external  to  the  brain  or  more  frequently  in  its  interior. 
It  is  due  to  some  vice  in  the  development  of  the  brain  or  its  membranes  or 
to  a  pathological  state  occurring  in  them  during  intra-uterine  life.  This 
disease  is  in  some  patients  apparent  from  the  symptoms  and  appearances  at 
birth,  but  not  always.  Occasionally  nothing  unusual  is  observed  in  the 
shape  of  the  head  or  aspect  of  the  infant  till  after  the  lapse  of  some  weeks, 
when  the  characteristic  physiognomy  begins  to  appear.  In  these  cases  the 
disease  is  still  congenital,  since  there  is  every  reason  to  believe  that  the 
abnormal  state  to  which  the  excessive  production  of  fluid  is  due  existed 
from  birth.  In  cases  of  arrested  or  partial  development  of  the  brain — as, 
for  example,  when  a  considerable  portion  of  the  hemispheres  is  absent — there 
is  often  an  unusually  large  quantity  of  fluid  which  serves  as  a  compensation 
for  the  lack  of  brain.  I  do  not  regard  such  cases  as  examples  of  hydro- 
cephalic disease,  since  the  eff"ect  of  the  fluid  is  not  injurious,  but  rather 
useful.  I  restrict  the  term  congenital  hydrocephalus  to  those  cases  in  which 
the  brain  is  complete,  or,  if  incomplete,  the  quantity  of  fluid  is  more  than 
sufiicient  to  supply  the  deficiency. 

Anatomical  Characters. — According  to  M.  Breschet,  the  fluid  in  con- 
genital hydrocephalus  may  be — 1st,  between  the  dura  mater  and  the  cranium  ; 
2d,  between  the  dura  mater  and  the  parietal  arachnoid ;  3d,  in  the  cavity  of 
the  arachnoid ;  4th,  in  the  ventricles ;  5th,  between  the  arachnoid  and  the 
brain. 

In  a  large  majority  of  hydrocephalic  patients  the  eff"usion  occurs  in  the 
ventricles.  As  the  quantity  of  fluid  increases,  the  pressure  from  within  grad- 
ually unfolds  the  convolutions  of  the  brain,  at  the  same  time  producing  expan- 
sion of  the  cranial  arch.  When  the  amount  of  fluid  is  considerable — and  it 
becomes  so  in  the  course  of  a  few  weeks  or  months — the  hemispheres  are 
spread  out  in  a  thin  lamina  on  either  side,  gradually  decreasing  in  thickness 
from  the  base  of  the  cranium  to  the  vertex,  where  the  brain-substance  is 
sometimes  so  thin  as  to  be  scarcely  perceptible.  Complete  absence  of  brain 
in  this  situation — namely,  at  the  vertex,  even  in  extreme  cases  of  expansion 
and  flattening  of  the  hemispheres  from  the  pressure  of  the  liquid — is  rare, 
though  the  brain-substance  at  this  point  is  sometimes  almost  as  thin  as  either 
of  the  membranes,  so  that  the  wall  of  the  sac  is  translucent.  The  membranes 
which  surround  the  brain  do  not  usually  undergo  any  alteration,  except  such 
as  arises  from  the  distention.  The  falx  cerebri  sometimes  disappears,  and 
sometimes  the  meninges  present  a  whiter  hue  from  maceration  than  in  health. 
The  distention  also  causes  such  an  expansion  of  the  pia  mater  that  it  becomes 
very  thin,  and  in  places  scarcely  visible,  but  its  presence  in  every  point  can 
be  demonstrated. 

The  accompanying  woodcut  represents  congenital  hydrocephalus  as  it  ordi- 
naril}^  occurs.  I  saw  this  infant  when  it  was  a  few  days  old,  and  examined 
it  from  time  to  time  till  its  death.  The  parents  are  healthy  and  have  other 
healthy  children.  This  infant  when  nine  days  old  began  to  have  clonic  convul- 
sions of  a  mild  form  in  the  muscles  of  the  face,  neck,  and  limbs,  which  occurred 
almost  daily  till  the  age  of  six  weeks,  and  sometimes  every  five  or  ten  minutes. 
When  the  convulsions  ceased  in  the  sixth  week  the  head  was  observed  to 
enlarge,  and  its  excessive  growth  continued  till  death,  which  occurred  at  the 


590 


LOCAL  DISEASES. 


aoe  of  seven  months  and  one  week.  AVhile  the  volume  of  the  head  progres- 
sively increased,  the  trunk  and  limbs  emaciated.  At  death  the  occipito-frontal 
circumference  of  the  head  was  nineteen  and  a  half  inches ;  the  vertical  from 
auditor}'  meatus  to  meatus,  thirteen  and  a  half  inches. 

The  changes  which  the   cranial    bones  undergo,  both  in  their  chemical 
character  and  in  their  shape,  in  hydrocephalic  patients,  if  the  amount  of  fluid 

Fig.  188. 


^"m/v^ 


be  considerable,  are  interesting  and  remarkable.  The  base  of  the  cranium 
undergoes  little  change,  but  those  portions  of  the  frontal,  parietal,  and  occip- 
ital bones  which  constitute  the  arch  are  expanded  in  all  directions,  while  they 
become  much  thinner.  There  is  deficiency  of  lime  in  their  constittition,  so 
that  the  organic  elements  are  greatly  in  excess.  This  renders  them  flexible 
and  semi-transparent.  Notwithstanding  the  expansion  of  the  bones,  there  are 
usually  interspaces  between  them,  of  greater  or  less  size  according  to  the 
amount  of  fluid. 

The  scalp,  being  stretched  by  the  pressure  underneath,  becomes  tense  and 
thin,  and  is  scantily  covered  with  hair.  The  veins  which  ramify  in  it  are 
unusually  prominent  and  large,  and  the  head  is  elastic  on  pressure  from  the 
amount  of  liquid  beneath.  In  the  common  form  of  congenital  hydrocephalus 
— namel}',  that  in  which  the  liquid  is  in  the  interior  of  the  brain — the  shape 
of  the  orbital  plates  of  the  frontal  bone  is  often  changed,  so  that  the  eyeballs 
have  a  downward  direction.  This  change  in  the  axis  of  the  eyes  occurs  at 
an  early  period,  and  it  continues  through  the  entire  disease,  becoming  more 
and  more  marked  as  the  quantity  of  liquid  increases.  If  the  amount  be 
large,  the  lower  part  of  the  cornea  is  buried  under  the  under  eyelid,  while 
the  conjunctiva  is  visible  between  the  cornea  and  the  upper  eyelid.  The  per- 
sistent downward  direction  of  the  eyes  is  characteristic  of  this  disease,  and  in 
connection  with  enlargement  of  the  head  is  an  important  diagnostic  sign. 
Nevertheless,  hydrocephalus,  even  of  the  ventricular  variety,  sometimes 
occurs  without  change  in  the  direction  of  the  eyes. 

If  we  examine  the  interior  of  the  cavity  after  the  fluid  is  evacuated,  we 
will  find  at  its  base  the  parts  which  lie  in  the  floor  of  the  lateral  ventricles, 
but  changed  in  appearance  in  consequence  of  pressure.  The  cornua  are 
enlarged  and  the  thalami  optici  and  corpora  striata  are  flattened.     In  the 


CONGENITAL  HYDROCEPHALUS 


591 


early  stages  of  the  disease,  when  the  amount  of  fluid  is  small,  there  is  prob- 
ably no  absorption  or  destruction  of  parts  in  the  interior  of  the  brain.  The 
various  portions  of  this  organ  retain  nearly  their  normal  relation  to  each 
other.  As  the  quantity  of  fluid  increases  the  foramen  of  Monro,  which  unites 
the  lateral  ventricles,  becomes  enlarged,  the  septum  lucidum  which  separates 
them  disappears,  and  the  two  ventricles  form  a  common  cavity.  In  most  fatal 
cases  we  find  this  single  large  cavity.  The  surface  which  surrounds  the  cavity 
occasionally  presents  a  whitish  or  semi-opaque  appearance,  which  has  led  to  the 
belief  that  at  a  period  antecedent  to  birth  there  was  subacute  inflammation 
of  this  surface,  and  hence  the  efi"usion. 

The  bones  of  the  face  are  ordinarily  less  developed  than  in  healthy  chil- 
dren of  the  same  age,  so  that  the  disproportion  between  the  head  and  face 
becomes  a  marked  peculiarity.  The  shape  of  the  forehead  and  face  is  nearly 
triangular. 

The  foregoing  remarks  in  reference  to  the  anatomical  characters  of  con- 
genital hydrocephalus  refer  in  the  main  to  cases  which  have  continued  for  a 
considerable  time,  so  that  their  characteristic  features  are  well  marked.  In 
very  young  infants,  in  whom  the  disease  is  still  recent,  similar  anatomical 
characters  are  present,  but  in  less  degree. 

Congenital  hydrocephalus  is  often  associated  with  other  vices  of  confor- 
mation, especially  with  spina  bifida.  The  two,  when  coexisting,  are  only  parts 
of  the  same  disease,  the  large  quantity  of  cerebro-spinal  fluid  preventing  the 
spinal  canal  from  closing  during  fcetal  development. 

The  fluid  in  congenital  hydrocephalus  consists  largely  of  water,  in  the 
proportion  even  of  99  parts  in  100.  In  addition  to  this  element  there  are 
traces  of  albumen,  chloride  of  sodium,  phosphate  and  carbonate  of  sodium, 
and  osmazome. 

I  have  had  an  opportunity  to  witness  only  one  post-mortem  examination 
in  a  case  of  congenital  hydrocephalus  in  which  the  liquid  was  exterior  to  the 
brain.  This  case  was  under  observation  in  the  children's  service  of  Charity 
Hospital  in  1866.  Full  notes  and  measurements  of  the  head  were  taken, 
which,  unfortunately,  were  mislaid  or  lost.  The  infant  had  congenital  syph- 
ilis and  had  a  pallid,  strumous  appearance.  The  shape  and  relative  size  of 
the  head  are  seen  in  the  woodcut  (Fig.  189),  from  a  photograph.  While  the 
whole  head  was  enlarged,  there  was  a  relative  excess  of  development  in  the 
part  between  and  above  the  ears.  The  axis  of  the  eyes  was  not  changed,  and 
the  vision  was  good.  The  appearance  corresponded  so  closely  with  descrip- 
tions of  hypertrophy  of  the  brain  that  this  was  supposed  to  be  the  anatomical 
state.  Antisyphilitic  treatment  was  employed,  and 
the  syphilitic  eruptions  had  disappeared  when 
diarrhoea  supervened,  followed  by  death.  At  the 
autopsy  a  quantity  of  transparent  or  light  straw- 
colored  liquid,  estimated  at  six  or  seven  ounces, 
was  found  exterior  to  the  brain  in  the  great  cavity 
of  the  arachnoid,  lying  mostly  over  the  superior 
surface  of  the  organ.  There  was  no  excess  of  liquid 
in  the  ventricles,  and  the  bi'ain,  though  of  good  size, 
was  not  abnormally  large,  nor  did  it  possess  the 
firmness  which  is  present  in  true  hypertrophy. 

All  cases  of  congenital  hydrocephalus  may  be 
embraced  in  two  groups — namely,  that  in  which 
the  liquid  is  in  the  interior  of  the  brain,  and  that 
in  which  it  lies  exterior  to  the  organ.  Liquid  pri- 
marily in  the  arachnoidean  cavity  permeates  the 
meshes  of  the  pia  mater,  and  lies  in  part  underneath  it,  or  this  delicate  mem- 


FiG.  189. 


592  LOCAL  DISEASES. 

brane  may  be  ruptured.  Four  of  the  groups,  therefore,  described  by  Breschet, 
may  properly  be  reduced  to  one — namely,  those  groups  in  which  the  liquid 
lies  under,  between,  or  external  to  the  meninges.  It  is  probable  that  some  of 
the  cases  which  led  to  Breschet's  classification  were  examples  of  acquired 
circumscribed  hydrocephalus,  the  result  of  extravasation  of  blood. 

Etiology. — The  constitutional  vice  which  gives  rise  to  this  disease  is 
probably  different  in  different  cases.  I  have  been  able,  I  think,  to  attribute 
correctly  a  considerable  proportion  of  cases  which  I  have  observed  to  con- 
genital syphilis,  but  in  other  instances  from  the  character  of  the  parents  I 
could  not  assign  this  cause. 

Symptoms. — If  there  be  a  considerable  amount  of  hydrocephalic  fluid 
prior  to  the  birth  of  the  child,  so  that  the  head  is  abnormally  large,  partu- 
rition is  seriously  interfered  with.  The  scalp  and  meninges  may  become 
ruptured  by  the  severity  of  the  pains,  so  that  the  fluid  escapes.  If  this  do 
not  occur,  the  labor  is  often  necessarily  instrumental.  Whether  the  liquid  be 
present  before  birth  or  accumulate  subsequently  to  it,  the  tendency  is  to  an 
increase  of  the  quantity  and  a  corresponding  enlargement  of  the  head. 

The  digestive  function  in  this  disease  is  at  first  well  performed.  The 
infant  nurses  readily  and  has  its  evacuations  with  the  regularity  of  other 
children.  Not  many  weeks,  however,  elapse,  in  the  majority  of  cases,  before 
defective  nutrition  is  apparent. 

While  the  volume  of  the  head  increases,  other  parts  are  imperfectly  nour- 
ished and  stunted  in  their  growth.  Emaciation  of  the  neck,  trunk,  and 
limbs, is  common,  associated  with  progressive  feebleness.  In  the  last  stages 
of  this  disease  there  is  more  or  less  vomiting,  with  constipation.  If  there 
were  previously  the  ability  to  support  the  head,  it  is  now  lost,  and  the  erect 
position  is  no  longer  possible.  In  marked  cases,  when  there  is  great  dispro- 
portion between  the  head  and  the  rest  of  the  system,  there  is  frequently  not 
even  the  ability  to  rotate  the  head  on  the  pillow.  So  long  as  the  cranial 
bones  yield  readily  to  the  pressure  from  within  and  there  is  no  compression 
of  the  brain,  the  function  of  this  organ  is  not  seriously  impaired.  The  child 
recognizes  its  mother  or  nurse,  and  it  can  be  amused  like  other  children, 
though  easily  fatigued.  The  state  of  the  senses  is  different  in  different  cases, 
and  sometimes  at  different  stages  of  the  same  case.  The  sight  and  hearing 
in  some  are  perfect,  in  others  impaired,  while  in  others  still  they  are  good  at 
first,  but  gradually  become  obscured  and  lost.  It  is  said  that  the  sense  of 
smell  may  be  perverted,  so  that  agreeable  odors  are  unpleasant,  and  vice  versa. 
Many,  reaching  the  age  at  which  children  begin  to  walk,  cannot  walk,  or,  if 
they  do,  it  is  with  a  tottering,  unsteady  gait. 

When  the  liquid  increases  to  that  extent — and  it  usually  does  sooner  or 
later — that  the  brain  begins  to  be  compressed,  dangerous  cerebral  symptoms 
arise.  The  child  becomes  drowsy  and  takes  less  notice  of  objects.  Spas- 
modic muscular  contractions,  and  finally  convulsions,  occur.  The  pupils  act 
feebly  or  irregularly  by  light,  or  one  is  more  dilated  than  the  other.  Strabis- 
mus also  occurs.  As  death  approaches,  eclampsia,  partial  or  general,  be- 
comes more  frequent,  and  is  succeeded  by  stupor  from  which  the  patient 
cannot  be  aroused. 

The  following  case,  which  I  copy  from  my  note-book,  is  an  example  of  the 
common  form  of  congenital  hydrocephalus ;  it  will  give  an  idea  of  the  ordinary 
course  of  this  disease,  and  show  the  difficulty  which  we  meet  with  in  its  treatment : 
Female,  born  November  9,  1859,  with  the  aid  of  forceps.  At  birth  the  fontanelles 
were  unusually  large,  the  cranial  bones  separated,  and  the  aspect  in  a  marked  de- 
gree hydrocephalic.  She  nursed  at  first,  but,  the  mother's  milk  failing,  she  was 
afterward  bottle-fed.  At  the  age  of  four  months  her  head,  which  had  increased 
faster  than  her  general  growth,  measured  from  one  auditory  meatus  to  the  other, 


CONGENITAL  HYDROCEPHALUS.  593 

over  the  vertex,  seventeen  inches  ;  the  occipito-frontal  circumference,  twenty-three 
inches.  At  this  time  she  manifested  considerable  intelligence,  being  able  to  distin- 
guish her  mother  from  other  persons,  though  the  head  was  so  large  that  it  was 
necessary  to  support  it  constantly  on  a  pillow.  From  the  age  of  four  to  six  months 
the  operation  of  tapping  was  performed  six  times  with  a  small  hydrocele  trocar  by 
Dr.  Stephen  Smith,  at  a  point  near  the  coronal  suture  and  from  one  inch  to  one 
inch  and  a  half  from  the  sagittal.  At  each  operation  an  amount  of  fluid  varying 
from  twelve  ounces  to  one  pint  was  removed,  and  the  head  then  covered  with  strips 
of  adhesive  plaster,  so  as  to  form  a  complete  cap.  It  was  necessary,  however, 
within  the  twelve  hours  succeeding  each  operation  to  loosen  the  dressing  on  account 
of  either  the  occurrence  of  convulsions  or  symptoms  premonitory  of  them.  The 
head  within  a  week  subsequently  to  each  operation  regained  its  former  size,  and,  as 
there  was  no  permanent  benefit,  this  treatment  was  discontinued.  She  finally  died 
of  entero-colitis  at  the  age  of  ten  months  and  five  days. 

At  the  autopsy  the  distance  from  one  auditory  meatus  to  the  other  was  twenty 
and  a  quarter  inches ;  the  occipito-frontal  circumference,  twenty-six  and  a  quarter 
inches.  The  anterior  fontanelle  measured  antero-posteriorly  four  and  three-fourths 
inches  ;  transversely,  seven  and  three-fourths  inches.  The  parietal  bones  were 
separated  from  each  other  to  the  distance  of  two  or  three  inches,  and  they  measured 
in  length  nine  and  a  half  inches. 

On  opening  the  cranial  cavity,  seven  pints,  by  measurement,  of  transparent 
fluid  escaped,  exposing  a  vast  open  space  at  the  bottom  of  which  were  the  parts 
which  constitute  the  floor  of  the  ventricles,  somewhat  changed  in  shape,  and  from 
them  on  either  side  the  hemisphere  was  spread  in  a  lamina,  so  as  to  cover  the 
internal  surface  of  the  cranial  bones.  The  laminge  near  the  base  of  the  brain 
measured  in  thickness  from  half  an  inch  to  one  inch,  and  they  gradually  became 
thinner  on  approaching  the  vertex,  at  which  point  the  brain-substance  was  ex- 
ceedingly thin,  so  as  to  be  scarcely  demonstrable. 

The  brain  had  its  normal  vascularity  and  consistence,  and  the  cerebellum, 
medulla  oblongata,  the  base  of  the  brain,  and  cranial  nerves  presented  their  usual 
appearance.  On  folding  the  brain  together,  it  had  the  size,  shape,  and  aspect  of 
this  organ  in  its  ordinary  development.  Nothing  unusual  was  observed  in  the 
membranes  except  their  great  expansion.  The  above  case  corresponds  in  its  gen- 
eral features  with  most  cases  met  in  practice. 

Diagnosis. — The  ordinary  form  of  congenital  hydrocephalus,  that  in 
which  the  liquid  occupies  the  interior  of  the  brain,  can  in  most  cases  be 
readily  diagnosticated.  If  there  be  only  a  moderate  amount  of  liquid,  it 
may  be  confounded  with  hypertrophy  of  the  brain.  In  hydrocephalus  there 
are  commonly  more  rapid  growth  and  greater  expansion  of  the  head  ;  more- 
over, the  enlargement  occurs  equally  on  all  sides,  while  in  hypertrophy, 
though  all  parts  of  the  cranial  vault  are  expanded,  the  enlargement  is  more 
at  the  vertex  than  elsewhere.  The  hydrocephalic  head  yields  more  readily 
to  pressure  than  the  hypertrophied,  and  often  communicates  a  fluctuating 
sensation.  Moreover,  in  the  ordinary  form  of  hydrocephalus  the  change  in 
the  axis  of  the  eyes  described  above  is  an  important  diagnostic  sign.  In 
rachitis  the  volume  of  the  head  is  often  considerably  enlarged,  due  some- 
times, in  part  at  least,  to  a  deposit  of  calcareous  matter  on  the  exterior  of 
the  cranial  bones.  The  differential  diagnosis  is  based  on  the  shape  of  the 
head,  round  in  one,  square  or  with  prominences  in  the  other,  on  palpation, 
direction  of  the  eyes,  etc.  The  smaller  the  amount  of  liquid,  the  greater 
the  liability  to  error  of  diagnosis  ;  but  if  the  amount  be  inconsiderable  and 
not  increasing,  little  treatment  is  required  except  hygienic  and  tonic,  which 
is  also  proper  in  both  hypertrophy  and  rachitis.  If  the  liquid  be  exterior  to 
the  brain,  as  in  the  case  represented  in  Fig.  189,  diagnosis  may  be  difficult, 
but  such  cases  are  infrequent. 

Prognosis. — In  the  majority  of  the  cases  this  is  unfavorable,  since  the 
secretion  of  liquid  usually  continues.  The  most  favorable  result  is  no  in- 
crease, or  but  slight,  in  the  quantity,  while  the  natural  growth  of  the  infant 
38 


594  LOCAL  DISEASES. 

increases,  and  thus  the  disproportion  between  the  head  and  the  rest  of  the 
system  gradually  disappears.  Such  patients  may  live  to  maturity  and  have 
tolerable  health,  and  may  engage  in  occupation.  But  ordinarily  in  cases  left 
to  themselves,  and  even  in  a  large  proportion  of  those  having  the  best  treat- 
ment, the  body  and  limbs  gradually  waste  from  defective  nutrition,  and  the 
patient,  if  not  cut  off  by  an  intercurrent  disease,  finally  succumbs  with  cere- 
bral symptoms  produced  by  pressure  of  the  liquid.  Probably  more  than 
half  of  the  hydrocephalic  patients  die  before  the  close  of  the  second  year. 

Treatment. — We  may  attempt  to  diminish  the  quantity  of  fluid  by  the 
use  of  diuretics.  Digitalis,  squills,  nitrate  and  acetate  of  potassium  have 
been  used.  The  most  efl&cient  diuretic  in  these  cases,  however,  is  the  iodide 
of  potassium.  This  may  be  given  in  doses  of  one  to  two  grains  every  two 
hours  to  an  infant  of  three  months.  Constipation,  if  present,  should  be 
relieved  by  an  occasional  purgative.  If  it  be  tolerated,  we  may  partially 
prevent  the  expansion  of  the  head  by  a  close-fitting  cap.  For  this  purpose 
strips  of  adhesive  plaster,  about  one-third  of  an  inch  in  width,  should  be 
applied  so  as  to  cover  the  entire  head.  The  proper  way  of  applying  these  is 
as  follows :  First,  one  strip  from  each  mastoid  process  to  the  outer  part  of 
the  orbit  on  the  opposite  side ;  secondly,  from  the  back  of  the  neck,  along 
the  longitudinal  sinus,  to  the  root  of  the  nose  ;  thirdly,  over  the  whole  head, 
so  that  the  different  strips  will  cross  each  other  at  the  vertex  ;  and,  lastly,  a 
strip  long  enough  to  pass  three  times  around  the  head  should  be  applied, 
passing  above  the  eyebrows,  the  ears,  and  below  the  occipital  protuberance. 
Too  tight  an  application  should  be  avoided,  as  it  may  give  rise  to  convul- 
sions or  other  cerebral  symptoms.  If  the  cap  can  be  tolerated  and  the  gen- 
eral health  be  good,  the  prospect  is  more  favorable ;  but  usually,  from  the 
increase  in  the  quantity  of  fluid,  it  is  necessary  in  a  few  days  to  remove  or 
loosen  the  strips  in  order  to  prevent  convulsions,  or,  which  is  preferable,  to 
diminish  the  size  of  the  head  and  relieve  the  pressure  by  tapping.  In  56 
cases  collected  by  Dr.  West  in  which  tapping  was  employed,  4  recovered. 
The  operation  is  simple,  easily  performed,  devoid  of  danger,  and  it  frequently 
gives  temporary  relief.  It  should  therefore  be  recommended  to  the  parents, 
even  if  it  do  not  effect  a  cure.  It  should  be  performed  by  a  very  small 
trocar,  which  should  be  introduced  in  the  coronal  suture,  about  an  inch  ex- 
ternal to  the  anterior  fontanelle.  A  few  ounces  should  be  removed,  and  strips 
of  adhesive  plaster  or  an  elastic  skull-cap  applied.  In  a  few  days  the  opera- 
tion should  be  repeated  as  the  liquid  increases.  It  is  important  to  maintain 
compression  of  the  skull  before  and  after  the  operation  (Treves).  Some- 
times a  dozen  or  more  tappings  are  required  at  intervals  of  a  few  days  or 
weeks,  when  the  secretion  may  come  to  a  standstill.  In  the  Med.-Chir. 
Trans.  (1864)  a  ease  is  related  in  which  two  tappings  eff"ected  a  cure,  but  so 
good  a  result  is  exceptional.  Iodine  injections  in  connection  with  tapping 
have  so  far  not  produced  any  satisfactory  result.  Sir  James  Paget  ^  relates 
a  case  in  which  he  injected  ten  grains  of  iodine  and  twenty  grains  of  iodide 
of  potassium  in  one  ounce  of  water,  but  the  child  died  of  convulsions  after 
the  second  injection.  No  appreciable  good  result  has  followed  the  use  of 
irritating  or  sorbefacient  applications  to  the  head.  Nutritious  diet  and  atten- 
tion to  the  general  health  are  requisite. 

^  Medical  Times  and  Gazette,  1860. 


ACQUIRED  HYDROCEPHALUS.  595 

CHAPTER    ly. 

ACQUIKED  HYDEOCEPHALUS. 

Hydrocephalus,  or  dropsy  of  the  brain,  may  also  occur  in  those  who  at 
birth  are  well  formed  and  free  from  disease.  Pathologists  call  this  acquired 
hydrocephalus.  It  is  in  nearly  all  cases  the  result  of  disease,  which  is 
located  sometimes  within  the  cranium,  but  often  in  other  parts  of  the  system. 

Causes. — The  diseases  within  the  cranium  which  most  frequently  produce 
serous  effusion  are  the  meningeal  inflammations,  both  simple  and  tubercular, 
tumors  or  other  causes  which  obstruct  the  venous  circulation,  and  hemor- 
rhagic effusion  ending  in  the  formation  of  cysts.  Prolonged  passive  conges- 
tion often  ends  in  transudation  of  serum  throiigh  the  coats  of  the  capillaries. 
Therefore,  all  causes  of  congestion,  except  such  as  have  a  transient  or 
momentary  effect,  may  be  regarded  as  causes  of  serous  effusion.  In  rare 
instances  chronic  hydrocephalus  results  from  cerebro-,spinal  fever  (menin- 
gitis), as  has  been  stated  in  my  remarks  on  the  latter  disease. 

Among  the  diseases  external  to  the  cranium  which  produce  serous  effu- 
sion within  or  upon  the  brain  may  be  mentioned  retropharyngeal  abscess, 
tuberculization  or  inflammation  of  the  bronchial  glands,  scarlet  fever,  and 
certain  affections  of  an  exhausting  nature,  especially  protracted  diarrhoeal 
maladies.  In  at  least  five  cases  which  have  fallen  under  my  notice,  and  in 
which  post-mortem  examinations  were  made,  the  cause  was  enlarged  tuber- 
cular bronchial  glands,  which,  by  pressure  on  the  venae  innominatae,  so 
retarded  the  flow  of  blood  from  the  brain  as  to  cause  congestion  and  effu- 
sion. The  causal  relation  of  these  glands  to  cerebral  congestion  is  described 
in  our  remarks  in  reference  to  this  disease. 

Dropsy  of  the  brain  is  common  in  protracted  infantile  diarrhoea ;  as,  for 
example,  in  advanced  cases  of  intestinal  catarrh  of  the  sixmmer  months  in 
the  cities.  It  is  preceded  and  accompanied  by  passive  congestion  of  the  cere- 
bral veins  and  sinuses,  due  in  part  to  feebleness  of  circulation  in  consequence 
of  the  exhausted  state  of  the  patient,  and  in  part  to  wasting  of  the  brain, 
which  always  give  rise  to  more  or  less  passive  congestion,  unless  in  young 
infants,  in  whom  the  cranial  bones  become  depressed  and  override  each  other. 
Dropsy  of  the  brain,  resulting  from  scarlet  fever,  and  that  peculiar  circum- 
scribed dropsy  which  results  from  hemorrhagic  effusions,  are  described  else- 
where. But  the  most  severe  and  injurious  form  of  acquired  hydrocephalus 
is  that  which  results  from  cerebro-spinal  fever,  since  it  causes  great  and  in- 
creasing cranial  expansion  and  loss  of  sight,  and  sometimes  of  hearing. 

A  few  cases  have  been  related  by  different  observers,  Abercrombie  among 
others,  in  which  the  dropsy  of  the  brain  seemed  to  be  essential.  Nothing 
abnormal  was  observed  except  the  serous  effusion.  But  the  reports  of  such 
cases  are.  for  the  most  part,  meagre,  and,  as  Barrier  has  well  said,  we  are  not 
to  accept  such  cases  as  examples  of  essential  dropsy  of  the  brain  unless  the 
post-mortem  inspection  be  so  complete  as  to  render  it  certain  that  there  was 
no  pathological  state  which  might  cause  the  dropsy. 

Anatomical  Characters. — Acquired  hydrocephalus  usually  occurs 
after  the  cranial  bones  are  firmly  united,  and  therefore  the  shape  of  the  head 
is  not  materially  altered.  If  it  occur  at  an  early  age,  before  there  is  firm 
union,  there  may  be  expansion  of  the  cranial  arch,  as  we  sometimes  observe 
in  the  circumscribed  hydrocephalus  resulting  from  hemorrhage.  The  effu- 
sion in  acquired  hydrocephalus  occurs  over  the  surface  of  the  brain,  in  the 
subarachnoid  space,  or  in  the  lateral  ventricles.     In  the  dropsy  of  protracted 


596  LOCAL  DISEASES. 

cliarrhoeal  maladies  I  have  rarely  failed  to   find  the  liquid   over  the  whole 
superior  surface  of  the  brain  as  well  as  at  its  base. 

The  quantity  of  fluid  in  this  disease  is  not  large.  In  the  majority  of 
cases  it  does  not  exceed  four  ounces  and  is  often  much  less.  It  is  trans- 
parent or  it  has  a  slightly  yellowish  tinge.  The  membranes  of  the  brain 
sometimes  present  their  normal  appearance,  but  in  other  cases  they  are 
injected.  The  brain  itself  in  some  instances  has  an  injected  appearance  from 
passive  congestion  of  the  veins  and  capillaries  ;  but  in  others,  when  there  has 
been  more  or  less  compression  of  the  brain,  there  is  no  more  than  the  ordi- 
nary, or  even  less  than  the  ordinary,  vascularity,  and  the  convolutions  are 
somewhat  flattened. 

Symptoms. — The  symptoms  of  the  pathological  state  which  gives  rise  to  the 
dropsy  precede  and  accompany  those  which  are  referable  to  the  dropsy  itself. 
The  dropsy  declares  itself  by  symptoms  which  are  alarming  from  the  first. 

In  children  old  enough  to  speak  or  manifest  intelligence  there  may  be  at 
first  complaint  of  headache.  The  child  is  irritable,  its  mind  confused  or  wan- 
dering at  times,  or  there  is  actual  delirium.  After  a  time  drowsiness  occurs. 
The  head  seems  too  heavy  for  the  body  and  is  buried  in  the  pillow.  In  fatal 
cases  the  features  become  pallid,  the  pupils  sluggish,  and  perception  and 
consciousness  are  gradually  lost.  The  child  lies  in  profound  sleep,  which 
increases.  There  are  now  often  convulsive  movements,  partial  or  general, 
and  these  soon  end  in  coma,  in  which  the  patient  dies. 

In  January,  1890,1  exhibited  to  the  Xew  York  Pfediatric  Society  a  child 
with  acquired  hydrocephalus  which  dated  back  to  an  attack  of  cerebro-spinal 
fever  of  mild  type  that  occurred  a  few  months  previously. 

Prognosis. — Acquired  hydrocephalus  commonly  ends  unfavorably.  The 
prognosis  depends  not  only  on  the  quantity  of  liquid,  but  on  the  nature  of 
the  cause.  If  the  cause  be  venous  obstruction  within  the  cranium  or  thorax, 
death  is  inevitable,  since  we  have  no  means  of  removing  it.  If  it  be  an  ex- 
hausting disease,  as  entero-colitis  or  scarlet  fever,  although  the  case  is  not 
absolutely  hopeless,  the  prospect  is  still  unfavorable.  It  is  only  favorable 
when  the  quantity  of  eflFused  fluid  is  small,  the  system  not  much  reduced, 
and  the  primary  disease  mild.  When  acquired  hydrocephalus  arises  from 
meningeal  apoplexy,  the  case  is  usually  chronic. 

The  SYMPTOMS  and  termination  of  this  form  of  the  disease  are  very 
similar  to  those  in  congenital  hydrocephalus. 

Treatment. — The  treatment  in  acquired  hydrocephalus  must  vary  in 
difi"erent  cases  according  to  the  nature  of  the  disease  on  which  it  depends. 
I  shall  indicate  the  treatment,  in  part,  at  least,  in  the  description  of  these 
diseases.  Occasionally  the  condition  of  the  patient  is  such  that  no  material 
improvement  can  result  from  any  mode  of  treatment. 


CHAPTER    V. 

MENINGITIS  (TUBERCULAE  AND  NON-TUBEKCULAR). 

The  most  interesting  and  important  disease  of  the  cerebro-spinal  system 
in  early  life  is  that  which  is  now  designated  meningitis.  It  is  not  infrequent. 
The  mortuary  statistics  of  this  city  show  that  it  is  the  cause  of  death  in  from 
1  in  25  to  1  in  50  of  the  entire  number  of  deaths,  the  proportion  varying 
somewhat  in  difi"erent  years. 


MENINGITIS.  597 

In  1768  the  attention  of  the  profession  was  particularly  called  to  this 
malady  by  Dr.  Whytt  of  Edinburgh.  This  observer  and  the  pathologists 
succeeding  him,  forming  their  opinion  of  meningitis  from  its  most  prominent 
anatomical  character — namely,  serous  effusion — believed  it  a  dropsy.  They 
accordingly  designated  it  acute  hydrocephalus.  The  disease  is  now  properly 
regarded  as  inflammatory,  and  hence  the  name  by  which  its  true  pathological 
character  is  expressed.  Inflammation  limited  to  the  dura  mater  has  been 
designated  pachymeningitis,  in  consequence  of  the  thickness  of  this  mem- 
brane ;  and  that  affecting  the  thin  and  soft  membranes,  the  pia  mater,  and 
arachnoid  has  for  a  similar  reason  been  designated  leptomeningitis. 

Sometimes  meningeal  inflammation  in  children  occurs  without  tubercles. 
In  other  instances  it  results  from  the  presence  of  tubercles,  and  in  most,  if  not 
in  all,  such  patients  there  are  tubercles  in  or  under  the  meninges,  which  excite 
the  inflammation  in  the  same  manner  as  in  the  lungs  they  cause  pneumonitis 
or  pleuritis.  Therefore  two  forms  of  meningitis  are  recognized — to  wit,  tuber- 
cular and  non-tubercular.  Meningitis  is  also,  as  we  have  seen,  the  characteristic 
anatomical  character  of  cerebro-spinal  fever,  but  as  this  is  a  general  disease, 
with  the  meningitis  as  a  local  manifestation,  we  have  treated  of  it  among  the 
constitutional  maladies. 

In  patients  over  the  age  of  eighteen  months,  although  the  proportion  of  tuber- 
cular to  non-tubercular  cases  is  larger  than  under  this  age,  the  excess  is  not  so 
great,  according  to  my  statistics,  as  the  remarks  of  some  observers  lead  us  to  sup- 
pose. There  can  be  no  accurate  statistics  of  tubercular  meningitis  without  careful 
post-mortem  examination  of  the  state  of  the  brain  and  other  organs  in  each  supposed 
case,  and  this  examination  sometimes  shows  the  meningitis  to  be  non-tubercular 
when  the  symptoms  and  signs  had  indicated  its  tubercular  character.  As  an  example 
may  be  mentioned  a  case  which  occurred  in  the  children's  service  of  Charity  Hos- 
pital in  March,  1868.  The  infant  died  at  the  age  of  twenty  months,  having  had  a 
cough  of  moderate  severity  at  least  three  weeks  before  death,  and  symptoms  of 
meningitis  about  four  days.  It  was  considerably  wasted,  and  was  supposed  to  have 
tuberculosis.  At  the  autopsy  no  tubercles  were  found  in  any  part  of  the  body,  but 
portions  of  both  lungs  were  hepatized.  A  fibrinous  deposit,  varying  in  thickness, 
was  found  over  the  pons  Varolii,  the  optic  commissure,  along  the  fissures  of  Sylvius, 
over  the  superior  surface  of  the  anterior  half,  and  also  upon  the  superior  lobe  of  each 
cerebral  hemisphere.  As  the  examination  failed  to  disclose  any  tubercles,  the  menin- 
gitis was  considered  non-tubercular.  Those  who  make  these  examinations,  failing 
to  find  tubei'cles  in  the  lungs  and  other  organs  in  which  they  usually  occur,  should 
examine  the  lymphatic  glands,  since  cheesy  glands  may  be  the  cause  of  the  forma- 
tion of  tubercles  in  the  meninges,  while  the  organs  of  the  trunk  remain  unaffected. 
The  presence  of  cheesy  glands  in  the  absence  of  visceral  tubercles  and  with  granu- 
lations upon  the  meninges,  small,  covered  with  fibrin,  and  of  a  doubtful  character, 
goes  far  toward  establishing  the  tubercular  nature  of  the  meningitis.  Since  the 
cases  embraced  in  the  following  statistics  were  observed,  now  more  than  twenty 
years  ago,  I  have  been  led  by  a  more  extended  experience,  and  especially  by  the  ob- 
servation of  cases  in  the  New  York  Foundling  Asylum,  where  there  is  ample  mate- 
rial, to  regard  not  only  the  presence  or  absence  of  tubercles,  but  also  of  caseous 
substance,  as  the  proper  test  of  the  form  of  meningitis.  Xot  a  few  that  seem  at  first 
to  have  non-tubercular  meningitis  will  be  found,  on  more  thorough  examination,  to 
have  caseous  substance  in  some  part,  the  result  of  a  pre-existing  inflammation  ;  and 
if  we  regard  the  inflammation  of  the  meninges  occurring  under  such  circumstances 
as  tubercular,  the  relative  proportion  of  tu1:iercnlar  cases  will  be  considerably  aug- 
mented. The  following  is  an  example:  AVhen  on  duty  in  the  asylum  in  August, 
1881,  an  infant  one  year  old  died  of  meningitis.  No  tubercles  were  observed  in 
the  fibrin  at  the  base  of  the  brain  and  along  the  fissures  of  Sylvius,  but  one  inflam- 
matory nodule  (cerebritis)  as  large  as  a  chestnut,  with  suppuration  inside,  was  found 
at  the  summit  of  one  hemisphere.  No  tubercles  coukl  be  detected  in  any  of  the 
organs  of  the  trunk,  unless  a  few  whitish  spots  in  the  spleen  were  of  this  nature, 
but  the  bronchial  glands  were  cheesy  and  softened,  and  the  middle  lobe  of  the  right 
lung  also  contained  cheesy  substance.     It  seemed  to  me  probable  that  some  of  this 


598  LOCAL  DISEASES. 

degenerated  product  taken  up  by  the  vessels  had  lodged  in  the  meninges  and  pro- 
duced the  tubercular  neoplasm 'there  which  was  hidden  under  the  fibrin.  (See 
chapter  on  Tuberculosis.) 

_^(3E. — The  following  table  gives  the  age  in  meningitis,  tubercular  and 
non-tubercular,  in  forty-two  cases  in  my  collection,  which  is  a  small  propor- 
tion of  those  which  I  have  observed ;  but  these  are  the  only  cases  of  which 
I  have  preserved  notes : 

Cases.  Age- 

1  .    .    .        2j  weeks  (autopsy). 

2 3  months. 

20 From  3  to  12  months. 

10 From  1  year  to  2  years. 

5 '.  From  2  years  to  5  years. 

4 Over  5  years. 

42 

Rilliet  and  Barthez  have  also  published  statistics  of  the  age  in  _  meningitis. 
Their  cases  were  observed  chiefly  in  hospital  practice,  and  the  result  is  somewhat 
different.  In  32  cases  of  non-tubercular  meningitis  observed  by  these  authors,  8 
were  under  the  age  of  one  year,  6  from  two  years  to  five,  and  18  over  the  age  of  five 
years.  In  98  cases  of  tubercular  meningitis,  2  were  under  the  age  of  one  year,  51 
between  the  ages  of  one  year  and  five,  38  between  the  ages  of  five  years  and  ten, 
and  7  between  ten  and  fifteen  years.  Growers  states  that  the  age  at  which  menin- 
gitis is  most  frequent  is  between  the  first  and  tenth  years. 

Pathological  Anatomy. — This  diifers  considerably  in  different  eases. 
The  dura  mater  is  usually  unaffected  or  is  affected  secondarily.  In  many 
cases  it  retains  its  normal  appearance,  its  internal  surface  remaining  smooth 
and  polished,  while  in  others  it  is  more  or  less  injected  and  its  internal  sur- 
face dim  or  lustreless.  The  free  sui'face  of  the  pia  mater,  formerly  designated 
the  visceral  arachnoid,  is  in  a  great  part  of  its  extent  unchanged,  but  is  often 
hyperaemic  or  dry  and  cloudy  or  opaque  over  the  seat  of  inflammation.  Exu- 
dation does  not  occur  upon  the  free  surface  of  the  pia  mater,  however  intense 
the  inflammation. 

In  meningitis,  tubercular  and  non-tubercular,  the  inflammatory  action 
occurs  in  the  pia  mater.  In  its  meshes  or  underneath  them  those  lesions 
result  which  characterize  the  disease,  and  to  which  other  lesions  are  secondary. 
Tubercular  meningitis  is  most  frequently  basilar,  or  is  basilar  chiefly  and  pri- 
marily, although  the  inflammation  may  extend  along  the  sides  of  the  hemi- 
spheres. The  meningitis  is  ordinarily  most  intense  around  the  pons  Varolii, 
in  the  subarachnoid  space,  and  along  the  fissures  of  Sylvius,  for  the  tubercular 
neoplasm  occurs  chiefly  at  the  base  of  the  brain  and  along  the  vessels.  In 
non-tubercular  meningitis  the  inflammation  may  also  occur  at  the  base.  It 
may  in  young  infants  be  quite  diffuse,  and  of  little  intensity  in  any  one  place, 
producing,  in  addition  to  hyperaemia  of  the  pia  mater,  slight  cloudiness  and  a 
moderate  or  slight  escape  of  leucocytes  from  the  blood,  these  (pus-cells)  being 
perhaps  visible  only  under  the  microscope.  In  meningitis  due  to  extension 
of  inflammation  from  an  otitis  media  the  inflammatory  action  is  intense,  con- 
fined to  the  portion  of  the  meninges  nearest  the  ear,  and  is  often  attended  by 
inflammation  of  the  adjoining  brain-substance^  with  perhaps  the  formation  of 
an  abscess.  If  the  cause  be  exposure  to  the  sun's  rays  or  traumatism,  the 
meningitis  is  usually  at  the  summit  of  the  brain. 

The  exudation  of  fibrin  is  greatest  along  the  course  of  the  vessels  and  in 
the  depressions  between  the  convolutions,  and  the  opacity  is  most  marked  in 
these  situations.  Pus,  when  present,  is  often  semi-solid,  from  the  small  pro- 
portion of  liquor  puris  which  it  contains,  even  in  recent  cases.     If  the  disease 


MENINGITIS.  599 

have  continued  several  days,  the  liquor  puris  may  be  mostly  absorbed,  and  the 
pus-cell,  becoming  shrivelled, 'irregular,  and  aggravated,  may  resemble  closely 
the  cheesy  transformation  of  tubercle-cells. 

The  fibrinous  exudation  presents  features  of  interest.  It  does  not  usually 
attain  much  thickness,  but  by  its  opacity  it  conceals  from  view  the  brain 
underneath.  If  it  occur  in  the  fissures  of  Sylvius,  the  anterior  and  middle 
lobes  are  united  by  it.  It  is  usually  infiltrated  through  the  substance  of  the 
pia  mater.  Sometimes  little  masses  of  variable  size,  often  not  as  large  as  a 
pin's  head,  appear  at  the  point  of  inflammation.  These  masses  are  firm,  of  a 
whitish  color  or  a  light  yellow,  and  their  number  varies  in  diff"erent  cases. 
They  consist  of  a  firm,  homogeneous  substance  containing  granular  matter 
and  cells  which  often  bear  a  close  resemblance  to  tubercle-corpuscles,  but  are 
distinct.  These  corpuscular  bodies  are  plastic  nuclei  or  plastic  cells,  often 
shrunken.  It  is  seen,  then,  there  are  two  morbid  products  which  may  be  mis- 
taken for  tubercles— one,  pus  which  has  been  in  great  measure  deprived  of  its 
liquid  element,  and  which  may  resemble  cheesy  tubercular  matter ;  the  other, 
plastic  nuclei  collected  in  little  bodies,  so  as  to  resemble  the  ordinary  form  of 
crude  tubercle.  I  once  carried  to  one  of  the  best  microscopists  and  pathologists 
of  New  York  some  of  the  exudation  from  a  case  of  meningitis,  the  cellular 
element  in  which  could  not  readily  be  distinguished  from  shrunken  tubercle- 
corpuscles.  The  exudation  was  from  a  child  two  years  and  eight  months  old, 
with  good  health  previously  to  the  meningitis,  without  tubercles  in  any  part 
of  the  body,  with  parents  healthy,  and  with  no  predisposition  to  tubercular 
disease.  The  microseopist,  not  knowing  the  history  of  the  case  or  character 
of  the  family,  and  ignorant,  like  all  of  us  at  that  time,  of  the  true  tubercle- 
cell,  pronounced  the  exudation  tubercular  after  a  careful  examination  with 
the  microscope. 

In  the  tuberculosis  of  young  children  I  have  found  in  a  large  proportion 
of  cases  in  which  I  have  had  an  opportunity  to  make  post-mortem  exami- 
nations miliax-y  tubercles  disseminated  through  the  lungs  and  perhaps  other 
organs  in  small  masses,  many  of  them  not  larger  than  a  pin's  head,  and  some 
occurring  as  mere  specks  scarcely  visible.  These  minute  tubercular  formations 
have  ordinarily  been  semi-transparent,  and  sometimes  even  transparent  like 
minute  drops  of  water,  and  containing  the  true  and  unchanged  tubercle  bacil- 
lus. Now,  if  in  such  a  case  meningitis  occur,  we  may  find  the  tubercle-cell 
in  or  with  the  fibrin  at  the  base  of  the  brain.  But  failure  to  find  it,  even  with 
protracted  microscopic  examination,  does  not  prove  its  absence  from  this 
locality,  for  I  consider  it  almost  impossible  to  discover  in  the  midst  of  the 
fibrinous  exudation  such  minute  points  of  tubercular  matter  as  are  seen  in 
the  lungs,  liver,  or  elsewhere. 

The  pia  mater  is  often  firmly  adherent  to  the  brain  at  the  seat  of  inflam- 
mation, so  that  on  raising  it  a  portion  of  the  brain  may  be  detached  and  re- 
moved with  it.  The  extent  of  the  inflammation  varies  much  in  diff"erent  cases. 
There  may  in  extreme  cases  be  pretty  general  inflammation  of  the  pia  mater. 
In  cases  of  such  extensive  meningitis  the  symptoms  are  usually  severe  and 
the  cour.se  of  the  disease  rapid. 

Thus,  in  the  month  of  April.  1866,  a  fi'irl  eleven  years  of  age.  in  the  Protestant 
Episcopal  Orphan  Asylum  of  this  city,  had  complained  occasionally  of  dizziness, 
but  was  otherwise  in  good  health,  cheerful  and  with  excellent  appetite,  till  Thurs- 
day, when  she  was  affected  with  vertigo,  more  persistent  than  previously,  and  with 
headache.  At  2  p.  m.  on  the  following  day  she  was  seized  with  general  convulsions, 
and  continued  insensible  or  nearly  so,  with  occasional  convulsive  movements,  till 
Monday,  when  she  died  comatose.  The  pia  mater  at  the  vertex,  sides,  and  base  of 
the  brain  had  a  cloudy  appearance,  and  underneath  it  in  places  was  a  thick,  creamy 
substance  in  small  quantity,  which,  examined  ]>y  the  microscope,  proved  to  be  pus 


600  LOCAL  DISEASES. 

the  largest  amount  being  near  the  pons  Varolii.  There  was  no  tubercle  under  the 
meninges  or  elsewhere,  and  no  appreciable  fibrinous  exudation.  The  meningitis, 
though  of  brief  duration,  was  nearly  general.  The  only  additional  lesions  noted 
■were  moderate  congestion  of  the  brain  and  an  increase  in  the  quantity  of  the  cerebro- 
spinal fluid. 

If  the  disease  be  protracted  three  or  four  weeks,  which  is  rare,  or  even  less 
time,  the  exuded  substance  may  undergo  further  changes,  such  as  occur  in  simple 
exudations  in  other  parts  of  the  system.  Thus,  on  the  30th  of  April,  1860,  we 
made  the  post-mortem  examination  of  an  infant  at  the  Nursery  and  Child's  Hos- 
pital who  had  symptoms  of  cerebral  disease,  it  was  stated,  for  several  weeks,  but 
the  exact  time  was  not  ascertained.  Pi'ominent  among  the  symptoms  referable  to 
the  cerebro-spinal  system  toward  the  close  of  life  Avere  the  hydrocephalic  cry  and 
rigidity  of  the  neck.  The  appearance  at  the  autopsy  was  remarkable.  The  ante- 
rior half  of  the  brain  was  completely  encased  in  a  deposit  which  had  nearly  the 
appearance  of  lard.  It  filled  the  fissures  of  Sylvius  and  appeared  slightly  on  the 
anterior  aspect  of  the  cei'ebellum.  Examined  under  the  microscope,  this  substance 
•was  found  to  contain  numerous  cells,  among  which  could  be  distinguished  some 
resembling  pus-cells,  but  nearly  all  had  undergone  more  or  less  fatty  degeneration. 
Here  and  there  was  seen  a  large  cell  containing  numerous  small  oil-globules,  the 
compound  granular  cell  of  pathologists. 

The  brain  itself  in  meningitis  is  usually  hypersemic.     On  making  an  in- 
cision through  it  red  points  are  seen  upon  the  cut  surface,  which  indicate  the 
seat  of  the  congested  vessels.     The  inflammation  rarely  extends  to  the  walls 
of  the  ventricles,  but  the   choroid   plexus   is   injected.     In   exceptional   in- 
stances pus  or  fibrin  is  found  in  the  lateral  ventricles.     In  the  infant  two 
and  a  half  weeks  old   whose  case   has  already  been   alluded   to   about  two 
ounces  of   purulent  fluid  escaped    on  opening  the  left  ventricle.     A  small 
amount  of  liquid  of  a  similar  character  was  contained  in  the  right  ventricle. 
The  distention  of  the  lateral  ventricles  with  serum  is  one  of  the  common 
results  of  meningitis.     This  fluid  is   clear  or  straw-colored,  or  it  is  turbid. 
The  quantity  does  not  exceed  two,  three,  or  four  ounces,  and  is  often  not 
more  than   one  ounce  or  an  ounce  and  a  half.     The  distention  of  the  two 
ventricles  is  ordinarily  uniform,  as  they  are  united  by  the  foramen  of  Monro, 
but  now  and  then  one  ventricle  is  found  more  distended  than  the  other.     If 
there  be  considerable  effusion,  the  brain  is  compressed  and  the  convolutions 
have  a  flattened  appearance,  unless  the  cranial  bones  are  still  separated  so  as 
to  yield  to  the  pressure.     If  the  sutures  and  fontanelles  be  open,  the  cranial 
arch  is  expanded,  sometimes  quite   perceptibly  to  the  eye.     From  the  same 
cause  the  anterior  fontanelle,  if  open,  is  elevated.     The  foramen  of  Monro 
is  enlarged  according  to  the  amount  of  efi"usion,  and  the  portions  of  the  brain 
which  separate  the  ventricles  are  sometimes  lacerated.     In  many  cases  the 
cerebral  substance  surrounding  the  lateral  ventricles  is  softened.     The  soft- 
ening is  found  in  all  degrees,  from  the  least  appreciable  deviation  from  the 
normal  consistence  to  a  state  of  diflJuence,  so  that  the  brain-substance  pre- 
sents the  appearance  of  cream.     Hypotheses  have  been  advanced  to  explain 
the  cause  of  this  change  in   consistence  which  are  not  entirely  satisfactory. 
Whatever  the  explanation,  the  fact  is  attested  by  all  observers,  though  there 
are  exceptional  cases.     Thus  Dr.  West  has  records  of  the  condition  of  the 
brain  in  59  cases,  in  37  of  which   there  was   considerable  softening,  and  in 
the  remaining  22  the  consistence  was  normal. 

Since  a  majority  of  the  cases  of  meningitis  in  children  are  basilar,  and 
portions  of  all  the  cerebral  nerves  lie  at  the  base  of  the  brain,  it  is  easy  to 
understand  why  the  functions  of  these  nerves  are  so  seriously  impaired  in 
this  malady.  Compression  of  these  nerves  or  extension  of  inflammation  to 
their  sheaths  affords  explanation  of  many  of  the  symptoms,  as  the  sighing 
respiration,  abnormalities  of  the  eye,  etc. 

Although   the   above  remarks   relatina;   to  the  anatomical  characters  of 


MENINGITIS.  601 

meningitis  are  applicable  to  a  large  majority  of  the  cases,  sometimes  at  the 
autopsies  of  young  infants  who  died  with  all  the  symptoms  of  meningitis, 
the  physician  is  surprised  in  not  finding  more  lesions.  Moderate  hyperajmia 
of  the  pia  mater,  slight  opacity  or  cloudiness  at  the  base  of  the  brain  or 
elsewhere,  with  the  presence  of  a  few  wandering  white  corpuscles,  without  any 
fibrinous  exudation,  with  no  increase  of  liquid  external  to  the  brain,  but  a 
considerable  increase  of  it  in  the  lateral  ventricles,  and  hyperaemia  of  the 
choroid  plexus,  with  nearly  natural  appearance  and  consistence  of  the  brain, 
have  in  some  instances  been  the  only  lesions  when  I  had  expected  to  find 
marked  anatomical  changes. 

I  am  fully  convinced  from  my  observations  that  in  some  instances  physi- 
cians who  supposed  that  they  were  treating  tubercular  meningitis,  and  at 
the  autopsies  discovered  within  the  cranium  tubercles,  without  any  inflam- 
matory lesion,  but  with  an  increase  of  the  cerebro-spinal  liquid,  have  been 
treating  cases  in  which,  in  addition  to  the  meningeal  tubercles  which  were 
latent,  the  bronchial  glands  were  tubercular  and  cheesy,  so  that  by  their 
increased  size  they  compressed  the  venje  innominatae  within  the  thorax,  thus 
preventing  the  free  flow  of  blood  from  the  brain,  and  causing,  as  I  have 
elsewhere  stated,  cerebral  and  meningeal  congestion,  with  more  or  less  trans- 
udation of  serum,  but  with  no  meningitis.  In  tubercular  meningitis  the 
anatomical  characters  are  like  those  in  simple  meningitis,  with  the  addition 
of  tubercles,  which  at  first  are  minute  and  transparent,  and  are  most  easily 
detected  when  the  inflammation  has  been  slight.  Located  in  the  pia  mater, 
they  cause  some  prominence  of  the  arachnoid,  and  are  best  seen  when  so 
minute  by  an  oblique  light. 

Causes. — The  causes  of  non-tubercular  meningitis  are  not  fully  ascer- 
tained. Active  cerebral  congestion  frequently  occurring,  however  produced, 
appears  to  be  one  of  the  common  causes  in  young  infants.  In  at  least  three 
instances  I  have  known  meningitis  to  occur  in  infants  between  the  ages  of 
four  and  eight  months  after  severe  and  protracted  bronchitis,  which  had 
been  attended  with  the  usual  heat  of  head.  This  disappearance  of  eruption 
upon  the  scalp  at  or  immediately  before  the  commencement  of  the  menin- 
gitis has  also  been  observed.  I  have  witnessed  it  at  the  commencement  of 
non-tubercular  meningitis,  as  well  as  of  meningitis  which,  if  not  tubercular, 
occurred  at  least  in  a  decidedly  scrofulous  state  of  system. 

The  direct  effect  of  the  solar  rays  upon  the  head  and  the  prolonged  action 
of  a  high  atmospheric  temperature  are  believed  to  be  an  occasional  cause  of 
meningitis.  I  once  attended  a  child  with  this  disease  who  had  been  much 
exposed  bareheaded  to  the  direct  rays  of  the  sun  in  August  and  Septem- 
ber, and  at  his  death,  which  occurred  toward  the  close  of  the  hot  weather, 
found  hyperjemia,  opacity,  and  fibrinous  exudation  in  the  pia  mater  at  the 
summit  of  the  brain,  while  the  base  of  the  brain  seemed  nearly  or  quite 
normal. 

Dr.  Soltmann  ^  of  Breslau  reports  three  cases  in  which  intense  cerebral 
hyperaemia,  and  probably  meningitis,  occurred  from  solar  heat.  In  all  three 
children  the  attack  was  sudden,  the  febrile  movement  and  heat  of  head  in- 
tense, and  the  progress  rapid.  The  first  had  convulsions,  the  second  auto- 
matic movements,  and  the  third,  the  oldest,  aged  four  years,  when  able  to 
speak  complained  of  violent  headache. 

The  statistics  of  New  York  City  show  that  congestive  and  inflammatory 
maladies  of  the  brain  and  its  covering  are  more  common  during  July  and 
August,  which  are  the  months  of  maximum  atmospheric  heat,  than  in  other 
months  of  the  year.  For  example,  in  July  and  August,  1875,  167  died  of 
these  maladies,  or  1  in  every  9.8  who  died  from  local  disease,  while  during 
^  Jahrbuchf.  Kinderkrank. ,  for  October,  1875. 


602  LOCAL  DISEASES. 

the  entire  year  only  710  died  from  the  same,  or  1  in  every  15  who  perished 
from  local  diseases. 

July,  1876,  in  New  York  City  was  characterized  by  excessive  and  long- 
continued  atmospheric  heat,  the  temperature  of  the  Central  Park  Observatory 
in  the  shade  never  falling  below  61°,  though  never  above  98°,  and  having  a 
mean  of  82.9°.  There  was  also  unusual  dryness  of  the  atmosphere,  since 
during  the  entire  month  prior  to  July  30th  there  were  only  fourteen  hours 
of  rain  with  a  rainfall  of  0.77  of  an  inch,  and  the  average  atmospheric 
humidity  was  represented  by  65,  saturation  being  denoted  by  100.  During 
this  month  I  treated  in  my  private  practice  four  fatal  cases  all  between  the 
ages  of  two  and  seven  years,  which  I  diagnosticated  meningitis,  none  of  them 
presenting  any  symptoms  of  otitis  or  tuberculosis.  It  would  seem  that  the 
atmospheric  heat  had  much  to  do  with  the  development  of  the  disease  in 
these  cases.  One  died  in  two  days,  but  in  the  others  there  was  the  usual 
duration.     Gowers  also  mentions  insolation  among  the  occasional  causes. 

A  not  infrequent  cause,  especially  among  the  strumous  families  of  cities, 
is  otitis  media  and  caries  of  the  petrous  portion  of  the  temporal  bone,  the 
inflammation  extending  to  the  meninges.  Any  suppurative  inflammation 
occurring  outside  the  dura  mater,  but  in  immediate  proximity  with  it,  may 
by  extension  cause  meningitis  ;  but  the  most  common  cause  of  this  kind  is 
purulent  otitis.  The  external  discharge  of  pus  from  the  ear  usually  ceases 
when  the  meningitis  begins.  Gowers  states  that  several  cases  are  on  record 
of  meningitis  occurring  from  traumatic  inflammation  of  the  eye,  the  inflam- 
mation probably  passing  along  the  sheath  of  the  optic  nerve.  He  also  states 
that  the  following  acute  diseases  occasionally  sustain  a  causal  relation  to 
meningitis :  measles,  scarlet  fever,  smallpox,  typhoid  fever,  pneumonia,  and 
acute  rheumatism.  But  the  meningitis  occurring  with  or  from  pneumonia 
is  probably  cerebro-spinal  fever,  and  meningitis  occurring  from  the  acute 
infectious  diseases  mentioned  by  Gowers  is  certainly  rare,  and  perhaps  its 
coexistence  with  them  is  in  at  least  some  instances  a  coincidence.  Septic 
processes  in  any  part  of  the  system  occasionally  cause  meningitis  from 
microbes,  which,  entering  the  circulation,  are  conveyed  to  the  meninges. 
Since  tubercular  meningitis  is  due  to  the  irritating  effect  of  tubercles  in  or 
under  the  pia  mater,  it  usually  occurs  where  tubercles  are  most  abundantly 
developed ;  that  is,  at  the  base  of  the  brain  and  along  the  course  of  the 
vessels  in  the  intergyral  spaces.  The  inflammation  is  commonly  excited 
when  they  are  still  small,  even  minute. 

Premonitory  Stage.  —  Meningitis  is  usually  preceded  by  symptoms 
which,  if  rightly  interpreted,  are  of  the  greatest  value.  In  most  cases  of 
this  malady  which  I  have  seen  there  was  a  prodromic  period  varying  from 
a  few  days  to  several  weeks.  The  symptoms  of  this  period  are  obscure,  and 
are  liable  to  be  mistaken  for  those  of  other  and  distinct  affections. 

The  child  in  whom  meningitis  is  approaching  loses  his  accustomed 
vivacity  and  cheerfulness.  He  has  a  melancholy  and  subdued  appearance, 
being  quiet  a  few  minutes,  and  then  fretful,  without  apparent  cause.  He 
can  sometimes  be  amused  by  his  playthings  or  companions  for  a  brief  pei'iod, 
when  he  turns  from  them  with  evident  displeasure.  Unexpected  and  loud 
noises  and  bright  lights  are  evidently  painful.  If  old  enough  to  describe  his 
sensations,  he  complains  of  transient  dizziness,  and  at  other  times  of  head- 
ache. His  ill-humor,  if  his  wishes  are  not  immediately  gratified  or  if  they 
are  denied,  is  often  scarcely  endurable  on  the  part  of  friends  who  are  ignorant 
of  the  cause.  There  is  great  difference,  however,  in  different  cases  as  regards 
this  symptom.  Some  are  inclined  to  be  taciturn  and  quiet,  while  others  are 
almost  constantly  fretting.  The  appetite  is  capricious;  at  one  time  it  is 
pretty  good,  at  another  it  is  poor  or  even   entirely  lost.     The  patient  may 


3IENINGITIS.  603 

take  a  few  mouthfuls  of  food,  or,  if  an  infant,  may  nurse  a  moment,  when  his 
hunger  appears  satisfied  and  he  will  take  nothing  more.  The  bowels  are 
regular  or  inclined  to  constipation.  The  pulse  is  natural  or  it  has  times 
of  acceleration,  especially  in  the  latter  part  of  the  day  and  toward  the  close 
of  the  premonitory  stage.  The  duration  of  this  stage  is  very  different  in 
different  cases.  Upon  an  average  it  is  perhaps  about  two  weeks,  but  it  is 
often  longer.  In  tubercular  meningitis  the  symptoms,  both  during  the 
inflammation  and  previously,  are  often  complicated  by  those  which  arise 
from  tubercles  in  other  parts  of  the  system.  Of  the  symptoms  premonitory 
of  the  disease  and  present  in  its  first  stages,  headache  and  vomiting  are 
especially  prominent. 

Unless  the  prodromic  period  be  of  short  duration  the  effect  of  imperfect 
nutrition  is  obvious  before  it  closes.  The  flesh  becomes  soft  and  flabby  or 
there  is  emaciation,  though  generally  slight.  The  patient  loses  his  strength, 
becoming  less  able  to  stand  or  to  walk,  and  more  easily  fatigued.  Occasion- 
ally, especially  in  the  non-tubercular  form,  premonitory  symptoms  are  absent 
or  are  slight  and  of  short  duration. 

Symptoms. — Dr.  Whytt,  living  in  the  last  century,  when  the  tendency 
was  toward  refinement  rather  than  simplicity  in  classification,  divided  menin- 
gitis into  three  stages,  according  to  the  symptoms,  especially  the  pulse. 
Many  subsequent  writers,  following  Whytt's  example,  have  recognized  three 
stages,  based  not  upon  the  anatomical  characters  of  the  disease,  but  upon  the 
succession  of  symptoms.  Such  division  of  meningitis  is  in  great  measure 
arbitrary,  since  in  one  case  the  same  symptoms  occur  at  an  earlier  period 
than  in  another. 

When  the  premonitory  stage  has  passed  and  inflammation  is  developed, 
some  of  the  symptoms  which  were  previously  present  remain  and  are  inten- 
sified, and  other  new  and  more  characteristic  symptoms  appear.  There  are 
fewer  intervals  of  apparent  improvement.  The  child  is  quiet,  often  lying 
with  his  eyes  shut.  If  aroused  he  has  a  wild  expression  of  the  face,  and  is 
irritated  by  attempts  to  engage  his  attention  or  amuse  him.  He  rarely 
smiles  or  takes  his  playthings,  or  he  notices  them  for  a  moment,  when  he 
turns  away  with  disgust.  Daring  sleep  there  is  often  at  first  a  placid  expres- 
sion of  countenance,  but  when  aroused  he  has  the  aspect  of  real  sickness ; 
the  eyebrows  are  sometimes  contracted,  as  if  from  headache ;  the  features 
wear  a  melancholy  look,  and  are  turned  away  to  avoid  the  gaze  of  the 
observer  or  to  shun  the  light.  If  the  anterior  fontanelle  be  open,  it  is 
observed  to  be  prominent  and  pulsating  forcibly.  If  consciousness  be  not 
lost  and  the  patient  be  of  sufficient  age,  he  complains  of  headache  or  of  pain 
in  some  part  of  the  body.  The  tongue  is  moist  and  covered  with  a  hght  fur ; 
the  appetite  is  lost  or  poor ;  there  is  seldom  much  thirst ;  more  or  less  nausea 
and  constipation  are  present.  As  the  inflammation  continues,  and  usually 
within  three  or  four  days  from  its  commencement,  symptoms  arise  which 
dispel  all  doubts,  if  there  were  any,  as  to  the  nature  of  the  disease.  The  vital 
powers  are  now  evidently  beginning  to  yield.  The  surface  generally  is  more 
pallid,  and  there  is  the  curious  phenomenon  of  the  sudden  appearance — and 
after  some  minutes  disappearance — of  spots  or  patches,  or  even  streaks,  of 
active  congestion  upon  the  face,  forehead,  or  ears.  These,  having  a  bright- 
red  color,  contrast  strongly  with  the  general  pallor.  Ordinarily  they  are 
irregularly  circular  or  oval,  and  from  one  inch  to  an  inch  and  a  half  in 
diameter.  A  red  spot  or  streak  is  also  produced  if  the  finger  be  pressed 
upon  the  surface  or  drawn  forcibly  across  it.  It  continues  a  few  minutes, 
and  then  gradually  fades.  Trousseau  calls  attention  to  this  fact  as  a  diag- 
nostic sign.  It  is  known  as  the  tdche  cerehrah  of  Trousseau,  and  it  affords 
some  aid  in  diagnosis,  but  the  tdche  cerehrale  is  common  in  some  other  diseases. 


604  LOCAL  DISEASES. 

Another  curious  phenomenon  is  the  variation  in  temperature.  The  face 
and  limbs  at  one  time  feel  quite  cool,  and  after  some  minutes,  without  any 
excitement  or  other  appreciable  cause,  the  temperature  rises,  so  that  the  sur- 
face is  warm  to  the  touch. 

Consciousness  in  severe  cases  may  be  lost  at  an  early  period.  On  the 
other  hand.  I  have  known  it  in  a  case  of  moderate  severity  to  remain,  though 
partially  obscured,  till  within  t went}' -four  or  thirty-six  hours  of  death.  The 
patient  will  usually  open  his  mouth  for  drinks  which  are  placed  to  his  lips 
when  there  is  no  other  evidence  of  intelligence  and  when  sight  and  hearing 
are  evidently  lost. 

The  loss  of  the  senses  constitutes  an  interesting  but  melancholy  feature 
of  the  disease.  Among  the  first  unequivocal  signs,  and  frequently  the  very 
first,  are  such  as  pertain  to  the  eye.  This  organ  should  be  watched  from  day 
to  day  when  the  diagnosis  is  uncertain.  Deviation  from  its  normal  state 
aifords  evidence  of  meningitis.  The  pupils  are  seen  to  dilate  or  contract 
sluggishly  by  variations  in  the  intensity  of  the  light,  or  they  are  not  of  the 
same  size  with  those  of  another  individual  to  whom  the  same  amount  of 
light  is  admitted.  Sometimes  the  first  perceptible  deviation  from  the  normal 
state  is  an  inequality  in  the  size  of  the  pupils,  while  in  others  oscillation  of 
the  iris  is  observed.  Later,  when  convulsions  have  occurred,  the  parallelism 
of  the  eyes  is  lost.  After  elFusion  has  taken  place  the  pupils  are  commonly 
dilated.  As  death  approaches  the  eyes  become  bleared  and  a  puriform  secre- 
tion collects  in  the  inner  angle  of  the  eye  and  between  the  eyelids.  This 
secretion  is  not  abundant,  but  it  is  sometimes  sufficient  to  unite  the  lids. 
The  sense  of  hearing  is  probably  lost  as  soon,  or  nearly  as  soon,  as  that  of 
sight,  but  the  sense  of  touch  continues  longer.  The  tongue  is  covered  with 
a  moist  fur.  unless  near  the  close  of  life,  when  it  is  sometimes  dry.  The 
appetite  is  gradually  lost,  but  often  drinks  are  taken  with  apparent  relish, 
even  when  there  is  no  other  evidence  of  consciousness.  There  are  two  symp- 
toms pertaining  to  the  digestive  system  which  are  rarely  absent,  and  which 
possess  great  diagnostic  value :  one  is  vomiting,  the  other  constipation.  In 
some  patients  irritability  of  stomach  begins  at  so  early  a  period  that  it  is 
really  prodromic  ;  it  is  rarely  absent.  Barrier  collected  the  records  of  80 
patients  with  meningitis,  and  in  75  of  these  this  symptom  was  present.  It 
is  due  to  the  intimate  relation  existing  between  the  stomach  and  brain 
through  the  ganglionic  system  of  nerves.  The  vomiting  occurs  without 
effort,  and  usually  at  intervals  for  several  days.  It  is  a  sudden  ejection  of 
the  contents  of  the  stomach,  apparently  without  preceding  or  subsequent 
nausea.  It  contrasts,  therefore,  with  the  vomiting  due  to  an  emetic,  which 
is  attended  by  distressing  symptoms.  With  some  it  occurs  frequently,  with 
others  not  more  than  two  or  three  times  daily.  Commencing  in  the  first 
stages  of  meningitis  or  even  prior  to  it,  it  occurs  less  often  as  the  drowsiness 
becomes  more  profound,  and  finally  ceases.  Constipation  is  also  present, 
usually  from  the  commencement  of  the  meningitis.  It  is  one  of  the  most 
constant  and  persi-stent  symptoms,  continuing  throughout  the  entire  sickness, 
unless  relieved  by  medicine  or  unless  there  be  a  coexisting  diarrhoeal  affec- 
tion. Often,  when  diarrhoea  precedes  the  meningitis,  it  ceases  the  moment 
the  latter  commences.  The  constipation  in  this  disease  is  easily  overcome  by 
purgatives.  Several  writers  speak  of  retraction  of  the  abdomen  as  a  sign  of 
meningitis.  A  hollow  or  sunken  appearance  of  the  abdomen,  according  to 
Golis.  aids  in  distinguishing  meningitis  from  fever.  The  anterior  abdominal 
wall  approaches  the  spine,  so  that  the  pulsations  of  the  abdominal  aorta  are 
distinctly  felt.  Rilliet  and  Barthez,  who  have  rarely  observed  this  retrac- 
tion except  in  cerebral  diseases,  attribute  it  to  the  state  of  the  intestines 
rather  than  to  the  action  of  the  abdominal  muscles. 


MENINGITIS.  605 

The  pulse  in  the  first  stages  of  meningitis  is  accelerated,  or  it  is  nearly 
natural  during  certain  hours  and  afterward  accelerated.  When  the  disease 
has  continued  a  few  days,  often  not  more  than  three  or  four,  the  pulse  under- 
goes a  marked  change.  It  becomes  slower  and  at  the  same  time  irregular. 
The  irregularity  usually  consists  in  an  intermittence  of  the  pulse  after  each 
six  or  eight  beats.  Sometimes  the  force  of  the  pulse  varies,  so  that  a  feeble 
pulsation  is  succeeded  by  one  of  greater  volume  and  strength.  The  decrease 
in  the  frequency  of  the  pulse  cannot  fail  to  arrest  attention.  From  110  or 
120  beats  per  minute  in  the  first  stage  of  the  inflammation  it  often  descends 
to  a  frequency  even  less  than  that  of  the  normal  adult  pulse.  At  an  ad- 
vanced period,  as  death  approaches,  the  pulse  again  becomes  accelerated 
and  feeble. 

The  change  in  respiration  is  as  marked  as  that  of  the  pulse.  In  the 
beginning  of  meningitis  the  breathing  is  in  some  patients  moderately  accel- 
erated ;  in  others  it  is  natural.  When  the  disease  has  continued  a  few  days, 
the  time  usually  varying  from  three  or  four  days  to  more  than  a  week,  a 
marked  alteration  occurs  in  the  respiratory  movements.  Their  rhythm,  like 
that  of  the  pulse,  is  changed.  The  breathing  is  irregular,  intermittent,  and 
accompanied  by  sighs.  The  change  in  pulse  and  respiration  corresponds 
with  the  loss  of  consciousness,  and  shows  that  the  brain  is  becoming  seriously 
involved. 

When  the  pulse  and  respiration  undergo  the  changes  which  have  been 
described,  another  prominent  and  grave  cerebral  symptom  is  sometimes  pres- 
ent— to  wit,  convulsions.  Their  occurrence  diminishes  greatly  the  prospect 
of  a  favorable  issue.  The  severity  and  extent  of  the  convulsive  movements 
vary  in  different  cases.  They  may  be  partial  or  general.  Their  duration  is 
often  brief,  but  they  recur  three  or  four  times  through  the  day.  They  are 
preceded  by  cephalalgia  in  those  old  enough  to  express  their  sensations, 
and  often  by  drowsiness.  Each  convulsive  attack  ends  in  still  greater 
drowsiness. 

With  this  group  of  symptoms  another  should  be  mentioned.  I  refer  to 
the  hydrocephalic  cry.  At  intervals  the  patient,  without  being  disturbed 
and  without  any  change  in  symptoms,  utters  a  scream  or  sharp  cry,  and 
immediately  relapses  into  his  former  state.  This  cry  is  more  common  in  the 
commencement  of  the  meningitis  than  subsequently,  and  in  many  it  is  absent 
or  is  not  a  marked  symptom.  The  glandular  system  participates  in  the  gen- 
eral loss  or  derangement  of  function.  Tears  are  seldom  shed  even  when  the 
child  is  much  irritated,  and  the  urinary  secretion  is  diminished.  The  small 
amount  of  urine  passed  sustains  an  important  relation  to  the  progress  of  the 
disease  and  the  therapeutics. 

The  patient  usually  lingers  several  days  after  the  pulse  and  respiration 
are  changed  in  the  manner  stated.  The  drowsiness  becomes  moi'e  profound, 
the  vomiting  ceases  as  well  as  the  convulsive  attacks,  and  sensation  and  con- 
sciousness are  entirely  lost.  But  even  in  this  state,  if  nutriment  and  stimu- 
lants be  administered  with  regularity,  the  child  often  lives  several  days 
longer  than  appeared  possible.  At  length. increasing  feebleness  and  rapidity 
of  pulse  and  coldness  of  the  face  and  limbs  indicate  the  near  approach  of 
death,  which  occurs  in  a  state  of  coma. 

The  symptoms  described  above  are  such  as  we  observe  in  ordinary  cases 
of  meningitis,  and  in  the  order  which  I  have  indicated,  but  this  description 
does  not  apply  to  all  cases. 

Meningitis  may  be  so  violent  and  rapid  that  both  the  character  and  suc- 
cession of  symptoms  are  different  from  those  which  have  been  stated.  Thus, 
I  have  related  the  case  of  a  girl  who,  with  no  prodromic  symptoms  excepting 
occasional   dizziness   and   slight  headache,  was  taken  sick  on  Thursday,  had 


606  LOCAL  DISEASES. 

convulsions  on  Friday,  and  from  this  time  continued  either  in  convulsions  or 
coma  till  her  death  on  Monday.  Again,  even  in  cases  of  the  usual  duration 
and  anatomical  character  some  of  the  most  prominent  symptoms  upon  which 
we  rely  for  diagnosis  may  be  lacking.  The  following  was  a  case  of  this 
kind  : 

Case. — On  the  5th  of  April,  1862, 1  was  asked  to  see  a  boy,  two  years  and  eight 
months  old,  of  healthy  parentage,  who  during  the  preceding  year  had  been  in  uni- 
form good  health,  but  previously  had  had  two  or  three  severe  attacks  of  sickness. 
His  head  was  unusually  large,  and  whenever  much  indisposed  he  often  had  symp- 
toms premonitory  of  convulsions,  which  were  always,  however,  prevented. 

One  night  in  the  latter  part  of  March  his  parents  noticed  that  his  sleep  w^as 
restless,  but  on  the  following  day  he  seemed  entirely  well,  and  the  restlessness  at 
night  was  attributed  to  a  late  and  hearty  supper.  On  succeeding  nights,  however, 
he  was  restless,  and  when  questioned  complained  of  pain  in  the  abdomen.  In  a  few 
days  he  was  observed  to  be  drooping  in  the  daytime,  and  his  appetite  was  not  quite 
so  good  as  previously.  He  had  continued  in  this  way  about  a  week  when  my  first 
visit  was  made. 

The  abdominal  pain  had  at  this  time  become  more  constant,  but  was  never 
severe  or  accompanied  by  moaning.  When  asked  where  he  felt  sick,  he  placed  his 
hand  upon  the  epigastrium,  pressure  upon  which  was  sometimes  tolerated,  but  at 
other  times  painful.  The  following  symptoms  were  noted  :  tongue  slightly  furred, 
anorexia,  thirst,  constipation,  scantiness  of  urine,  no  headache  or  unusual  heat  of 
head  during  any  part  of  his  sickness.  He  vomited  at  intervals  from  about  the  7th 
to  the  K  ith  of  April,  when  the  irritability  of  stomach  ceased  and  there  was  no  return 
of  this  symptom. 

About  April  7th  the  respiration  was  first  observed  to  be  irregular  and  sighing, 
and  the  pulse  intermittent.  These  symptoms,  so  tardily  developed,  were  the  first 
which  indicated  cerebral  disease.  He  now  lay  most  of  the  time  in  bed  with  eyes 
closed,  surface  commonly  pallid,  with  occasional  rose-colored  spots  or  patches  upon 
the  cheek  or  forehead.  The  pupils  responded  to  light  in  the  usual  manner  till  near 
the  close  of  life,  but  bright  lights  were  painful ;  the  last  two  or  three  days  of  his 
life  the  left  pupil  was  more  dilated  than  the  right.  He  had  no  convulsions  or  any 
spasmodic  movement,  and  was  conscious  till  within  a  few  hours  of  death  :  the 
mother  states  that  there  was  unequivocal  evidence  of  his  recognition  of  her  on  the 
last  day  of  his  life.  He  died  April  17th,  nearly  three  weeks  after  the  commencement 
of  the  disease  and  ten  days  after  the  commencement  of  symptoms  which  were  clearly 
referable  to  the  brain. 

Autopsy. — Abdominal  organs  healthy,  though  epigastric  pain  had  been  so  con- 
stant and  prominent  a  symptom  ;  brain  and  its  membrane  somewhat  injected.  The 
meninges  covering  the  base  of  the  brain  from  the  most  prominent  part  of  the  pons 
Varolii  to  the  first  pair  of  nerves  presented  evidences  of  inflammation.  There  was 
such  opacity  of  the  pia  mater  in  places  as  to  conceal  the  brain  from  view.  The  ante- 
rior and  middle  loljes  of  each  hemisphere  were  glued  together  by  fibrinous  exuda- 
tion, and  on  the  left  side,  along  the  fissure  of  Sylvius,  was  a  thick  deposit  of  the  same 
character.  The  lateral  ventricles  contained  about  an  ounce  of  clear  serum,  and  about 
half  an  ounce  escaped  from  the  base  of  the  brain.  The  foramen  of  Monro  was  con- 
siderably enlarged,  and  the  brain-substance  surrounding  the  lateral  ventricles  was 
softened. 

In  this  case  it  is  seen  that  the  prominent  symptom — and,  indeed,  almost 
the  only  marked  symptom  in  the  first  stages  of  the  disease — was  pain  in  the 
abdomen,  and  yet  the  abdominal  organs  were  healthy.  At  the  very  moment 
when  it  was  highly  important  that  a  correct  diagnosis  should  be  made,  the 
evidences  of  cerebral  disease  were  lacking.  This  case  is  therefore  interesting 
on  account  of  the  variation  in  symptoms  from  those  in  the  usual  form  of 
meningitis.  There  were  no  convulsions,  and  consciousness  was  retained,  as 
well  as  vision,  till  near  the  close  of  life,  and  yet  the  lesions  were  such  as  are 
commonly  present  in  meningeal  inflammation.  It  is  in  such  cases  that  a 
wrong  diagnosis  is  frequently  made,  to  the  injury  of  the,  patient  and  the 
reputation  of  the  physician. 


MENINGITIS.  607 

Occasionally  meningitis  may  continue  so  long  as  almost  to  justify  its 
laeing  called  chronic,  even  when  there  is  a  large  amount  of  exudation  upon 
the  pia  mater.  In  the  few  cases  which  end  favorably  the  symptoms 
abate  gradually.  I  shall  describe  more  fully  the  termination  in  speaking  of 
Prognosis. 

Diagnosis. — It  is  of  the  utmost  importance  to  diagnosticate  meningitis 
in  its  first  stages,  since  treatment  to  be  successful  must  be  comnienced  early. 
Certain  writers  describe  at  length  the  means  of  diagnosticating  the  simple 
from  the  tubercular  form  of  the  inflammation.  Differential  diagnosis  is  often 
difficult,  and  sometimes  impossible  ;  but  it.  matters  little,  practically,  whether 
the  form  of  the  disease  be  ascertained.  On  the  other  hand,  it  is  very  im- 
portant, in  order  that  the  treatment  be  appropriate,  to  diagnosticate  the  pre- 
monitory or  initial  stage  of  meningitis  from  certain  other  affections  not  located 
within  the  cranium.  Sometimes  remittent  or  continued  fever  or  constitu- 
tional disturbances  arising  from  irritation  in  the  digestive  system  simulate 
closely  incipient  meningeal  disease,  so  that  the  greatest  care  and  discrimi- 
nation are  required  in  order  to  make  a  correct  diagnosis.  Within  a  compara- 
tively recent  period  I  have  known  in  three  different  instances  experienced 
physicians  of  this  city  to  mistake  commencing  meningitis  for  fevers,  not 
aware  of  the  serious  error  they  had  made  till  the  inflammation  had  reached  a 
stage  from  which  recovery  was  impossible.  In  order  to  avoid  error  in  the 
diagnosis  in  the  premonitory  or  initial  stage  of  meningitis,  the  physician 
should  take  time  to  observe  the  physiognomy  and  note  every  symptom. 
More  than  one  protracted  visit  is  often  required  to  remove  doubt  as  to  the 
exact  pathological  state. 

Meningitis  is  usually  preceded,  and  in  its  commencement  accompanied, 
by  greater  restlessness,  fretfulness,  intolerance  of  light,  and  a  greater  varia- 
tion of  symptoms,  than  most  other  maladies.  One  familiar  with  the  physiog- 
nomy of  infancy  and  childhood  will  discover  in  the  features  indication  of 
greater  suffering,  of  more  serious  sickness,  than  is  commonly  present  in  other 
maladies  which  simulate  this.  The  eye  should  always  be  carefully  observed. 
Inequality  of  the  pupils,  their  oscillation,  strabismus,  nystagmus,  and  espe- 
cially the  altered  state  of  the  optic  disks,  which  a  distinguished  oculist  has 
designated  "  outlying  portions  of  the  brain,"  will  often  assist  in  making  the 
diagnosis  positive. 

Sometimes  the  sudden  disappearance  of  a  chronic  eruption  upon  the  scalp 
will  aid  in  the  diagnosis.  This  is  a  sign  of  importance,  taken  in  connection 
with  the  symptoms.  Headache  and  vomiting,  symptoms  of  early  occurrence, 
should  especially  arrest  attention,  or  in  absence  of  headache,  pain  of  a  neur- 
algic character  in  some  other  part.  But  we  may  repeat  that  familiarity 
with  the  symptoms  of  meningitis  will  not  protect  from  error,  if  the  visits  of 
the  physician  are  hasty  and  his  examinations  imperfect.  When  the  eyes 
become  affected,  the  respiration  and  circulation  irregular,  and  especially  when 
convulsive  attacks  begin,  diagnosis  is  easy.  In  fact,  an  incorrect  diagnosis 
would  then  be  unpardonable ;  but,  unfortunately,  if  proper  treatment  have 
not  been  commenced  till  this  period  it  will  be  of  little  service. 

Prognosis.— Meningitis  is  one  of  the  most  fatal  maladies  of  early  life. 
Whether  the  form  be  tubercular  or  not,  if  the  initial  stage  have  passed  with- 
out proper  treatment,  death  may  be  considered  inevitable.  Tubercular  men- 
ingitis, however  early  recognized,  is  rarely  amenable  to  treatment.  M.  Guer- 
sant  ^  believes  that  recovery  from  the  first  stage  of  this  form  of  meningitis 
is  possible.  "  In  the  second  stage,"  says  he,  "  I  have  not  seen  one  child 
recover  out  of  a  hundred,  and  even  those  who  seemed  to  have  recovered 
have  either  sunk  afterward  under  a  return  of  the  same  disease  in  its  acute 
1  Diet,  med.,  t.  xix.  p.  403. 


608  LOCAL  DISEASES. 

form  or  have  died  of  phthisis.  As  to  patients  in  whom  the  disease  has 
reached  its  third  stage,  I  have  never  seen  them  improve  even  for  a  moment." 
The  very  few  reported  cases  which  resulted  favorably  may  have  been,  as  M. 
Guersant  has  intimated  in  the  context,  cases  of  the  non-tubercular  form. 
Rilliet  and  Barthez  believe  that  in  a  few  instances  tubercular  meningitis 
has  been  cured  in  its  first  stage,  but  they  state  also  that  it  is  likely  to 
return. 

The  PROGNOSIS  in  non-tubercular  meningitis  is  not  so  unfavorable,  provided 
that  treatment  be  commenced  at  a  sufficiently  early  period.  It  is  now  gen- 
erally admitted  that  it  may  not  infrequently  be  averted  when  threatening, 
and  even  arrested  in  its  incipiency.  In  many  such  cases  we  cannot,  from  the 
nature  of  the  disease,  be  certain  that  the  diagnosis  is  correct.  But  when  we 
see  children  relieved  who  present  precisely  those  premonitory  and  even  initial 
symptoms  which  occur  in  meningitis,  we  must  believe  that  at  least  some  of 
them  would  have  had  the  genuine  disease  if  not  relieved  by  the  measures 
employed.  That  in  its  commencement  recovery  is  possible  is  also  obvious 
from  the  fact  that  a  few  recover  even  in  the  second  stage,  when  there  can  be 
no  error  of  diagnosis. 

Although  a  considerable  proportion  of  patients  with  epidemic  cerebro- 
spinal meningitis  recover,  even  when  the  symptoms  have  been  most  grave, 
I  have  known  only  two  recoveries  from  sporadic  meningitis  when  it  had 
reached  that  stage  in  which  the  functions  of  the  brain  and  cranial  nerves 
were  impaired.  One  of  these  recovered  with  permanent  loss  of  sight,  the 
other  with  loss  of  hearing.  Both  seem  to  have  ordinary  intelligence.  An- 
other ease  has  been  communicated  to  me  in  which  the  patient,  a  little  child, 
recovered  completely,  but  for  several  months  after  the  attack  seemed  nearly 
idiotic. 

Sometimes,  even  in  the  second  stage  of  meningitis,  treatment  properly 
employed  is  attended  by  amelioration  of  symptoms.  Though  such  improve- 
ment may  serve  to  encourage  physician  and  friends,  it  should  not  be  the  basis 
for  a  favorable  prognosis  unless  it  continue  three  or  four  days. 

Apparent  improvement  during  a  few  hours  or  a  considerable  part  of  a 
day  is  not  unusual  in  those  who  finally  die.  Thus,  in  an  infant  whose  bowels 
were  previously  confined  I  have  known  the  pulse  and  respiration  to  become 
more  regular  and  the  symptoms  generally  improve,  though  only  for  a  brief 
period,  by  the  action  of  a  purgative.  Dr.  Watson  says  of  the  advanced  stage 
of  this  disease,  it  is  "  often  attended  with  remissions,  sometimes  sudden  and 
sometimes  gradual — deceitful  appearances  of  convalescence.  The  child  re- 
gains the  use  of  its  senses,  recognizes  those  about  it  again,  appears  to  its 
anxious  parents  to  be  recovering,  but  in  a  day  or  two  it  relapses  into  a  state 
of  deeper  coma  than  before.  And  these  fallacious  symptoms  of  improvement 
may  occur  more  than  once." 

Most  fatal  cases  of  meningitis  terminate  between  the  third  or  fourth  and 
the  twentieth  day,  the  duration  varying  according  to  the  extent  and  intensity 
of  the  inflammation  and  the  vigor  and  age  of  the  patient.  But  there  are 
cases  in  which  it  may  continue  much  longer.  It  is  surprising  sometimes 
how  long  the  patient  lives  when  the  symptoms  are  such  that  death  seems 
impending.  Sensation  and  consciousness  may  be  extinguished,  convulsions 
occur  at  intervals,  and  the  surface  have  acquired  almost  a  cadaveric  aspect, 
and  yet  the  patient  lives  on.  Rilliet  and  Barthez  say  :  "  Often  have  we 
inscribed  upon  our  notes  death  imminent,  and  been  astonished  the  next  day 
to  find  still  alive  children  to  whom  we  had  scarcely  allowed  two  hours  of 
life."  The  symptom  which  I  have  found  to  be  the  most  reliable  prognostic 
of  the  near  approach  of  death  has  been  a  pulse  gTadually  becoming  more 
frequent  and  feeble,  though  other  symptoms  remain  as  before.     This  change 


MENINGITIS.  609 

in  the  pulse  is  usually  very  apparent  during  the  last  twenty-four  hours  of 
life. 

Treatment. — Such  remedial  measures  should  be  prescribed  during  the 
premonitory  stage  as  are  calculated  to  relieve  the  fretfulness  or  irritability  of 
temper  and  quiet  the  action  of  the  brain,  and  at  the  same  time  produce  a 
derivative  efi'ect  from  this  organ.  To  this  end  the  patient  should  be  kept 
from  all  causes  of  excitement,  and  the  bowels  should  be  opened  daily — if  not 
naturally,  by  the  use  of  proper  medicines.  A  mustard  foot-bath  at  night  and 
occasionally  through  the  day  is  useful,  as  it  produces  both  a  derivative  and 
soothing  effect.  It  will  commonly  produce  a  few  hours'  undisturbed  rest, 
while  other  measures  except  medicines  fail.  If  dentition  be  taking  place  and 
the  gums  are  swollen,  it  has  been  the  practice  to  employ  the  gum-lancet, 
and  still  is  with  some  physicians,  but  I  for  one  have  discarded  its  use  for 
this  purpose.  Restlessness  from  dentition  or  restlessness  premonitory  of 
meningitis  requires  large  doses  of  bromide  of  potassium,  which  will  relieve 
the  symptoms  more  effectually  than  the  lancet.  Three  grains  should  be 
given  to  a  child  of  six  months,  and  four  grains  to  one  of  ten  or  twelve 
months,  and  repeated  if  necessary  in  one  to  two  hours.  If  symptoms  indi- 
cate the  near  approach  of  meningitis  or  its  incipiency,  the  head  should  be 
kept  constantly  cool  by  a  cloth  wrung  out  of  ice-water,  or,  better,  an  India- 
rvibber  bag  containing  ice.  Some  physicians  have  recommended  vesication 
back  of  the  neck  or  ears,  but  it  is  a  measure  of  doubtful  benefit,  and  if  em- 
ployed at  all  should  be  restricted  to  the  application  of  cantharidal  collodion 
behind  the  ears.  All  purulent  collections  near  the  meninges  should  be 
opened  and  disinfected,  and  especially  should  the  ear  be  examined,  and  if 
the  membrana  tympani  be  bulging  or  hypergemic,  paracentesis  should  be 
performed,  and  followed  by  washing  with  a  warm  and  weak  solution  of 
boracie   acid. 

Many  children  who  are  threatened  with  meningitis  are  scrofulous.  They 
have  already  shown  symptoms  of  tubercular  disease.  They  are  perhaps,  to 
a  certain  extent,  emaciated,  and  may  have  been  aifected  with  a  cough.  If 
the  premonitory  symptoms  in  children  indicate  the  approach  of  the  tuber- 
cular form  of  meningitis,  a  more  sustaining  course  of  treatment  is  required 
than  in  those  who  are  robust.  To  such  children  cod-liver  oil  may  be  profit- 
ably given  three  times  daily,  together  with  the  syrup  of  the  iodide  of  iron, 
and  perhaps  the  bromide.  They  should  also  be  taken  into  the  open  air  with 
proper  precautions,  and  every  hygienic  measure  should  be  employed  which 
will  be  likely  to  invigorate  the  system  without  exciting  the  brain. 

Loss  of  blood  is  not,  in  general,  required  during  the  prodromic  period  nor 
in  the  disease.  Those  of  a  strumoiis  cachexia,  or  those,  whether  strumous  or 
not,  who  are  under  the  age  of  two  years,  do  not.  unless  in  very  rare  instances, 
require  depletion  by  leeches,  much  less  by  venesection.  There  is  one  class 
of  patients  in  whom  the  early  loss  of  blood  may  perhaps  be  of  service — 
namely,  those  who  in  a  state  of  robust  health  are  suddenly  seized  with 
inflammation,  especially  if  the  cause  be  insolation.  Leeches  may  then  be 
applied  to  the  head  of  the  patient  if  he  be  seen  at  an  early  period,  but  the 
majority  of  physicians  probably  wisely  recommend  the  ice-bag  in  preference 
to  leeching. 

Often,  notwithstanding  the  measures  employed,  the  patient  grows  worse  ; 
the  symptoms  become  more  continuous,  others  more  alarming  •  arise,  and 
meningitis  declares  itself.  Whatever  the  cause  of  the  inflammation,  and 
whatever  modifications  of  treatment  were  required  in  the  premonitory  stage 
on  account  of  special  indications,  the  purpose  now  is  to  subdue  the  inflam- 
mation by  every  resource  in  our  art  which  does  not  injure  or  too  much  pros- 
trate the  system.  In  former  days  calomel  was  largely  employed  as  the  main 
39 


610  LOCAL  DISEASES. 

remedy  in  this  disease,  but  when  administered  daily  it  has  a  very  depressing 
effect,  and  it  is  to  be  borne  in  mind  that  in  meningitis  the  vital  powers  pro- 
gressively fail  on  account  of  the  loss  of  appetite,  vomiting,  etc.  In  tuber- 
cular meningitis  depressing  treatment  is  of  course  strongly  contraindicated. 
Cases  have  occurred  in  which  calomel  was  given  at  short  intervals  for 
several  successive  days,  so  as  to  produce  a  laxative  eifect,  but,  though  the 
meningitis  seemed  to  be  controlled,  death  resulted  from  exhaustion  or  from 
some  intercurrent  affection  due  to  exhaustion.  Thus  in  one  case  formerly 
related  to  his  class  by  a  distinguished  Xew  York  professor,  fatal  gangrene  of 
the  mouth  supervened  from  the  mercurial  treatment  after  the  meningeal 
inflammation  had  apparently  subsided.  Although  calomel  during  these  last 
years  has  been  properly  discarded  as  the  main  remedy  and  its  daily  use 
rejected,  nevertheless  it  is  very  useful  as  an  occasional  laxative  in  the  more 
robust  cases  if  not  given  too  near  the  iodide  of  potassium  ;  and  it  is  especially 
indicated  as  a  derivative  from  the  head  in  children  of  four  or  five  years,  who, 
previously  hearty  and  strong,  have  become  suddenly  afi"ected  with  meningitis, 
as  from  exposure  to  the  sun's  rays  or  from  an  injury.  But  I  repeat  the 
belief  that  in  ordinary  cases  calomel  should  never  be  employed,  except  as 
an  occasional  laxative. 

The  two  remedies  upon  which  we  must  chiefly  rely  are  the  iodide  of 
potassium  and  the  bromide  of  potassium  or  sodium.  While  the  bromide 
quiets  the  restlessness,  pi'events  convulsions,  and  diminishes,  there  is  reason 
to  think,  to  a  certain  extent,  the  hyperjemia,  the  iodide  is  useful  as  a  sorbe- 
facient,  and  it  probably  has  some  control  over  the  inflammation.  The  iodide 
or  bromide  can  be  given  together  or  separately. 

The  iodide  should,  like  the  bromide,  be  given  early.  If  by  a  careful 
examination  the  absence  of  any  other  local  disease  or  constitutional  disease 
which  might  give  rise  to  the  symptoms  be  ascertained,  and  the  symptoms 
indicate  the  meningeal  disease,  the  iodide  should  be  immediately  prescribed. 
Obscurity  often  hangs  over  meningitis  at  this  early  stage,  but  it  is  better  to 
give  the  iodide,  even  if  the  diagnosis  be  wrong  and  no  inflammation  have 
commenced,  than  to  err  on  the  other  side,  and  withhold  it  in  the  initial  period 
of  the  true  disease;  for  it  is  nob  an  injurious  remedy  like  calomel,  and  to 
exert  any  marked  efi"ect  it  should  be  given  in  the  commencement  of  the 
inflammation.  An  infant  of  the  age  of  six  to  twelve  months  should  take  two 
grains  every  two  hours,  and  older  children  a  proportionate  dose.  At  the  same 
time  the  bromide  should  be  given  in  doses  twice  as  large  as  that  of  the  iodide 
if  the  indications  for  its  use  are  present — to  wit,  headache,  restlessness,  and 
symptoms  which  threaten  eclampsia.  The  bromide  is  a  harmless  remedy 
given  frequently  for  a  limited  time.  With  the  regular  and  continued  use 
of  the  iodide  and  occasional  doses  of  bromide,  the  quantity  of  urine  is  in 
most  cases  largely  increased.  If  the  patient's  condition  do  not  soon  begin 
to  improve  with  such  treatment,  there  is  no  remedy. 

If  convulsions  occur,  the  bromide  should  be  given  every  ten  or  fifteen 
minutes  till  they  cease.  If  they  be  not  controlled  by  the  bromide,  an  injec- 
tion, per  rectum,  of  three  to  five  grains  of  hydrate  of  chloral  in  a  teaspoonful 
of  water  should  be  used  in  addition.  Compresses  wrung  out  of  ice-water  fre- 
quently applied  to  the  head,  or  a  bladder  containing  pounded  ice  and  separated 
by  one  thickness  of  muslin  from  the  head,  materially  aid  in  reducing  the 
meningeal  hyperaemia.  Ergot,  recommended  by  Brown-Sequard  for  its  sup- 
posed efi"ect  in  diminishing  the  hyperaemia  in  the  inflammatory  diseases  of  the 
nervous  centres,  may  also  be  employed  as  an  adjuvant  in  the  treatment  of  this 
disease,  but  it  has  much  less  eff'ect  upon  the  hyperaemia  of  the  brain  or 
meninges  than  upon  that  of  the  uterine  system. 

In  the  first  stage  of  simple  meningitis  the  diet  should  be  mild  and  in 


SPURIOUS  HYDROCEPHALUS.  611 

moderate  quantity,  but  in  the  tubercular  form  it  should  from  the  first  be 
of  the  most  nourishing  kind,  consisting  of  beef  tea,  milk  porridge,  etc.  At  a 
more  advanced  stage  in  both  forms  of  the  malady  the  most  nutritious  diet 
should  be  allowed,  but  alcoholic  stimulants  should  not  be  given  unless  near 
the  close  of  life,  when  the  vital  powers  are  failing.  The  apartment  should  be 
cool  and  quiet. 


CHAPTER    VI. 

SPURIOUS  HYDROCEPHALUS. 

The  disease  known  as  spurious  hydrocephalus  might  with  more  propriety 
be  called  spurious  meningitis.  It  received  its  appellation  at  the  time  when 
meningitis  of  early  life  was  believed  to  be  essentially  a  hydrocephalus,  and 
was  so  called.  Attention  was  first  directed  to  it  by  London  physicians  of  the 
last  generation,  particularly  by  Drs.  Gooch,  Abercrombie,  and  Marshall  Hall, 
and  little  can  be  added  to  their  description  of  its  symptoms. 

Anatomical  Characters. — This  disease,  though  resembling  meningitis 
in  certain  of  its  phenomena,  is  not  in  its  nature  inflammatory,  nor  is  it 
primary.  It  is  the  result  of  some  malady  often  chronic,  but  occasionally 
acute,  which  has  produced  exhaustion,  especially  of  the  nervous  system. 
When  it  commences  there  is  usually  more  or  less  emaciation  and  the  symp- 
toms of  the  primary  disease  are  present.  To  this  disease  the  lesions  pertain 
which  are  found  in  other  organs  besides  the  brain. 

The  state  of  the  brain  in  spurious  hydrocephalus  is  not  the  same  in  all 
cases.  In  some  there  is  no  appreciable  anatomical  alteration  in  this  organ. 
There  is  no  apparent  diiference,  either  in  the  meninges  or  the  brain  itself, 
from  the  condition  which  we  often  observe  in  those  who  have  died  of  diseases 
which  do  not  affect  the  cerebro-spinal  system.  In  such  cases  the  pathological 
state  is  simply  deficient  innervation,  or  if  there  be  a  structural  change  in  the 
minute  anatomy  of  the  brain,  pathologists  have  not  yet  discovered  it. 

The  following  case,  which  occurred  in  the  Child's  Hospital  of  this  city,  is 
an  example  of  this  form  of  spurious  hydrocephalus : 

Case. — A  female  infant,  six  months  old,  died  on  the  24th  day  of  April,  1862, 
with  the  following  history :  It  was  wet-nursed,  fleshy,  and  apparently  well  till  six 
days  before  death,  when  symptoms  of  gastro-intestinal  inflammation  were  suddenly 
developed.  The  vomiting  especially  was  severe,  continuing  forty-eight  hours.  When 
it  ceased,  drowsiness  supervened  and  continued  till  the  close  of  life.  The  face  during 
the  four  days  of  stupor  was  pallid  and  cool ;  eyes  partly  open,  pupils  sluggish,  but 
of  equal  size  ;  bowels  rather  torpid  ;  anterior  fontanelle  depressed.  When  aroused 
the  infant  noticed  objects  for  a  moment,  and  immediately  relapsed  into  sleep ;  pulse 
accelerated  and  not  intermittent,  the  day  before  death  numbering  150  •,  respiration 
accelerated,  without  sighing,  numbering  on  the  same  day  30.  There  were  no  con- 
vulsions, and  death  occurred  quietly.  The  brain  weighed  twenty  and  a  half  ounces, 
and  its  appearance  was  perfectly  healthy,  both  as  regards  consistence  and  vascu- 
larity. The  amount  of  cerebro-spinal  fluid  in  the  ventricles  and  at  the  base  of  the 
brain  was  not  notably  increased.  The  stomach,  small  and  large  intestines,  were 
vascular  in  streaks  and  patches. 

In  this  case  the  cerebral  symptoms  were  obviously  due  to  exhaustion 
occurring  at  an  early  period  in  consequence  of  the  severity  of  the  gastro- 
intestinal malady. 


612  LOCAL  DISEASES. 

In  a  majority  of  cases,  however,  of  spurious  hydrocephalus,  according  to 
my  observation,  there  is  an  anatomical  alteration  in  the  state  of  the  brain  and 
meninges.  This  consists  in  passive  congestion  of  the  veins,  often  with  tran- 
sudation of  serum.  At  the  same  time,  the  cranial  sinuses  are  congested,  and 
are  found  at  the  post-mortem  examination  to  contain  larger  and  more  numer- 
ous clots  than  are  present  in  those  who  die  of  diseases  which  do  not  affect 
the  encephalon.  Cases  might  be  cited  as  examples.  The  cause  of  this  con- 
gestion and  effusion  is  in  a  great  measure  feebleness  of  the  circulation  due  to 
the  general  exhaustion  of  the  patient.  But  there  is  another  cause.  In  pro- 
tracted diseases,  especially  those  of  a  diarrhceal  character,  there  is  more  or 
less  wasting  of  the  brain  as  well  as  of  other  parts.  This  naturally,  by  way 
of  compensation,  gives  rise  to  congestion  of  the  cerebral  and  meningeal  veins 
and  capillaries  and  to  transudation  of  serum. 

The  transudation  commonly  occurs  in  this  malady  over  the  superior  sur- 
face of  the  brain  and  in  the  subarachnoidal  space,  perhaps  also  more  or  less 
in  the  lateral  ventricles.  So  common  is  it  in  the  last  stage  of  infantile 
entero-colitis,  the  summer  epidemic  of  cities,  that  this  stage,  which  is  really 
spurious  hydrocephalus,  has  been  called  the  stage  of  effusion.  I  shall  relate 
in  another  place  examples  which  show  the  anatomical  character  of  this  intes- 
tinal disease. 

Symptoms. — Spurious  hydrocephalus  most  frequently  results  from  pro- 
tracted diarrhoeal  complaints.  It  may,  however,  result  from  any  disease 
which  is  attended  by  great  prostration.  As  it  ordinarily  occurs,  the  patient 
has  for  days  or  weeks  been  gradually  losing  flesh  and  strength.  Finally, 
drowsiness  supervenes,  or  before  the  drowsiness  there  is  sometimes  a  period 
of  irritability. 

Marshall  Hall  describes  two  stages  of  spurious  hydrocephalus.  In  the 
first,  he  says.  "  the  infant  becomes  irritable,  restless,  and  feverish ;  the  face 
flushed,  the  surface  hot,  and  the  pulse  frequent ;  there  is  an  undue  sensitive- 
ness of  the  nerves  of  feeling,  and  the  little  patient  starts  on  being  touched 
or  from  any  sudden  noise ;  there  are  sighing  and  moaning  during  sleep,  and 
screaming ;  the  bowels  are  flatulent  and  loose  and  the  evacuations  are 
mucous  and  disordered."  The  second  stage  he  describes  as  that  of  torpor. 
The  first  stage  often,  however,  does  not  present  those  prominent  symptoms 
which  have  been  described  by  Dr.  Hall,  and  this  stage  may  even  be  absent 
or  not  appreciable,  especially  in  young  infants. 

Whether  or  not  commencing  with  the  stage  of  irritability,  the  disease,  if 
not  checked,  gradually  increases.  The  child  soon  becomes  drowsy.  He 
may  be  aroused  for  a  moment,  but  unless  constantly  disturbed  immediately 
relapses  into  sleep.  He  is  sometimes  fretful  when  aroused,  but  in  other 
instances  is  quite  indifferent,  observing  without  apparent  interest  objects 
employed  for  the  purpose  of  amusing  him.  Often  there  are  indications  of 
cerebral  pain  or  distress,  as  contractions  of  the  eyebrows,  etc.,  but  many  of 
those  affected  are  too  young  to  make  known  their  sensations.  Convulsions 
sometimes  occur  toward  the  close  of  life,  but  they  are  not  so  common  in  this 
disease  as  in  meningitis.  When  they  do  occur  they  are  generally  partial 
and  often  slight.  The  pulse  is  accelerated  in  most  patients  prior  to  and  in 
the  commencement  of  spurious  hydrocephalus.  As  the  disease  advances  it 
becomes  irregular  and  intermittent,  and  toward  the  close  of  life  it  is  pro- 
gressively more  frequent  and  feeble.  The  respiration  at  first  is  not  much 
disturbed,  but  at  length  it  becomes  irregular  like  the  pulse.  It  is  feeble  and 
accompanied  by  sighs.  Occasionally,  there  is  slight  cough.  The  eyelids 
are  partly  open,  the  pupils  no  longer  respond  to  light,  and  in  advanced  cases 
they  have  a  bleared  appearance.  The  diarrhoea,  which  in  most  instances 
precedes  and  causes  this  malady,  continues  till  the  stage  of  stupor  arrives, 


SPUEIOUS  HYDROCEPHALUS.  613 

■when  the  evacuations  becomes  less  frequent  or  cease  altogether.  In  infants 
the  stools  are  frequently  green,  in  older  children  brown  and  sometimes 
slimy.  The  febrile  heat  of  surfaces  which  preceded  the  disease,  and  which 
was  present  in  its  commencement,  disappears ;  the  face  and  hands  become 
cool,  the  features  pallid,  and  the  anterior  fontanelle,  if  opened,  is  depressed. 
Death  finally  occurs  in  a  state  of  coma,  or  if  the  disease  be  recognized  and 
proper  remedial  measures  employed,  the  result  may  be  favorable,  even  when 
the  symptoms  are  such  that  if  meningeal  inflammation  were  the  malady  we 
would  consider  the  case  necessarily  fatal. 

In  the  following  case  the  result  was  unfavorable.  This  case  is  interesting 
on  account  of  the  anatomical  characters  of  the  disease  as  disclosed  by  the 
post-mortem  examination : 

Case. — "  A  German  infant,  eighteen  months  old,  had  diarrhoea  four  weeks  with- 
out regular  and  proper  medical  attendance  ;  stools  from  the  first  brown  and  thin  : 
during  the  last  eight  or  nine  days  he  has  been  drowsy  ;  when  aroused  opens  his 
eyes  and  is  very  fretful,  but  immediately  the  upper  eyelids  gradually  droop,  and 
unless  disturbed  he  remains  asleep  with  his  eyes  partially  open  ;  forehead  warm, 
face  cool  and  pallid,  and  limbs  also  rather  cool  :  pulse  164,  respiration  32  ;  has  had 
a  slight  cough  about  one  week,  and  slight  dulness  on  percussion  over  the  left  infra- 
scapular  region  ;  depression  of  inframammary  region  on  inspiration.  Treatment : 
Ammon.  carbonat.,  gr.  1  every  two  hours  ;  nourishing  diet. 

"  Dec.  2Uth,  has  continued  drowsy  since  the  last  record  ;  pupils  moderately 
dilated  ;  a  thick  secretion  between  eyelids  ;  right  pupil  considerably  larger  than 
the  left ;  vision  apparently  lost  during  the  last  three  days ;  pulse  over  140 ;  respira- 
tion 44  per  minute,  accompanied  by  sighing  since  the  18th;  moans  much  when 
awake ;  rolls  the  head  frequently ;  during  the  last  six  days  the  surface  back  of  the 
ears  has  been  constantly  sore  by  vesication  ;  takes  the  most  nutritious  diet  with 
brandy.     The  stools  remain  thin  and  brown  and  number  three  or  four  daily. 

"  From  this  date  the  diarrhcea  continued,  except  as  it  was  restrained  by  medi- 
cine. The  pulse  continued  frequent  and  a  slight  cough  remained.  There  was  on 
the  21st  and  22d  partial  abatement  of  the  drowsiness,  but  on  the  23d  it  was  greater 
than  ever.  The  body  was  somewhat  reduced  at  the  commencement  of  the  cerebral 
symptoms,  but  it  was  now  markedly  emaciated.  The  prostration  increased  daily, 
and  the  hands  were  observed  to  tremble.  The  face  and  hands  became  more  cool, 
while  the  head  was  warm.  On  the  24th  partial  convulsions  occurred,  followed  by 
coma  and  death. 

"  The  cerebral  veins  and  sinuses  were  generally  congested,  except  in  the 
anterior  portion  of  the  brain,  where  the  appearance  was  normal.  Between  the 
brain  and  its  membranous  covering,  chiefly  at  the  vertex  and  the  base,  was  an 
effusion  of  clear  serum.  The  whole  amount  of  this  fluid  was  estimated  at  two 
ounces.  On  slicing  the  brain  numerous  '  puncta  vasculosa'  were  seen,  both  in 
the  gray  and  white  portions.  With  the  exception  of  the  congestion  the  sub- 
stance of  the  brain  presented  its  normal  appearance.  No  inflammatory  lesions 
were  present.     We  were  not  permitted  to  examine  the  condition  of  the  intestines." 

Diagnosis. — The  only  disease  with  which  spurious  hydrocephalus  is 
liable  to  be  confounded  is  meningitis.  The  points  of  differential  diagnosis 
are  the  history  of  the  ease,  especially  the  antecedent  diarrhoea  or  other  ex- 
hausting ailment,  evidence  of  prostration  when  the  cerebral  malady  com- 
menced, depression  of  the  anterior  fontanelle  if  it  be  open,  and  the  cool  face 
and  extremities. 

Prognosis.— If  the  pathological  state  of  the  brain  be  simple  exhaustion, 
the  disease  can  often  be  arrested  by  judicious  treatment.  If  an  incorrect 
diagnosis  be  made  and  the  treatment  employed  be  that  appropriate  for  menin- 
gitis, which  it  simulates,  death  is  almost  inevitable.  ,  If  transudation  of 
serum  have  occurred,  unless  slight,  the  result  is  usually  unfavorable  what- 
ever may  be  the  treatment.  This  disease  in  childhood  is  more  easily  man- 
aged than  in  infancy,  but  is  less  frequent.  The  prognosis  is  better  in  the 
cool  months  than  during  the  heat  of  summer.     It  is  more  favorable  if  the 


614  LOCAL  DISEASES. 

child  be  over  than  if  under  the  age  of  one  year.  The  occurrence  of  an 
irregular  and  intermittent  pulse,  of  respiration  accompanied  by  sighs,  of 
inequality  in  the  pupils  or  their  sluggish  movements,  with  increasing  stupor, 
indicates  an  unfavorable  issue.  The  cure  of  the  primary  disease,  with  the 
pulse  and  respiration  still  natural  or  accelerated,  without  change  of  rhythm, 
pupils  sensitive  to  light,  drowsiness  from  which  the  patient  is  easily  aroused 
to  a  state  of  entire  consciousness,  render  recovery  probable  with  proper 
medication  and  alimentation. 

Treatment.— The  indications  of  treatment  are  twofold :  first,  to  remove 
the  primary  pathological  state  which  is  the  cause  of  the  spurious  hydro- 
cephalus ;  and,  secondly,  to  cure  the  latter.  The  first  is  important,  since 
the  successful  treatment  of  a  disease  requires  the  removal  of  the  cause. 
The  measures  employed  for  this  purpose  are  pointed  out  in  our  description 
of  the  diarrhoeal  and  other  maladies  which  produce  spurious  hydrocephalus. 

We  may  here  say  that,  as  spurious  hydrocephalus  is  due  in  a  very  large 
proportion  of  cases  to  the  exhausting  efi"ect  of  long-continued  diarrhoea, 
regulation  of  diet,  subnitrate  of  bismuth,  pepsin,  and  stimulation  are  needed. 

Active  sustaining  measures  are  indicated.  Exhausted  nervous  power,  as 
well  as  passive  cerebral  congestion,  requires  these.  The  diet  .should  be 
highly  nutritious,  comprising  such  substances  as  milk  and  beef  juice,  and 
should  be  given  frequently.  Brandy  is  required  at  short  intervals.  Dr. 
Gooch  was  in  the  habit  of  giving  the  aromatic  spirits  of  ammonia,  properly 
diluted,  as  a  quick  and  active  stimulant.  Six  or  eight  drops  may  be  given 
in  sweetened  water  to  a  child  one  year  old,  and  repeated  every  hour  in  cases 
of  urgency.  If  by  proper  treatment  of  the  cause  and  by  the  use  of  stimu- 
lants and  nutritious  food  the  patients  do  not  within  a  few  hours  become  less 
stupid  and  more  conscious,  there  is  that  degree  of  prostration  or  of  serous 
transudation  from  the  engorged  cerebral  veins  which  will  render  death 
probable.  In  some  cases  it  is  proper  to  produce  moderate  vesication  behind 
the  ears. 


CHAPTER   VII. 
ECLAMPSIA. 

The  term  "  eclampsia  "  is  used  in  a  more  restricted  sense  by  some  writers 
than  by  others.  It  is  employed  in  the  following  pages  to  designate  those 
convulsive  seizures,  clonic  in  their  character,  sometimes  general,  sometimes 
partial,  which  affect  the  external  muscles,  and  are  due  to  some  exciting 
cause.  It  consists  in  rapid,  forcible,  and  involuntary  muscular  contraction 
alternating  with  relaxation.  It  is  distinguished  from  chorea  in  the  fact  that 
the  latter  is  a  more  permanent  state,  and  is  characterized  by  muscular  move- 
ments which  are  partially  under  the  control  of  the  will  and  are  not  so  violent. 
The  symptoms  of  eclampsia  closely  resemble  those  of  epilepsy,  but  these 
diseases  are  distinguished  from  each  other  by  characters  which  will  be 
mentioned  hereafter. 

Eclampsia  occurs  in  a  great  variety  of  diseases,  some  of  which  are  located 
in  the  cerebro-spinal  system,  some  in  other  parts  of  the  body,  and  some  are 
constitutional.  It  may  also  be  produced  by  temporary  derangements  of  sys- 
tem not  sufiiciently  severe  to  be  considered  diseases,  and  by  powerful  mental 
impressions,  those  of  an  emotional  nature  aifecting  the  delicate  and  sensitive 
nervous  system  of  the  child.     Pathologists  recognize  three  different  forms  of 


ECLAMPSIA.  615 

eclampsia.  The  term  essential  or  idiopathic  is  used  when  the  convulsions 
have  no  appreciable  anatomical  character ;  that  is,  when  there  is  no  apparent 
pathological  state  in  the  brain  or  elsewhere  which  gives  rise  to  the  attack. 
For  example,  if  a  child  die  in  convulsions  from  fright,  and  all  the  organs, 
including  the  brain,  are  found  in  their  normal  state,  the  eclampsia  is  called 
idiopathic  or  essential.  If  the  cause  be  disease  of  the  brain  or  spinal  cord,  it 
is  termed  symptomatic.  If  eclampsia  arise  from  local  disease  elsewhere  than 
in  the  cerebro-spinal  axis,  as  from  pneumonia,  the  term  sympathetic  is  em- 
ployed. This  is  in  the  main  a  good  division,  but  eclampsia  may  be  at  the 
same  time  sympathetic  and  symptomatic,  as  when  it  occurs  in  consequence 
of  congestion  of  brain  which  is  induced  by  severe  and  frequent  paroxysms 
of  whooping  cough. 

Causes. — Eclampsia  occurs  at  any  period  of  infancy  and  childhood,  but 
it  is  much  more  rare  after  the  period  of  six  or  seven  years  than  previously. 
Some  children  are  more  liable  to  it  than  others.  It  is  produced  in  one  by 
an  agency  which  in  another  has  no  appreciable  effect.  There  are  some,  gen- 
erally those  of  an  impressible  nervous  system,  who  are  seized  with  convul- 
sions whenever  there  is  any  slight  derangement  in  the  digestive  or  other 
organs.  Eclampsia  is  frequent  in  certain  families.  Thus,  Bouchut  mentions 
a  family  of  ten  persons  all  of  whom  had  convulsions  in  their  infancy.  One 
of  them  married  and  had  ten  children,  who,  with  one  exception,  had  convul- 
sions. 

The  exciting  causes  of  eclampsia  are  too  numerous  to  be  mentioned  in 
full.  It  is  a  symptom  in  nearly  all  cerebral  diseases.  It  is  produced  in  the 
nursling  by  changes  in  the  milk  with  which  it  is  nourished.  These  changes 
are  usually  due  to  violent  emotions  of  the  mother,  as  anger,  fright,  and 
grief,  to  the  use  of  acescent  or  indigestible  food,  or  to  derangement,  tempo- 
rary or  permanent,  in  their  health.  Thus,  in  a  case  related  to  me  the  cata- 
menia  so  affected  the  milk  that  the  infant  was  seized  with  eclampsia  at  each 
monthly  period.  In  childhood  the  most  common  cause  of  clonic  convulsions 
is  the  presence  of  some  irritant  in  the  primae  vias.  All  kinds  of  fruit,  even 
the  mildest,  may  produce  eclampsia,  especially  when  eaten  unripe  or  taken 
in  undue  quantity.  I  have  known  an  infant  to  be  seized  with  convulsions 
from  eating  strawberries,  which  parents  usually  regard  as  harmless,  and  one 
of  the  most  violent  and  protracted  cases  of  eclampsia  which  I  have  wit- 
nessed occurred  in  a  child  over  the  age  of  six  years  from  swallowing,  in  con- 
siderable quantity,  the  parenchymatous  portion  of  an  orange.  Constipation, 
worms,  dysentery,  intussusception,  and  painful  dentition  are  also  causes 
which  are  located  in  the  digestive  apparatus.  Inflammation  in  some  part  of 
the  respiratory  apparatus  is  a  not  infrequent  cause.  Thus,  eclampsia  occurs 
occasionally  in  severe  coryza,  in  consequence,  according  to  some,  of  the 
proximity  of  the  inflamed  surface  to  the  brain  and  the  consequent  afl3ux  of 
blood  to  this  organ.  It  is  a  common  complication  also  of  pertussis  and 
pneumonia.  It  occurs  often  at  the  commencement  of  two  of  the  eruptive 
fevers — namely,  smallpox  and  scarlet  fever,  and  in  the  course  of  the  latter 
disease. 

Violent  emotions  of  the  child  may  also  cause  eclampsia.  Bouchut  relates 
the  case  of  a  girl  five  years  old  who  was  corrected  before  her  companions, 
and  was  so  affected  by  anger  that  convulsions  ensued.  Residence  in  close 
and  overheated  apartments  or  in  streets  where  the  air  is  loaded  with  offen- 
sive vapors  and  is  stifling,  is  a  predisposing  cause,  so  that  there  is  a  larger 
proportion  of  deaths  from  convulsions  in  the  cities  than  in  the  country. 

In  young  children  burns,  even  when  not  very  severe,  are  liable  to  termi- 
nate suddenly  in  eclampsia,  succeeded  by  coma  and  death.  Urinary  calculi, 
both  renal  and  vesical,  may  produce  the  same  result. 


616  LOCAL  DISEASES. 

Such  are  the  more  common  causes  of  eclampsia.  It  is  seen  that  they 
are  of  two  kinds,  predisposing  and  exciting.  An  excitable  or  impressible 
state  of  the  nervous  system  constitutes  the  chief  predisposition  to  the  dis- 
ease. Plethora,  or  its  opposite  state  anaemia,  increases  the  liability  to  an 
attack. 

Premonitory  Stage. — In  the  majority  of  cases  there  are  prodromic 
symptoms  which  the  experienced  and  careful  physician  can  detect  so  as  to 
forewarn  friends.  The  child  is  perhaps  more  or  less  drowsy,  and,  when  dis- 
turbed, fretful.  The  eyes  often  have  a  wild  or  unnatural  appearance  ;  occa- 
sionally they  are  fixed  for  a  moment  on  an  object,  and  yet  apparently  with- 
out noticing  it.  The  sleep  is  disturbed  ;  in  some  there  is  unusual  heat  of 
head,  and.  if  old  enough,  complaint  of  headache.  At  times,  especially  if  the 
primary  disease  be  febrile  or  inflammatory,  there  is  incoherence  of  thought 
or  expression,  or  even  actual  delirium.  In  some  children  when  eclampsia  is 
threatening  the  thumbs  are  seen  to  be  carried  across  the  palms.  I  have 
observed  this  especially  during  the  convulsive  cough  of  pertussis.  A  very 
important  prognostic  symptom  is  sudden  starting  or  twitching  of  the  limbs. 
This  shows  that  the  nervous  system  is  profoundly  impressed,  and  but  slight 
additional  excitation  is  required  to  develop  eclampsia.  This  sudden  starting 
not  infrequently  precedes  the  attack  several  hours  and  gives  sufficient  fore- 
warning. 

The  prodromic  symptoms  are  often  disregarded  by  friends  who  do  not 
understand  their  significance.  Even  physicians,  in  the  haste  of  their  visits, 
in  many  instances  do  not  notice  them.  The  symptoms  which  precede  symp- 
tomatic and  sympathetic  eclampsia  are,  moreover,  blended  with  those  of  the 
primary  aifection,  and  hence  another  reason  why  they  are  frequently  over- 
looked. When  the  convulsions  are  about  to  commence  the  child  generally 
lies  quiet ;  the  eyes  are  open  and  fixed.  If  spoken  to  or  shaken  he  takes  no 
notice  and  does  not  speak.  The  direction  of  the  eyes  is  then  changed  ;  often 
they  are  turned  up  ;  occasionally  there  is  strabismus.  The  face  may  be  pale 
or  flushed,  and  sometimes,  especially  in  cerebral  diseases,  the  features  present 
patches  or  streaks  of  a  flushed  appearance,  while  around  them  the  natural 
color  is  preserved.  Immediately  before  the  spasmodic  movements,  the  child 
sometimes  utters  a  piercing  scream,  which  is  probably  involuntary,  though  it 
seems  like  a  supplication  for  help.  The  duration  of  the  prodromic  stage  is 
very  difi"erent  in  difi'erent  eases.  It  may  last  from  a  few  minutes  to  several 
hours,  or  even  more  than  a  day. 

Symptoms. — Eclampsia  is  general  or  partial.  If  general,  the  muscles  of 
the  face,  eyes,  eyelids,  and  of  all  the  limbs  are  in  a  state  of  rapid  involuntary 
contraction,  alternating  with  relaxation.  The  features  lose  their  natural 
expression  and  are  distorted ;  the  mouth  is  drawn  out  of  shape,  often  to  one 
side,  by  the  violent  muscular  action ;  the  teeth  are  pressed  together  by  tonic 
contraction  of  the  masseters,  and  may  be  violently  struck  together,  so  as  to 
lacerate  the  tongue  if  it  protrude,  or  are  ground  upon  each  other.  Unless 
the  attack  be  of  short  duration,  frothy  saliva,  perhaps  tinged  with  blood  from 
the  injured  tongue,  collects  between  the  lips.  The  eyelids  are  usually  open, 
and  in  severe  cases  the  eyes  are  turned  so  that  the  pupils  are  lost  under  the 
upper  eyelids,  or  the  muscles  of  the  eyes  are  involved  in  the  spasmodic  move- 
ment so  that  the  eyeballs  are  forcibly  drawn  from  side  to  side.  Occasionally 
strabismus  occurs.  While  the  features  are  thus  distorted  the  head  is  strongly 
retracted  or  is  turned  to  one  side ;  the  forearms  are  alternately  pronated  and 
supinated  ;  the  thumbs  and  fingers  are  convulsively  flexed,  so  that  the  thumbs 
lie  across  the  palms  and  are  covered  by  the  fingers  ;  the  great  toe  is  adducted, 
the  other  toes  flexed  ;  and  the  toes,  as  well  as  legs,  participate  more  or  less  in. 
the  spasmodic  movements. 


ECLAMPSIA.  617 

In  general  convulsions,  consciousness  is  usually  lost.  The  head  is  hot 
previously  to  and  during  the  attack — ^at  least  in  the  first  part  of  it — and  the 
face  flushed.  In  exceptional  cases,  especially  in  sympathetic  eclampsia,  the 
head  is  cool  and  the  face  pallid.  The  pulse  is  somewhat  accelerated,  as  well 
as  the  respiration,  and  the  latter  is  rendered  irregular  if  the  respiratory  mus- 
cles, especially  those  of  the  larynx,  are  involved,  as  they  generally  are.  The 
sphincters  are  relaxed  during  the  convulsive  attack,  so  that  in  many  eases  the 
urine  and  stools  are  passed  involuntarily. 

Partial  eclampsia  is  more  common  than  the  general  form  ;  it  occurs  in 
the  muscles  of  the  face,  including  tho,se  of  the  eye,  of  the  face  and  of  one 
or  both  upper  extremities,  or  of  the  face  and  the  extremities  on  one  side. 
The  spasmodic  movements  may  be  even  limited  to  the  muscles  of  the  eye, 
and  they  often  occur  only  in  these  muscles  and  those  of  the  face.  Earely, 
if  ever,  does  eclampsia  afi"ect  the  legs  without  aff"ecting  also  the  muscles  of 
the  arms  and  face.  In  partial  convulsive  attacks  sensation  and  consciousness 
are  in  some  patients  not  entirely  lost,  but  in  others  they  are  not  manifested 
if  present. 

The  duration  of  an  attack  of  eclampsia  varies  in  different  cases  from  a 
few  minutes  to  several  hours,  with  an  average  of  not  more  than  from  five  to 
fifteen  minutes.  The  movements  do  not  often  continue  longer  than  three  or 
four  hours  in  the  severest  cases.  They  are  sometimes  said  to  last  a  much 
longer  time,  even  for  days,  but  in  these  cases  there  are  intermissions.  Violent 
attacks  are  usually  short. 

When  the  convulsion  ends  favorably  the  spasmodic  movements  become 
less  and  less  .strong,  and  finally  cease.  The  child  then  takes  a  deep  inspira- 
tion, after  which  it  lies  quiet,  and  the  respiration  remains  regular  or  mode- 
rately accelerated.  Some  fully  recover  in  a  few  minutes  if  the  eclampsia 
have  been  light  and  the  cause  transient,  and  seem  to  experience  no  incon- 
venience except  soreness  of  the  muscles  and  fatigue.  Others  soon  recover 
consciousness,  and  their  temperature,  respiration,  and  circulation  become 
natural,  but  they  remain  dull  for  a  time,  their  minds  are  bewildered,  and 
they  are  perhaps  unable  to  speak.  In  a  few  hours  these  untoward  symptoms 
pass  away.  In  essential,  and  in  a  large  proportion  of  cases  of  sympathetic, 
eclampsia,  if  properly  treated  and  if  the  cause  be  recognized  and  removed, 
there  is  no  recurrence  of  the  convulsion ;  in  others  it  is  different.  In  many 
cases,  especially  of  symptomatic  eclampsia,  and  of  sympathetic  in  which  the 
cause  is  grave  and  persistent,  the  convulsions  return  after  a  variable  period 
of  a  few  minutes  or  a  few  hours.  Six  or  eight  or  more  convulsions  may 
occur  within  twenty-four  hours.  Earely  they  occur  several  times  daily  for 
several  consecutive  days,  but  severe  convulsions,  repeated  at  short  intervals 
for  twenty-four  or  forty-eight  hours,  usually  end  in  fatal  congestion  of  the 
brain  or  serous  efi"usion.  I  once  attended  an  infant  about  six  months  old 
who  had  from  four  to  twelve  convulsions  daily  for  eleven  days,  caused  prob- 
ably by  a  vesical  calculus,  as  there  was  dysuria  and  at  times  bloody  urine. 
Some  days  after  the  convulsions  were  controlled,  while  we  were  deferring 
exploration  of  the  bladder,  death  occurred  suddenly,  and  an  autopsy  was  not 
permitted.  This  case  will  be  detailed  elsewhere.  Bouchut  has  witnessed  a 
case  of  whooping  cough  in  which  there  were  daily  convulsions  for  eighteen 
days. 

In  severe  eclampsia  the  respiration  is  so  embarrassed  and  circulation  so 
retarded  that  congestion  of  various  organs  results.  This  passive  congestion 
in  the  respiratory  organs  is  indicated  by  moist  rales  in  the  larynx  and  bron- 
chial tubes  ;  occurring  in  the  brain,  it  is  indicated  by  profound  stupor.  It 
has  already  been  stated  that  death  may  occur  from  the  cerebral  congestion, 
which,  continuing,  is  apt  to  end  in  eff'usion  of  serum  or  extravasation  of  blood. 


618  LOCAL  DISEASES. 

In  these  cases  the  convulsive  movements  cease,  but  there  is  no  return  of  con- 
sciousness. The  child  lies  quiet,  as  if  in  sleep,  with  pupils  not  readily  acted 
on  by  lieht,  and  often  somewhat  dilated  ;  gradually  the  limbs  grow  cool  and 
the  pulse  feeble,  and  fatal  coma  supervenes. 

Death  does  not  ordinarily  occur  from  one  attack.  There  are  several  at 
intervals,  during  which  the  stupor  is  gradually  becoming  more  and  more  pro- 
found, till  finally  total  loss  of  consciousness  and  sensation  results,  terminating 
in  death.  Apnoea  may  occur  in  the  first  attack,  ending  life  abruptly  and 
unexpectedly,  but  in  other  instances  it  does  not  result  till  after  several  seiz- 
ures, when  at  length  one  more  violent  than  the  others  interrupts  the  respira- 
tory function  and  causes  death. 

Occasionally  when  life  is  preserved  there  is  some  permanent  ill-eifect  of 
eclampsia.  Bouchut  says :  "  The  origin  of  certain  permanent  contractions 
which  bring  on  deviation  of  the  head  or  other  parts,  retraction  of  the  limb, 
paralysis,  etc.,  must  be  referred  to  the  convulsions  of  the  muscles.  I  have 
seen  several  children  in  whom  torticollis  had  no  other  cause.  The  drooping 
of  the  upper  eyelid,  strabismus,  irregularity  of  the  mouth,  severe  contractions 
of  the  limbs,  often  depend  on  this  influence.  These  accidents  are  consequences 
of  essential  as  well  as  of  symptomatic  convulsions." 

Anatomical  Characters. — The  morbid  anatomy  pertaining  to  eclamp- 
sia is  in  most  cases  twofold :  first,  the  pathological  states  which  precede  and 
cause  the  convulsive  movements ;  secondly,  those  which  result  from  them. 
We  have  seen  that  in  sympathetic  eclampsia  the  diseases  which  sustain  a 
causal  relation  are  very  numerous ;  some  are  constitutional,  others  local,  and 
the  latter  may  have  their  seat  in  almost  any  part  of  the  economy  distinct 
from  the  cerebro-spinal  axis.  In  some  cases  of  sympathetic  eclampsia  the 
immediate  cause  is  a  too  active  circulation,  a  state  of  hypersemia  of  the  cere- 
bral vessels. 

It  has  already  been  stated  that  this  hyperaemia  may  be  diagnosticated  in 
young  infants  in  whom  the  anterior  fontanelle  is  open.  Such  infants,  seized 
with  acute  inflammation  of  one  of  the  mucous  surfaces,  often  present  a  full 
and  rapid  pulse  and  a  convex  and  forcibly  pulsating  fontanelle  before  the 
eclampsia  begins.  In  other  cases  of  sympathetic  eclampsia  the  primary 
disease  induces  passive  congestion  of  the  brain,  and  this  in  turn  gives  rise  to 
convulsions.  Eclampsia  occurring  during  the  paroxysms  of  whooping  cough 
afi'ords  an  example. 

In  some  cases  of  sympathetic  eclampsia  the  convulsive  movements  are  pro- 
duced by  the  primary  disease  acting  directly  on  the  nervous  system  through 
the  medium  of  the  nerves,  without  causing  any  appreciable  alteration  in  the 
state  of  the  cerebro-spinal  axis.  Thus,  Barrier  relates  three  fatal  cases  of 
convulsions  occurring  in  pneumonia,  in  none  of  which  was  there  anything^ 
abnormal  in  the  condition  of  the  brain  or  its  membranes. 

The  pathological  state  preceding  symptomatic  eclampsia  difiiers  in  difl'er- 
ent  cases,  since  convulsions  occur  in  almost  every  disease  of  the  brain  and 
its  membranes.  The  immediate  cause  of  this  form  of  eclampsia  may  be 
active  or  passive  cerebral  congestion,  with  or  without  eff'usion  ;  it  may  be 
compression  of  the  brain  from  various  causes  ;  it  may  be  a  deficiency  as  Avell 
as  excess  of  the  cerebro-spinal  fluid. 

The  congestion  resulting  from  eclampsia  may  give  rise  to  extravasation 
of  blood  and  the  formation  of  a  clot.  If  this  accident  occur,  there  is  often 
paralysis  aff"ecting  more  or  less  of  one  side  permanently,  or  gradually  disap- 
pearing. 

It  may  be  difficult  to  decide  whether  the  cerebral  congestion  precedes  the 
eclampsia  or  is  its  result ;  but  in  those  cases  in  which  it  precedes  and  operates 
as  a  cause  it  is  no  doubt  increased  during  the  convulsive  period.     The  spas- 


ECLAMPSIA.  619 

modic  muscular  action,  by  rendering  respiration  irregular  and  imperfect,  also 
leads  to  congestion  of  the  lungs,  and  sometimes  of  other  organs. 

Diagnosis. — -The  only  disease  which  resembles  eclampsia  is  epilepsy,  but 
the  diagnosis  can  ordinarily  be  made  by  recollecting  the  following  facts  : — 
Eclampsia  is  most  common  in  infancy.  If  it  occur  after  the  age  of  three 
years  there  is  some  manifest  exciting  cause  which  renders  the  child  seriously 
sick  independently  of  the  convulsions,  and  prior  also  to  their  occurrence.  But 
in  epilepsy  first  attacks  are  very  often  mild — the  j^etit  mal  of  writers  ;  in  other 
cases  they  are  tolerably  severe  from  the  first ;  but,  whether  mild  or  severe, 
they  occur  with  no  previous  or  coexisting  sickness  and  with  little  or  no  warning. 

The  SYMPTOMS  in  eclampsia  and  epilepsy  are  identical,  except  as  the 
causes  of  eclampsia  produce  certain  concomitant  symptoms,  and  there  is 
every  reason  to  believe  that  the  spasmodic  muscular  movements  proceed 
from  an  irritation  of  the  same  portion  of  the  cerebro-spinal  axis — to  wit,  the 
medulla  oblongata.  Writers  like  Niemeyer  have  given  reasons  for  the  belief 
that  spasmodic  muscular  movements  are  produced  by  functional  disturbance 
of  this  part  of  the  nervous  centre.  I  may  state  the  following,  to  which  I  am 
not  aware  that  any  one  has  alluded  :  If  the  exposed  medulla  of  an  acephalous 
monster  be  pressed  or  pinched,  convulsions  like  those  of  eclampsia  and  epilepsy 
result.  These  two  diseases,  therefore,  have  a  close  resemblance  anatomically 
and  clinically,  but  by  attention  to  the  above  facts  they  can  ordinarily  be 
distinguished  from  each  other. 

In  most  cases  of  eclampsia  the  child  has  fever  or  other  pronounced  symp- 
toms of  the  primary  disease,  which  sufiice  for  diagnosis ;  but  we  have  fre- 
quently examined  epileptics  in  the  Bureau  for  the  Relief  of  the  Out -door 
Poor  whose  first  attacks  were  evidently  produced  by  some  exciting  cause,  and 
were  eclamptic.  One  attack  of  clonic  convulsions  predisposes  to  another,  and 
therefore  eclampsia,  if  the  attack  be  repeated  a  few  times,  not  infrequently 
ends  in  epilepsy.  The  convulsions,  which  at  first  are  produced  by  an  obvious 
cause,  now  occur  without  apparent  cavtse. 

It  is  often  difl&cult  to  ascertain  the  form  of  eclampsia,  whether  essential, 
symptomatic,  or  sympathetic — in  other  words,  to  determine  the  cause — till 
after  the  convulsions  cease.  This  is  especially  true  when,  as  is  frequently 
the  case,  the  physician  is  not  summoned  till  the  convulsive  movements  begin, 
and  it  is  necessary  that  he  shovild  act  promptly,  with  but  little  knowledge 
of  the  child's  previous  history.  If  there  be  an  obvious  antecedent  disease, 
as  whooping  cough  or  meningitis,  the  cause  is  apparent ;  but  if  the  previous 
health  have  been  good  or  but  slightly  disturbed,  it  may  be  necessary  to  make 
more  than  one  visit  or  examination  in  order  to  ascertain  the  seat  and  character 
of  the  cause.  In  the  majority  of  cases  of  convulsions  occurring  suddenly  in  a 
state  of  previous  good  health  the  cause  is  seated  in  the  intestines,  but  sudden 
and  unexpected  attacks  may  be  due  to  the  commencement  of  some  inflamma- 
tory affection,  as  pneumonia,  or  of  a  febrile  disease,  as  smallpox.  Unless  the 
eclampsia  be  speedily  fatal,  the  physician,  if  he  examine  carefully,  will  in 
most  cases  soon  be  able  to  ascertain  the  nature  of  the  cause  and  diagnosticate 
the  form  of  the  disease. 

Prognosis. — Symptomatic  eclampsia  is  always  serious.  If  it  occur  in 
the  course  of  a  cerebral  disease,  it  indicates  the  approach  of  death,  but  if  at 
its  commencement,  the  patient  may  recover.  Its  recurrence,  whatever  the 
cerebral  disease,  is  usually  prognostic  of  death. 

In  idiopathic  or  essential  convulsions  the  prognosis  depends  on  the  severity 
of  the  attack  and  on  the  age,  strength,  and  previous  condition  of  the  child. 
If  there  be  predisposing  or  co-operating  causes,  as  a  nervous  or  excitable 
temperament  or  dentition,  the  prognosis  is  less  favorable  than  when  such 
causes  are  absent. 


620  LOCAL  DISEASES. 

In  sympathetic  eclampsia  the  prognosis  varies  greatly,  according  to  the 
nature  of  the  primary  disease  and  often  according  to  the  stage  of  that  disease. 
If  convulsions  occur  at  the  commencement  of  an  eruptive  fever,  they  generally 
subside  without  untoward  symptoms  and  the  fever  pursues  a  favorable  course. 
Eclampsia  after  the  appearance  of  the  eruption  is  premonitory  of  a  fatal  result. 
I  have  not  yet  known  a  patient  with  scarlet  fever  recover  who  had  convul- 
sions after  the  rash  had  covered  the  body,  and  experienced  physicians  of  this 
city  tell  me  that  their  observations  correspond  with  mine.  Dr.  J.  F.  Meigs, 
however,  relates  one  favorable  case.  If  the  cause  of  the  eclampsia  be  located 
in  or  upon  the  mucous  surfaces,  a  majority  recover  with  judicious  treatment. 
In  convulsions  consequent  upon  pneumonia  or  a  burn,  more  die  than  recover. 

The  prognosis  in  eclampsia  is  more  favorable  if  the  parallelism  of  the  eyes 
be  retained,  the  pupils  remain  sensitive  to  light,  and  consciousness  soon  return. 
A  fatal  termination  may  be  predicted  if,  after  the  convulsion,  the  child  remain 
stupid;  without  any  evidence  of  returning  consciousness,  and  the  pupils  do  not 
respond  to  light. 

Treatment. — Fortunately,  inasmuch  as  the  physician  is  often  required 
to  treat  eclampsia  in  ignorance  of  the  cause,  the  same  measures  are  demanded 
to  a  considerable  extent  in  all  cases,  whether  the  form  be  essential,  sympto- 
matic, or  sympathetic.  As  early  as  possible  in  the  attack  the  feet  should  be 
placed  in  hot  water  to  which  mustard  is  added,  or  if  it  can  be  procured  with 
little  delay  a  general  warm  bath  may  be  used  in  its  place.  This  has  a  sooth- 
ing effect  upon  the  nervous  system  and  promotes  muscular  relaxation,  while 
it  also  produces  derivation  of  blood  from  the  cerebro-spinal  axis.  It  is  there- 
fore useful,  especially  in  those  cases  in  which  active  or  passive  congestion 
precedes  the  eclampsia ;  it  is  also  useful  as  a  preventive  of  passive  conges- 
tion and  consequent  oedema  of  the  brain,  lungs,  and  other  organs,  which  are 
the  most  serious  results  of  eclampsia.  It  should  be  continued  from  six  to 
fifteen  or  twenty  minutes,  according  to  the  severity  and  duration  of  the 
attack ;  at  the  same  time  cold  applications  should  be  made  to  the  head  until 
its  temperature,  which  is  usually  increased,  is  reduced.  The  application  of 
cloths  placed  upon  ice  or  frequently  wrung  out  of  cold  water  is  the  most 
convenient  and  ready  mode  of  employing  this  agent.  Cold  thus  employed 
acts  promptly  in  contracting  the  vessels  of  the  brain  and  meninges  and 
diminishing  the  cerebral  congestion.  It  tends,  therefore,  to  remove  one  of 
the  chief  dangers. 

Cold  applications  are  also  useful  for  reducing  an  elevated  temperature  if 
it  be  present.  In  most  cases  of  eclampsia,  if  the  temperature  reach  103°,  the 
necessity  for  its  reduction  is  urgent,  and  the  cold  cloths  or  India-rubber  bag 
containing  ice  should  be  applied  not  only  upon  the  head,  but  also  along  the 
sides  of  the  face,  and  sometimes  over  the  great  vessels  of  the  neck. 

Since  a  large  proportion  of  convulsive  attacks  originate  in  the  condition 
of  the  intestines,  either  solely  or  in  part,  it  is  advisable  to  prescribe  an 
aperient  unless  there  be  previous  diari-hoea. 

The  common  enema  of  soap  and  water  will  usually  produce  a  free  and 
speedy  evacuation,  and  will  sometimes  disclose  the  cause  of  the  eclampsia  in 
the  expulsion  of  seeds  or  other  indigestible  substances  or  scybala.  A  cathartic 
is  also  often  required,  especially  if  the  enema  fail  to  produce  sufiicient  evacu- 
ations. In  those  that  are  robust,  and  especially  in  those  beyond  the  age  of 
two  or  three  years,  calomel  is  an  excellent  purgative,  is  easily  given,  and  is 
prompt  in  its  action.  If  the  symptoms  indicate  intestinal  inflammation,  the 
milder  purgatives,  as  castor  oil,  are  preferable,  as  they  also  are  in  young  or 
feeble  children.  If  the  recent  ingesta  of  the  patient  consisted  of  fruit  or  of 
substances  of  an  indigestible  character,  an  emetic  is  appropriate  ;  a  teaspoon- 
ful  of  the  syrup  of  ipecacuanha,  repeated  if  necessary  in  fifteen  or  twenty 


ECLAMPSIA.  621 

minutes,  may  be  given  to  a  young  child,  or  this  syrup  mixed  with  the  syrup 
scillae  compositus  to  one  older  and  more  robust.  Aside  from  the  ejection  of 
the  offending  substance  which  it  produces,  an  emetic  has  some  effect  in  con- 
trolling the  convulsive  movements.  But  the  cases  are  rare  in  which  emetics 
are  indicated. 

In  addition  to  the  local  measures  mentioned  above,  and  measures  calcu- 
lated to  relieve  the  digestive  canal  of  any  offending  substance,  a  safe  medici- 
nal agent  which  will  act  promptly  in  relieving  the  convulsions  is  urgently 
demanded,  since  eclampsia,  if  severe  and  protracted,  involves  great  danger. 
Fortunately,  such  agents  have  been  lately  introduced  into  therapeutics — 
namely,  the  bromide  of  potassium  or  sodium  and  hydrate  of  chloral.  These 
agents,  while  they  are  effectual,  are  safe,  and  therefore  their  use  has  sup- 
planted that  of  the  antispasmodics — asafoetida,  valerian,  lavender,  and  chloro- 
form— formerly  employed ;  not  one  of  which,  except  chloroform,  exerts  any 
direct  controlling  influence  over  the  convulsions,  and  chloroform  is  a  danger- 
ous remedy  unless  used  sparingly. 

The  bromide  of  potassium,  which  I  prefer,  should  be  given  every  ten 
minutes,  dissolved  in  cold  water,  till  the  convulsions  cease,  in  doses  of  four 
grains  to  a  child  of  one  year,  and  of  five  to  eight  grains  to  a  child  of  two  or 
three  years.  When  the  convulsions  cease  the  interval  between  the  doses 
should  be  lengthened.  In  one  instance  in  my  practice  an  infant  of  eighteen 
months  was  suddenly  seized  with  eclampsia,  and  the  mother,  in  her  fright 
mistaking  the  directions,  gave  thirty  grains  of  bromide  at  one  dose.  Two 
hours  afterward,  when  I  was  able  to  attend,  I  found  that  the  convulsions  had 
ceased  at  once  and  that  the  patient  was  playful.  Such  cases  show  the  innoc- 
uousness  of  a  large  dose  of  the  bromide  and  the  safety  in  administering  the 
medicinal  dose  often. 

In  severe  cases  the  bromide  does  not  always  act  with  suflacient  prompt- 
ness and  power.  The  hydrate  of  chloral  should  then  be  employed,  given  by 
the  mouth  or  dissolved  in  two  or  three  drachms  of  water  and  given  with 
a  small  glass  or  gutta-percha  syringe  per  rectum.  If  used  in  sufficient 
quantity,  per  rectum^  and  retained  by  pressure  with  a  napkin,  it  is  quickly 
absorbed,  and  will  usually  in  about  fifteen  or  twenty  minutes  control  the 
eclampsia.  For  a  child  of  one  year  I  employ  about  two  grains,  and  for  one 
of  four  years  four  grains,  given  by  the  mouth,  or  double  this  quantity  given 
per  rectum.  With  the  use  of  the  measures  indicated  above  eclampsia  is,  in 
my  practice,  much  more  amenable  to  treatment  than  in  former  years.  Unless 
the  cause  be  such  that  recovery  is  impossible  from  the  very  nature  of  the 
case,  the  convulsions  will  soon  cease  with  these  measures.  It  is  interesting 
to  observe  the  effect  of  the  chloral  enema.  In  from  five  to  ten  minutes 
the  convulsive  movements  cease  in  the  muscles  of  the  face,  a  moment  later 
in  those  of  the  arms,  and  lastly  in  those  of  the  lower  extremities. 

But  additional  treatment  may  be  required,  according  to  the  pathological 
state  which  has  brought  on  the  eclampsia.  If  it  be  an  eruptive  fever,  as 
scarlatina,  and  the  eruption  have  receded,  active  revulsive  measures,  as  hot 
mustard  baths,  are  required ;  if  in  dysentery  or  other  internal  inflammation, 
the  flaxseed  and  mustard  poultice  should  be  applied  over  the  parts  affected. 

In  those  dangerous  cases  in  which  symptoms  of  cerebral  congestion  con- 
tinue after  the  eclampsia  ceases  additional  treatment  is  required.  The  child 
remains  drowsy,  does  not  speak  or  apparently  suffer  in  any  way,  and  the 
pupils  act  less  readily  than  in  health.  If  this  condition  remain  after  the 
lapse  of  a  few  hours  there  is  probably  serous  effusion.  All  attacks  of 
eclampsia,  unless  the  mildest,  are  followed  by  a  period  of  drowsiness,  but 
the  persistence  of  it,  with  symptoms  which  indicate  hyperemia,  with  per- 
haps effusion  within  the  cranium,  calls  for  the   employment   of  additional 


622  LOCAL  DISEASES. 

measures.  Vesication  by  cantliaridal  collodion  should  then  be  produced 
behind  the  ears,  mild  revulsives  be  applied  to  the  extremities,  the  head  kept 
cool,  the  bowels  open,  and  in  certain  cases  a  diuretic  like  iodide  of  potassium 
may  be  advantageously  employed.  The  utmost  care  should  be  enjoined  in 
reference  to  the  hygienic  management  of  those  who  are  subject  to  eclampsia. 
The  diet  should  be  nutritious  but  bland,  and  all  causes  of  excitement  be 
studiously  avoided. 


CHAPTER    VIII. 
EPILEPSY. 

Epilepsy  is  a  paroxysmal  disease.  The  paroxysms  are  manifested  by 
impairment  or  loss  of  consciousness,  and  in  fully-developed  and  typical  cases 
also  by  convulsive  movements  of  more  or  fewer  of  the  voluntary  muscles. 
Epilepsy  is  a  neurosis  or  functional  aifection  of  the  nervous  system,  not  due, 
therefore,  to  any  appreciable  structural  change  in  the  brain  or  spine.  The 
convulsions  are  tonic  or  clonic,  or  most  frequently  both,  the  tonic  preceding 
the  clonic. 

Etiology. — In  a  large  proportion  of  cases  we  are  able  to  discover  both 
predisposing  and  exciting  causes  of  the  first  attack,  but  one  convulsion  pro- 
duces such  a  change  in  the  nervous  system  that  the  liability  to  another 
attack  is  increased.  Hence  after  the  epileptic  habit  is  established  after  one 
or  a  few  attacks,  convulsions  usually  occur  without  any  apparent  exciting 
causes ;  and  if  such  a  cause  be  discovered,  it  is  evidently  insufficient  without 
the  presence  of  a  strong  predisposition. 

Predisposing  Causes. — Prominent  among  these  is  a  neurotic  inherit- 
ance. Echiverria,  whose  observations  were  made  in  the  epileptic  wards  on 
BlackweH's  Island,  states  that  28  per  cent,  of  the  300  epileptic  patients 
examined  by  himself  pi'esented  evidences  of  inheritance.  In  Reynolds's 
cases  the  number  was  31  per  cent.,  and  in  1218  cases  examined  by  Gowers 
the  number  who  presented  evidences  of  an  inherited  predisposition  was  429, 
or  35  per  cent.  The  morbid  state  in  the  parent  which  gives  rise  to  an  inher- 
ited predisposition  to  epilepsy  in  the  child  is  most  frequently  epilepsy  or 
insanity.  Less  frequently,  according  to  Growers,  the  parental  disease  is 
chorea,  hysteria,  or  a  spinal  malady.  Inherited  predisposition  is  said  to  be 
more  frequently  from  the  mother  than  from  the  father.  The  occurrence  of 
epilepsy  in  a  brother  or  sister  renders  it  probable  that  the  patient  has  inher- 
ited a  predisposition,  although  we  may  be  unable  to  trace  it  to  either  parent 
or  any  of  the  ancestry.  The  evidence  of  a  strongly  inherited  predisposition  is 
sometimes  apparent  by  the  number  of  near  relatives  affected  by  the  same  dis- 
ease. Thus,  Gowers  states  that  in  one  instance  the  patient's  mother,  aunt, 
two  uncles,  and  a  cousin  were  epileptic,  and  in  another  instance  fourteen  near 
relatives  had  epilepsy. 

Age. — Statistics  relating  to  the  age  at  which  epilepsy  begins  have  been 
published  by  Haase,  Gowers.  and  others.  These  show  that  three-fourths  of 
the  cases  begin  under  the  age  of  twenty  years,  one-fourth  under  the  age  of 
ten  years,  and  about  one-eighth  under  the  age  of  three  years. 

Exciting  Causes. — Immediate  or  exciting  causes  of  epilepsy  are  usu- 
ally most  apparent  in  eases  which  begin  during  infancy  or  childhood.  The 
history  of  a  large  number  of  epileptic  children  has  been  ascertained  during 


EPILEPSY.  623 

the  last  twenty  years  in  the  children's  class  in  the  Out-door  Department  at 
Bellevue,  and  very  frequently  we  were  informed  that  at  the  first  attack  the 
child  was  feverish  or  constipated  or  had  some  acute  ailment,  which  served  as 
the  exciting  cause.  Often  the  first  convulsions  were  attributed  to  dentition, 
but  we  now  know  that  most  of  the  cases  which  were  attributed  by  the  parents 
to  teething  are  due  to  other  causes,  as  constipation,  diarrhoea,  the  presence  of 
indigestible  or  irritating  ingesta  in  the  intestines,  rachitis,  or  some  acute 
infectious  or  inflammatory  disease.  If  the  child  have  a  succession  of  dis- 
eases giving  rise  to  convulsions,  they  may  be  sufficient  to  establish  the  epi- 
leptic habit,  even  when  there  is  no  apparent  predisposition  to  epilepsy. 
Thus,  Gowers  relates  the  case  of  a  child  of  healthy  parentage  and  without 
any  inherited  predisposition,  that  had  a  fit  at  the  age  of  six  months,  attrib- 
uted to  teething ;  another  at  the  age  of  two  years,  from  scarlet  fever ; 
another  at  four  and  a  half  years,  from  measles ;  and  another  at  sixteen  and 
a  half  years,  from  a  carbuncle.  These  repeated  convulsive  attacks  ended  in 
a  permanent  epilepsy. 

Mental  Emotion. — Fright  or  great  excitement,  from  whatever  cause,  is 
the  most  common  arid  potent  of  the  immediate  causes  of  epilepsy.  It  pro- 
duced the  first  convulsive  attack  in  157  of  Gowers's  cases,  or  in  more  than 
one-third  of  those  in  which  an  exciting  cause  was  assigned.  This  cause  is 
operative  chiefly  in  the  periods  of  childhood  and  youth,  when  the  emotions 
are  strong,  and  in  females  more  frequently  than  in  males.  Among  the  enu- 
merated causes  of  the  mental  excitement,  authors  mention  fire-alarms,  burg- 
laries, thunder-storms,  and  pretended  ghosts.  Gowers  states  that  a  soldier 
on  sentry-duty  at  night  was  so  frightened  by  some  white  goats  that  appeared 
suddenly  on  the  wall  of  an  adjacent  cemetery  that  he  was  seized  with  con- 
vulsions and  became  an  epileptic.  Sudden  and  profound  emotion  has  some- 
times been  the  exciting  cause  of  chorea,  and  in  some  instances  of  epilepsy, 
cases  which  I  have  observed ;  in  one  instance  in  an  emotional  child,  the  sight 
of  the  corpse  of  a  favorite  uncle  producing  this  result.  In  another  instance 
a  physician  of  my  acquaintance,  in  treating  a  female  child  with  scarlatinous 
nephritis,  ordered  a  warm  bath.  The  next  day,  visiting  the  patient  and 
learning  that  his  directions  had  not  been  heeded,  he  prepared  a  bath  and  in  a 
rude  manner  plunged  the  child  into  it.  She  was  much  frightened,  and  imme- 
diately had  a  severe  convulsion.  The  scarlatinous  uraemia  probably  predis- 
posed to  the  attack,  but  the  fright  was  the  exciting  cause.  She  has  been  a 
confirmed  epileptic  from  that  day,  the  fits  being  frequent  and  severe.  Treat- 
ment employed  at  intervals  during  the  last  ten  or  twelve  years  has  had  but 
little  eff"ect  in  controlling  them.  Gowers  states  that  in  an  aggregate  of  76 
cases  in  which  epilepsy  resulted  fi'om  fright,  the  convulsion  occurred  imme- 
diately in  28,  within  a  few  hours  in  16  others,  after  the  first  day,  but  within 
seven  days,  in  19,  and  at  a  later  period  than  one  week  in  13. 

Protracted  cares  or  anxieties,  which  prevented  the  needed  mental  rest, 
have  also  in  some  instances  been  the  only  assignable  cause  of  epilepsy,  but 
this  cause  is  less  frequent  in  childhood  than  in  adult  life. 

Traumatism. — Usually  the  injury  received  is  upon  the  head,  either  from 
a  fall  or  a  blow,  by  which  the  patient  is  stunned  or  rendered  unconscious  for 
a  time.  The  convulsion  may  occur  immediately  or  not  until  the  lapse  of  a 
day  or  more.  Traumatism  is  ordinarily  attended  by  much  mental  excite- 
ment, and  this  has  its  infiuence  in  producing  the  convulsive  attack. 

Among  the  less  frequent  but  occasional  causes  of  epilepsy  in  infancy  and 
childhood  we  may  mention  inherited  syphilis,  intestinal  worms,  scarlet  fever, 
measles,  pneumonia,  rheumatism,  exposure  to  a  high  degree  of  heat,  especi- 
ally to  the  sun's  rays,  masturbation,  renal  disease,  and  peripheral  causes 
having  a  reflex  action,  as  phimosis,  cicatrices,  and  a  decayed  tooth.     When 


624  LOCAL  DISEASES. 

these  causes  are  removed,  the  clonic  convulsions  which  they  have  produced 
may  cease,  but  in  other  instances  they  continue,  the  epileptic  habit  having 
been  established. 

Symptoms. — Two  forms  of  epilepsy  have  long  been  recognized  and 
described  in  standard  treatises — the  mild  and  severe  forms,  the  epilepsia 
mitior  and  epilepsia  gravior ;  or,  in  the  French  language,  le  petit  mal  and  le 
grand  mal.  As  the  terms  imply,  this  classification  is  based  on  the  diiference 
in  the  severity  of  the  attacks. 

Minor  Attacks. — These  are  characterized  by  momentary  dizziness  and 
usually  loss  of  consciousness.  The  patient  has  a  bewildered  look ;  his  speech 
is  interrupted,  even  in  the  middle  of  a  sentence,  and  his  work,  whatever  it 
may  be,  is  also  interrupted,  so  that  whatever  he  is  holding  drops  from  his 
hands.  His  pallor,  bewildered  look,  and  strange  actions  attract  attention, 
but  in  a  moment  he  resumes  his  work  and  his  speech.  When  the  attack  is 
over  he  may  be  at  once  in  his  ordinary  mental  and  physical  condition,  and 
seem  quite  well,  but  he  does  not  have  a  clear  recollection  of  what  has  hap- 
pened. Some  patients  after  the  attack  ceases  remain  for  a  time  in  a  drowsy 
state  and  without  full  perception,  or  their  speech  and  acts  may  be  passionate 
and  violent  until  they  regain  their  normal  state. 

Major  Attacks. — These  begin  abruptly  with  strong  tonic  contraction  of 
the  muscles,  which  causes  rotation  of  the  head  to  one  side,  a  fixed  lateral,. 
and  sometimes  upward,  deviation  of  the  eyes,  and  a  constrained  and  awk- 
ward position  of  the  extremities.  The  facial,  thoracic,  and  abdominal  mus- 
cles participate,  causing  distorted  features  and  embarrassment  of  respiration. 
The  face,  at  first  pallid,  soon  becomes  livid,  the  pupils  are  dilated,  the  con- 
junctiva insensitive,  and  the  eyes  are  in  some  patients  open,  but  in  others 
closed.  The  cyanosis  deepens  and  the  surface  becomes  very  livid.  In  a 
moment  the  muscles  begin  to  vibrate  and  undergo  alternate  relaxations  and 
contractions.  The  second  stage,  or  that  of  clonic  convulsions,  begins.  The 
head,  face,  body,  and  limbs  are  violently  jerked,  saliva  tinged  with  blood 
flows  from  the  mouth,  and  sometimes  the  urine  and  feces  are  expelled.  The 
patient  presents  a  striking  and  shocking  spectacle,  which  gave  rise  in  olden 
times  to  the  belief  of  demoniacal  possession.  Presently  the  muscular  relaxa- 
tions become  longer,  more  air  is  inhaled,  and  the  blueness,  which  was  in- 
tense, begins  to  abate.  The  muscular  contractions,  though  as  severe  as  at 
first,  are  less  frequent,  and  finally  cease,  and  the  patient,  weak  and  uncon- 
scious, sleeps  quietly  but  soundly.  Occasionally,  instead  of  a  simultaneou& 
commencement  of  the  attack  in  all  parts  of  the  body,  it  begins  in  one  region 
and  extends  to  others  on  the  same  side,  and  then,  diminishing  on  this  side, 
it  begins  on  the  opposite  side.  In  this  form  of  epilepsy  the  patient  may  not 
lose  consciousness  until  late  in  the  attack,  so  that  he  at  first  is  aware  of  his- 
condition,  and  the  convulsions  may  be  clonic  from  the  first. 

Aura. — Certain  patients  exhibit  symptoms  which  are  premonitory  of  the 
attack  some  hours  before  its  occurrence.  One  of  these  is  the  sudden  jei'king 
of  certain  muscles,  as  of  the  arms  or  legs.  This  usually  occurs  when  the 
patient  is  awake,  but  it  may  occur  when  he  is  asleep  or  is  falling  asleep. 
Another  occasional  premonitory  symptom  is  persistent  dizziness,  preceding 
the  attack  some  hours  or  even  days.  A  ravenous  appetite,  a  stifling  sensa- 
tion in  the  chest,  as  if  from  want  of  aiv,  numbness,  cephalalgia,  impairment 
of  sight,  the  vision  of  red  fiery  sparks  (Aretaeus),  and  irritability  of  temper 
occasionally  precede  the  attacks,  so  as  to  forewarn  the  patient  and  friends. 
Bootius  in  1649  described  a  premonitory  symptom  which  was  observed  in  rare 
instances,  but  which  was  thought  to  justify  the  recognition  of  a  variety  of 
the  disease  that  was  designated  epilepsia  cursiva.  The  patient  ran  a  short  dis- 
tance and  then  was  seized  with  the  convulsion.     Another  similar  precursory 


EPILEPSY.  625 

symptom  immediately  preceding  the  attack  is  mentioned  by  some  writers. 
The  patient,  if  walking,  even  if  entering  his  home,  turns  around,  retraces 
his  steps,  and  falls  down  in  a  fit.  The  premonitory  symptoms  described 
above,  which  enable  the  epileptic,  with  the  aid  of  his  friends,  to  reach  a 
place  <?f  safety  before  the  attack  begins,  occurs  in  a  small  proportion  of  cases. 

Many  epileptic  fits  begin  with  an  aura — a  term  first  employed  by  Pelops, 
the  predecessor  and  teacher  of  Galen,  to  indicate  a  sensation  which  com- 
mences in  some  part  away  from  the  brain  and  ascends  toward  it.  In  olden 
times  the  aura  was  supposed  to  be  a  vapor,  which  traversed  the  vessels  to  the 
brain  and  caused  the  attack.  It  is  now  known  that  it  ordinarily  has  a  cen- 
tral origin,  is  due  to  commencing  functional  disturbance  of  the  brain,  and  is 
a  part  of  the  fit.  It  is  true  that  the  immediate  application  of  a  ligature  or 
tight  band  above  the  aura,  which  arrests  its  ascension  to  the  brain,  will  often 
prevent  the  fit,  but  Odier,  Brown-Sequard,  and  Gowers  have  shown  that  this 
occurs  in  epilepsy  due  to  cerebral  tumors,  even  more  frequently  than  in  epi- 
lepsy which  has  no  appreciable  anatomical  cause.  Therefore,  this  fact  of  the 
arrest  of  the  convulsion  by  ligation  above  the  aura  cannot  be  employed  as  an 
argument  in  support  of  the  theory  of  the  peripheral  origin  of  the  attacks. 

The  statistics  of  Romberg,  Sieveking,  and  Gowers  show  that  an  aura 
occurs  in  about  half  the  cases.  The  aura  may  begin  in  any  peripheral  por- 
tion of  the  system,  in  any  of  the  organs  of  the  special  senses,  and  in  many 
of  the  internal  oi'gans.  By  knowing  from  what  portion  of  the  brain  the 
nerve  arises  which  supplies  the  part  that  is  the  seat  of  the  aura,  we  are 
enabled  to  state  which  of  the  divisions  of  the  brain  is  probably  so  affected 
as  to  produce  epilepsy. 

The  aura  varies  greatly  in  its  character  as  well  as  location.  It  is  a  sen- 
sation of  pain,  numbness,  burning  or  tingling,  or,  instead  of  being  sensory,  it 
may  be  wholly  or  chiefly  motor,  as  cramps,  jerking,  twitching  of  a  certain 
muscle  or  group  of  muscles  may  occur.  Sometimes  the  aura  is  at  the  same 
time  both  sensory  and  motor.  The  sensory  aura  commonly  ascends,  as  we 
have  already  stated,  toward  the  head,  but  it  occasionally  descends  a  limb, 
and  when  it  reaches  a  certain  point  the  convulsion  begins.  The  aura  often 
occurs  in  one  side  of  the  face,  tongue,  or  trunk,  or  in  one  limb.  In  other 
instances  it  is  bilateral  or  general,  commencing  simultaneously  in  correspond- 
ing limbs  of  the  two  sides.  Aurae  in  the  trunk,  and  not  in  the  viscera,  occur 
almost  entirely  in  the  back,  along  the  spine,  and  are  known  as  the  spinal 
aurje.  General  aurse  are  sometimes  characterized  by  faintness,  malaise,  or 
powerlessness,  or  a  general  tremor  or  a  general  sensation  of  coldness  or  of 
heat.  Visceral  aurfe  occur  for  the  most  part  in  viscera  supplied  by  the 
pneumogastric.  The  most  common  of  these  aurae  is  the  epigastric,  a  pain 
or  a  sensation  in  the  epigastrium,  vaguely  described  as  a  "  heat,"  "  coldness," 
"  trembling,"  a  "  twisting  "  or  "  winding  up."  The  epigastric  aura  may  be  a 
little  above  or  below  or  to  the  left  of  the  epigastrium.  In  some  cases  the 
aura  is  located  in  the  chest  or  throat.  A  sensation  of  suffocation  or  tingling 
or  burning,  or  an  indescribable  feeling,  is  experienced  in  the  chest  or  throat 
immediately  before  the  attack  begins.  The  patient  perhaps  presses  upon  his 
chest  or  throat  with  his  hands  and  immediately  becomes  convulsed.  The 
heart  also  derives  its  innervation  from  the  pneumogastric,  and  the  aura  is 
sometimes  referred  to  this  organ.  In  some  patients  the  cardiac  region  is  the 
seat  of  a  vague  sensation  variously  described,  or  the  aura  may  be  manifested 
by  increased  action  or  palpitation,  with  perhaps  more  or  less  dyspnoea.  Of 
the  cephalic  aurje,  vertigo  is  perhaps  the  most  common,  attended  in  some  by 
rotation  of  the  head  and  occasionally  of  the  body.  In  certain  epileptics 
there  is  the  sensation  of  rotation  without  actual  movement,  and  in  some 
instances  objects  seem  to  move.  Cephalic  aurae  in  a  considerable  number  of 
40 


626  LOCAL  DISEASES. 

instances  consist  of  headaclie  or  a  sensation  in  the  head  described  as  heavi- 
ness, pressure,  coldness,  burning,  etc. 

In  certain  cases  the  aurje  are  entirely  emotional,  having  usually  the  form 
of  fear,  which  is  sometimes  so  great  that  extreme  terror  is  depicted  on  the 
countenance,  and  yet  there  may  be  no  remembrance  of  it  after  the  convulsion 
is  over.  In  a  considerable  number  of  instances  the  aur^e  are  manifested  in  the 
organs  of  the  special  senses,  and  consist  in  an  aberration  of  their  functions. 
The  olfactory  aura  is  usually  an  unpleasant  smell,  as  of  sulphur,  putrid  mat- 
ter, pus.  decaying  animal  substances.  The  gustatory  aura  is  a  bitter,  sour, 
metallic,  or  nauseous  taste.  The  ocular  aura  is  an  unusual  sensation  in  the 
eye — diplopia,  an  apparent  change  in  the  size  of  objects  viewed,  sudden 
blindness,  or  the  perception  of  unusual  or  striking  objects,  as  a  flash,  sparks, 
colored  lights,  or  persons  or  things  not  present,  sometimes  quiet,  sometimes 
in  motion.  The  auditory  sensations  occurring  as  aurae  are  sounds  of  many 
kinds — of  music,  of  bells,  thunder,  a  whistle,  the  wind,  an  explosion  or  any 
other  startling  sound.  It  is  seen  that  the  aurge,  although  having  a  central 
origin,  occur  in  almost  every  part  of  the  system,  remote  from  as  well  as  near 
the  brain,  and  are  of  many  difi^erent  kinds. 

In  some  epileptics  a  harsh  scream  or  groan  announces  the  commencement 
of  the  fit,  but  in  children,  according  to  my  observations,  it  rarely  occurs.  It 
is  apparently  produced  by  a  spasm  of  the  laryngeal  muscles,  which  causes 
narrowing  of  the  passage  through  the  larynx,  and  a  spasmodic  contraction 
of  the  thoracic  and  abdominal  muscles,  which  causes  a  rapid  and  forcible 
expiration.  The  patient  is  unconscious  of  the  scream,  or  he  may  be  conscious 
of  it,  but  unable  to  prevent  it. 

In  the  fit.  when  of  ordinary  severity,  consciousness  is  early  lost,  and  it 
does  not  return  until  the  somnolence  which  follows  the  attack  has  abated ; 
but  in  the  mild  disease,  the  pe//f  mal.  the  patient,  though  confused,  often 
retains  consciousness  during  the  attack.  In  the  grand  mal  the  attack  begins 
with  a  tonic  spasm  of  the  muscles,  causing  rotation  of  the  head  and  deviation 
of  the  eyes  to  one  side.  Sometimes  there  is  rotation  of  the  entire  body,  so 
that  the  patient  turns  round  one  or  more  times  before  he  falls.  The  position 
of  the  limbs  during  the  tonic  spasm  varies.  Commonly  the  arms  are  slightly 
abducted,  the  forearms  flexed  to  a  right  angle,  the  hands  flexed  on  the  wrists, 
the  fingers  flexed  on  the  hands,  but  extended  at  the  other  joints,  and  the 
thumb  is  pressed  upon  the  palm  or  fore  finger.  The  legs  are  ordinarily 
extended,  but  the  legs  as  well  as  arms  may  assume  dilFerent  positions. 

Clonic  convulsions,  or  the  second  stage  of  the  attack,  supervene  in  a  few 
seconds  or  after  two  or  three  minutes.  As  the  tonic  spasm  slowly  relaxes, 
the  clonic  spasms  gradually  supervene.  The  clonic  convulsions,  or  alter- 
nate contraction  and  relaxation,  rapidly  succeeding  each  other,  occur  in  the 
muscles  of  the  face,  tongue,  palate,  and  larynx,  as  well  as  in  the  muscles  of 
trunk  and  extremities.  The  tongue  is  frequently  bitten,  both  in  the  tonic  and 
clonic  spasms,  so  that  the  blood  oozes,  and.  mixed  with  frothy  saliva,  exudes 
from  the  mouth.  The  pupils  are  dilated  during  the  attack,  and  they  do  not 
contract  by  light.  As  soon  as  consciousness  begins  to  return,  the  pupils 
begin  to  contract  and  respond  to  light.  Exceptionally,  at  the  close  of  the 
fit  the  pupils  alternately  contract  or  dilate  at  intervals  of  one  or  two  seconds, 
and,  as  already  stated,  the  conjunctiva  loses  its  sensitiveness,  so  that  it  can 
be  touched  without  producing  reflex  action  of  the  orbicularis.  Eelaxation 
of  the  .sphincters  also  often  occurs  during  the  fit,  so  that  fecal  and  ui'inary 
evacuations  take  place. 

The  pulse  may  be  normal  or  rather  feeble  in  the  beginning  of  the  attack, 
but  its  frequency,  and  sometimes  its  fulness,  increase  during  the  muscular 
spasms.     The  features,  usually  pallid,  but  sometimes  flushed  at  the  beginning 


EPILEPSY.  627 

of  the  attack,  become  congested  and  even  cyanotic  in  less  than  a  minute. 
The  congested  and  livid  features  present  an  alarming  appearance,  and  fre- 
quently the  general  surface  is  bathed  in  perspiration  before  the  attack  ends. 
Ophthalmoscopic  examination  of  the  eyes  during  the  convulsion  is  difficult, 
but  during  the  cyanotic  stage  the  retinal  vessels  have  been  seen  presenting 
an  engorged  and  dusky  appearance.  Gowers  states  that  in  one  instance,  in 
which  fits  occurred  in  rapid  succession  during  several  days,  he  observed  con- 
gestion of  the  discs  with  slight  oedema,  which  disappeared  after  the  attacks 
ceased.  In  the  intervals  of  the  paroxysms  nothing  has  been  noticed  in  the 
appearance  of  the  eyes  which  throws  light  on  the  nature  of  the  disease.  The 
duration  of  the  second  stage  of  an  epileptic  fit  or  that  of  clonic  spasms  varies 
from  a  minute  or  two  to  a  considerably  longer  time.  When  it  ceases  the 
patient  passes  into  a  sleep  or  deep  stupor,  which  continues  a  quarter  of  an 
hour  or  longer.  If  aroused  from  the  stupor  he  complains  of  severe  headache, 
and  this  continues  often  for  hours  after  the  stupor  ceases. 

Languor  and  muscular  weakness  are  common  after  the  fit.  and  they  grad- 
ually pass  ofiF.  When,  as  occasionally  happens,  paralysis  occurs  after  the  fit, 
and  continues  for  weeks  or  permanently,  organic  cerebral  disease  is  present, 
either  preceding  and  causing  the  fit  or  resulting  from  it.  If  no  paralysis  or 
cerebral  symptoms  have  preceded  a  fit,  and  it  is  followed  by  paralysis  of  one 
or  more  of  the  extremities,  it  is  highly  probable  that  intracranial  hemor- 
rhage has  occurred  during  the  attack.  Todd.  Hughlings  Jackson,  and  others 
attribute  the  muscular  weakness  following  an  epileptic  attack  "  to  exhaustion 
of  part  of  the  brain  by  the  excessive  action."  but  protracted  or  permanent 
loss  of  muscular  power  in  an  epileptic  having  good  general  health  indicates 
organic  disease  in  the  brain. 

The  above  description  relates  to  epilepsy  as  it  ordinarily  occurs,  but  there 
are  many  cases  which  vary  from  the  typical  form.  Tonic  convulsions  may 
occur  without  the  clonic,  and  clonic  convulsions  without  the  tonic,  and  the 
convulsions,  instead  of  being  general,  may  be  limited  to  a  limb  or  to  one 
region  of  the  system.  Of  155  cases  of  minor  epilepsy.  Growers  states  that 
in  rtS  the  disease  was  indicated  by  momentary  attacks  of  unconsciousness, 
faintness,  or  sleepiness  ;  in  25  by  dizziness;  in  17  by  sudden  jerking  of  head, 
trunk,  or  limbs ;  in  17  by  loss  or  aberration  of  sight ;  in  8  by  a  mental  state, 
as  sudden  and  extreme  fright ;  and  in  the  remaining  42  by  sensations  of 
various  kinds,  or  momentary  rigidity,  or  by  tremors  or  twitching  occurring  in 
some  part  of  the  system.  Automatic  movements  sometimes  occur  during  the 
stage  of  unconsciousness  which  succeeds  the  attack,  and  the  attack  may  be 
so  light  that  it  is  not  noticed  by  the  bystanders.  Gowers  relates  several  such 
instances.  Some  patients  begin  to  undress  themselves,  whatever  the  sur- 
roundings :  others  make  the  motions  of  walking  up  stairs,  although  no  stairs 
are  present :  some  put  in  their  pockets  any  near  object,  without  regard  to  its 
nature  or  ownership.  Trousseau  states  that  an  architect  during  the  state  of 
unconsciousness  ran  from  plank  to  plank  on  the  scaffold  where  he  was  at 
work,  shouting  his  own  name.  One  of  Gowers's  patients  during  the  uncon- 
scious state  laughed  and  sang ;  another  threw  her  infant  down  stairs  ;  a  girl 
of  twenty  kissed  every  object  within  her  reach ;  and  a  man  struck  his  friend 
a  severe  blow.  Many  supposed  criminal  acts  have  been  perpetrated  by  un- 
conscious epileptics,  for  which  they  have  been  severely  punished. 

Anatomical  Characters. — Xo  information  has  been,  obtained  in  regard 
to  the  etiology  and  nature  of  idiopathic  epilepsy  by  a  study  of  its  anatomical 
characters.  If  the  patient  have  died  in  the  attack,  intense  venous  conges- 
tion is  observed  of  the  cerebro-spinal  axis  as  well  as  of  other  parts,  but  in 
recent  cases  nothing  else  abnormal  has  been  detected  in  the  brain  or  else- 
where.    The   thickening  and   opacity   of  the   cerebral   meninges   sometimes 


628  LOCAL  DISEASES. 

observed  in  chronic  cases,  and  the  induration  of  the  pes  hippocampi  described 
by  Meynert,  are  now  believed  to  be  results  of  the  repeated  attacks,  and  not 
their  cause.  Structural  change  in  the  brain  in  idiopathic  epilepsy,  if  there 
be  such,  which  sustains  a  causal  relation  to  the  attacks,  has  thus  far  eluded 
detection  by  the  microscope. 

Pathology. — Epileptic  attacks  are  believed  by  neuropathists  to  be  due 
to  a  sudden  and  exaggerated  functional  activity  of  nerve-cells  in  some  part 
of  the  brain.  The  theory  at  present  accepted  is  that  these  cells  generate  a 
nerve-force  which,  transmitted  along  the  nerves,  stimulates  the  muscles  to 
spasmodic  contraction.  In  regard  to  the  part  of  the  brain  in  which  these 
overacting  cells  reside,  we  may  state  that  Brown-Sequard  and  Kussmaul 
demonstrated  that  convulsions  may  be  produced  by  irritating  the  pons  and 
medulla  when  every  other  part  of  the  encephalon  lying  above  these  is 
removed.  Convulsions  can  also  be  produced  in  acranial  monsters,  as  I  have 
stated  above,  by  irritating  the  exposed  medulla  and  pons.  Nothnagel  has 
also  shown  that  there  is  a  "  convulsive  centre  "  in  the  medulla  oblongata. 
On  the  other  hand,  injuries  of  the  convolutions  more  frequently  cause  con- 
vulsions than  do  those  of  any  other  part  of  the  brain,  and  Wilks  and  others 
have  taught  that  in  ordinary  epilepsy  the  part  of  the  brain  which  is  most 
frequently  in  fault,  so  as  to  cause  convulsions,  is  the  superficial  portion  or 
the  convolutions.  Still,  the  exaggei'ated  production  of  nerve-force  which 
causes  the  convulsions  may  be  at  a  greater  depth  than  the  convolutions, 
even  when  the  attacks  are  due  to  traumatism,  since,  as  Burdon-Sanderson 
has  shown,  nerve-cells  more  deeply  seated  than  the  convolutions  may  be 
stimulated  to  increased  functional  activity  by  injuries  of  the  superficial 
regions.  Therefore,  Nothnagel,  aware  of  the  fact  that  injuries  of  the  cortex 
often  cause  convulsions,  states  that  he  sees  no  reason  to  modify  his  opinion 
that  the  exaggerated  production  of  nerve-force  which  causes  the  convulsions 
is  in  the  '-convulsive  centre  in  the  medulla  oblongata."  The  above  observa- 
tions seem  to  indicate  that  epileptic  attacks  do  in  some  instances  originate  in 
the  convolutions  or  hemispheres,  and  in  others  in  the  medulla. 

Recently,  Gowers  and  others  have  endeavored  to  determine  in  what  part 
of  the  brain  the  nerve-force  resides  which  causes  the  convulsions,  by  study- 
ing; the  aurae.  Since  the  aurse  have  a  central  orijjin  and  are  the  first  mani- 
festation  of  the  exaggerated  action  of  the  nerve-cells,  the  attempt  is  made  to 
determine  the  location  of  these  cells  by  observing  the  nature  and  the  seat 
of  the  aurae.  Gowers  says  that  one-fifth  of  the  auree  pertain  to  the  special 
senses,  and  the  nerve-centres  of  these  senses  "  are  certainly  situated  within 
the  hemispheres,  above  the  pons."  Therefore,  the  inference  is  inevitable  that 
in  these  cases  the  discharge  of  nerve-force  which  stimulates  the  muscles  to 
spasmodic  action  is  in  the  hemispheres.  Moreover,  a  fit  that  is  preceded  by 
an  emotional  or  mental  aura,  we  infer,  originates  from  the  nerve-cells  of  the 
hemispheres  which  are  the  seat  of  the  mind.  The  theory  is  therefore  plausi- 
ble and  apparently  sustained  by  clinical  observations,  that  in  at  least  some 
instances  the  epileptic  centre  in  the  brain  is  in  the  hemispheres,  though  it 
may  in  other  instances  be  at  the  base  of  the  brain — in  the  medulla  or  pons. 

What  occurs  in  the  brain  to  produce  the  phenomena  of  epilepsy  ?  It  is 
the  belief  of  many  specialists  in  nervous  diseases  that  epilepsy  results  from 
suddenly  developed  cerebral  anaemia  produced  by  spasmodic  contraction  of 
the  arterioles.  It  is  also  the  belief  of  some  that  the  primary  discharge  of 
nerve-force  occurs  in  the  medulla  at  the  vaso-motor  centre,  and  that  this  is 
followed  by  spasm  of  the  arterioles  in  the  hemispheres,  by  which  conscious- 
ness is  lost.  That  cerebral  anaemia  is  present  is  inferred  from  the  fact  that 
the  features  are  usually  pallid  when  the  attack  commences.  But  in  many 
instances,  especially  in  epilepsy  of  a  mild  type,  no  pallor  or  other  sign  of 


EPILEPSY.  629 

perijjlieral  anaemia  is  present,  and  in  sucli  cases  there  is  no  evidence  what- 
ever of  cerebral  anaemia.  Besides,  as  Gowers  has  forcibly  stated,  pallor  of 
the  features  does  not  necessarily  indicate  cerebral  angemia.  any  more  than 
flushing  of  the  face  indicates  cerebral  hyperjemia.  In  experiments  on  frogs 
irritation  of  the  brain  causes  contraction  of  the  peripheral  arterioles.  Prob- 
ably in  the  same  manner,  says  Gowers,  the  contraction  of  the  peripheral 
arterioles  and  the  pallor  result  from  the  irritation  of  the  brain,  occurring  in 
the  first  stage  of  the  fit.  That  cerebral  anaemia  occurs  in  the  attack,  and 
that  it  sustains  a  causal  relation  to  the  phenomena  of  epilepsy,  are  assump- 
tions destitute  of  proof. 

As  to  the  pathology  of  epilepsy,  we  have  said  or  have  intimated  that  it 
is  the  belief  of  the  majority  of  those  who  from  large  clinical  experience  are 
most  competent  to  express  an  opinion  that  the  epileptic  attacks  are  produced 
by  a  hyperactivity  of  nerve-cells  in  the  gray  matter  in  some  part  of  the 
brain,  and  an  increased  discharge  of  nerve-force,  which  stimulates  the  mus- 
cles to  spasmodic  action.  The  spinal  cord  and  the  nerves  are  implicated  as 
carriers  of  this  nerve-force.  Farther  than  this  we  are  unable  to  express  any 
theory  in  the  present  state  of  our  knowledge. 

Diagnosis. — In  a  considerable  number  of  instances  nocturnal  epilepsy 
is  entirely  overlooked.  Some  patients  awaken  at  the  beginning  of  the  attack, 
and  have  subsequently  a  vague  recollection  of  its  occurrence.  Others  are 
aware  of  the  fit  by  subsequent  signs  or  symptoms,  as  a  bitten  tongue,  blood 
on  the  bed-clothes,  a  swollen  and  ecchymotic  face,  conjunctival  extravasation, 
and  perhaps  evacuations  in  the  bed.  In  children  nocturnal  epilepsy  is  more 
likely  to  be  detected  than  in  adults,  since  they  are  more  closely  watched. 
Gowers  states  that  he  has  known  it  to  occur  twenty  years  without  being  sus- 
pected. In  mild  epilepsy  the  symptoms  may  escape  the  notice  of  friends, 
and  when  observed  by  the  patients  and  friends  their  import  is  often  misun- 
derstood. Those  suffering  from  j^^tit  mcd  are  in  many  instances  supposed  to 
have  attacks  of  faintness.  The  differential  diagnosis  between  epileptic  ver- 
tigo and  syncopal  faintness  is  made  by  the  fact  that  in  the  latter  the  pre- 
vious health  has  usually  been  poor,  the  action  of  the  heart  feeble,  and  there 
is  some  exciting  cause  of  the  sudden  cardiac  weakness  ;  whereas  in  epileptic 
vertigo  such  conditions  do  not,  as  a  rule,  exist.  In  epileptic  vertigo  there  is 
no  premonition  except  the  aura,  which  is  momentary,  and  recovery  or  return 
to  the  normal  state  is  rapid.  Syncope,  on  the  other  hand,  begins  and  ends 
in  a  more  gradual  manner. 

The  symptoms  of  eclampsia  and  epilepsy  are  identical  as  regards  the 
convulsive  movements.  We  designate  by  the  term  "  eclampsia  "  those  attacks 
which  are  due  to  local  or  general  causes,  which  do  not  recur  when  these 
causes  are  removed,  and  the  occurrence  of  which,  whatever  the  causes,  is 
limited  to  a  brief  period.  But,  as  we  have  seen,  one  attack  of  convulsions 
predisposes  to  another,  and  one  or  more  convulsive  fits  that  are  eclamptic 
frequently  establish  the  convulsive  habit,  so  that  epilepsy  results.  In  a 
large  proportion  of  the  cases  of  eclampsia,  the  convulsions  have  a  reflex 
origin.  They  are  produced  by  causes  located  at  a  distance  from  the  brain 
and  affecting  the  nervous  centres,  causing  convulsions  through  the  medium 
of  the  nerves.  Painful  and  swollen  gums  in  dentition,  constipation,  irrita- 
ting ingesta,  intestinal  woi'ms,  scarlet  fever,  nephritis  with  albuminuria,  are 
among  the  common  causes  of  eclampsia.  In  recent  convulsions,  when  such 
causes  are  present,  the  diagnosis  of  eclampsia  will  be  proper  in  the  great 
majority  of  instances,  and  the  attacks  will  cease  and  not  recur  when  the 
apparent  causes  are  removed.  Gowers  regards  rickets  as  a  common  cause  of 
eclampsia  in  young  children,  and  remarks  that  when  this  diathetic  state  is 
cured  by  "  cod-liver  oil  and  steel  wine  "'  the  convulsions  no  longer  occur ; 


630  LOCAL  DISEASES. 

but  if  proper  treatment  be  not  employed,  if  the  rickets  continue,  and  with 
it  the  frequent  convulsive  attacks,  the  epileptic  habit  may  be  established  and 
epilepsy  continue  during  the  remainder  of  life. 

Prognosis. — Epilepsy  is  rarely  fatal,  although  the  symptoms  are  very 
appalling  to  one  who  has  not  previously  witnessed  an  attack.  Asphyxia  has 
occasionally  occurred  by  the  patients  falling  into  water  during  the  fit.  Even 
little  depth  of  water  with  the  face  downward  is  sufficient  to  cause  fatal 
obstruction  to  inspiration.  Therefore,  not  a  few  epileptics  die  by  drowning. 
If  the  patient  roll  upon  the  face  during  the  fit,  or  vomit,  he  may  be 
asphyxiated  by  the  bed-clothes  or  by  the  entrance  of  particles  of  food  into  the 
larynx. 

The  spontaneous  cessation  of  the  epileptic  fits  and  spontaneous  cure  of 
epilepsy  rarely  occur,  since  each  attack  tends  more  strongly  to  establish  the 
epileptic  habit.  Fortunately,  since  the  therapeutic  uses  of  the  bromides  have 
become  known,  epilepsy  has  frequently  been  cured.  In  infancy  and  childhood, 
in  the  majority  of  instances,  epilepsy  is  rendered  milder,  so  that  the  fits  occur 
at  longer  intervals,  even  if  entire  cure  be  not  efi"ected.  Moreover,  the  pros- 
pect of  curing  epilepsy  is  better  in  children  than  in  adults,  in  accordance 
with  the  law  that  the  shorter  its  duration  and  the  fewer  the  attacks  which 
have  already  occurred  the  more  amenable  it  is  to  treatment.  Epilepsy  in 
which  several  days  intervene  between  the  attacks  is,  as  might  be  expected, 
more  likely  to  be  benefited  by  ti'eatment  than  when  the  attacks  are  frequent, 
K  the  mind  be  not  perceptibly  impaired,  if  the  fits  are  uniformly  severe, 
instead  of  some  being  severe  and  others  mild,  if  they  occur  only  during  sleep 
or  only  during  wakefulness,  and  if  hemiplegia  be  absent,  the  prognosis  is 
better  than  when  the  reverse  is  the  case.  In  ordinary  cases  of  epilepsy  in 
childhood,  the  attacks  immediately  become  less  frequent  by  the  bromide 
treatment.  If  a  sufficient  amount  of  the  bromide  be  administered  three 
times  daily,  months  often  elapse  before  a  recurrence  of  the  attack :  but  if 
the  remedy  be  discontinued  after  six  months  or  a  year  in  the  belief  that  the 
patient  is  cured,  a  recurrence  of  the  disease  is  probable.  A  patient  cannot 
be  pronounced  cured  until  three  years  have  elapsed  without  any  symptoms. 

Treatment. — No  mode  of  treating  epilepsy  which  will  effect  an  imme- 
diate cure  has  yet  been  discovered,  nor  is  it  probable  that  such  success  of 
treatment  will  ever  be  obtained.  Cure  is  effected  by  treatment  which  dimin- 
ishes the  hyperactivity  of  the  nerve-cells  that  are  in  fault,  and  prevents  the 
exaggerated  production  of  nerve-force.  Medicines  designed  to  effect  this 
object  must  be  given  daily  for  a  prolonged  period,  since  their  use  for  a  few 
days  or  weeks  does  not  suffice  to  produce  the  desired  change  in  the  nerve- 
centre. 

Since  the  bromides  have  come  into  general  use  in  the  treatment  of  nervous 
diseases,  the  first  place  is  universally  accorded  to  them  among  the  remedies 
for  epilepsy.  The  bromides  of  potassium,  sodium,  ammonium,  and  lithium 
have  probably  nearly  the  same  effect,  but  the  potassium  and  sodium  bromides 
are  usually  prescribed.  Xo  advantage  results  from  the  use  of  bromine  or 
hydrobromic  acid,  even  if  it  were  safe  and  convenient,  for  it  becomes  a 
bromide  as  soon  as  it  enters  the  alkaline  blood  (Gowers).  All  the  bromides 
produce  acne,  but  this  can  be  prevented  to  a  considerable  extent  by  the 
simultaneous  use  of  arsenic  in  small  doses.  The  bromide  should  be  given 
daily  for  weeks  or  months  in  the  smallest  dose  which  is  found  to  arrest  the 
fits  or,  if  it  do  not  entirely  arrest  them,  produces  the  most  decided  effect  upon 
them.  If  the  fit  occur  at  a  certain  hour,  one  daily  dose,  administei'ed  pre- 
viously, may  suffice  to  prevent  it,  but  usually  it  occurs  irregularly,  and  a 
morning  and  evening  dose  or  three  daily  doses  are  required.  Bromism, 
indicated  by  a  weak  pulse,  cold  extremities,  and  mental  and  physical  dulness, 


EPILEPSY.  631 

has  never,  according  to  my  observations,  seriously  interfered  with  the  treat- 
ment. During  my  connection  with  the  children's  class  of  the  Bureau  for 
the  Relief  of  the  Out-door  Poor  at  Bellevue  almost  every  week  new  cases 
of  epilepsy  have  been  presented  for  treatment,  and  it  has  seldom  been  neces- 
sary to  discontinue  the  use  of  the  bromide  on  account  of  bromism.  A  girl 
had  her  first  attack  of  clonic  convulsions  at  the  age  of  four  months.  When 
she  reached  the  age  of  three  years  and  a  few  months  she  began  to  have 
attacks  of  the  petit  mal,  manifested  by  pallor  and  an  epigastric  aura,  followed 
by  sleep  lasting  one  or  two  hours.  These  attacks  occurred  at  irregular  inter- 
vals. In  her  fourth  year  she  had  measles  and  scarlet  fever.  In  her  seventh 
year  she  came  under  observation.  A  strict  milk  diet  was  ordered,  and  she 
took  one  teaspoonful  in  the  morning  and  two  at  night  of  the  following 
mixture : 

R.  Sodii  bromidi  ^iiiss  ; 

Aquae,  S^vj. — Misce. 

The  treatment  was  continued  with  scarcely  an  interruption  during  her 
seventh,  eighth,  and  ninth  years,  with  complete  cure  of  the  disease,  and  with 
bromism  only  on  one  occasion.  Gowers,  writing  of  adults,  remarks  that  few 
patients  can  take  more  than  one  and  a  half  drachms  of  the  bromide  daily 
without  bromism.  But,  according  to  my  observations,  children  can  take 
larger  proportionate  doses  than  this  without  injury.  Although  prescribing 
the  bromide  of  potassium  daily  for  children  of  all  ages  during  many  years,  I 
have  seldom  observed  any  ill  effects  which  were  clearly  attributable  to  its  use 
except  the  occurrence  of  acne.  Bromism  soon  disappears  when  the  dose  of 
the  bromide  is  diminished  or  its  vise  is  discontinued.  In  general,  this  medi- 
cine should  be  given  twice  or  three  times  daily  during  as  long  a  period  as 
two  years  after  the  last  paroxysm,  without  diminishing  the  dose  which  is 
found  sufficient  to  cure  the  disease ;  and,  to  make  sure  of  a  cure,  it  should 
be  employed  a  third  year  in  a  gradually  diminishing  dose.  In  the  case 
related  above,  the  patient,  a  girl  then  at  the  age  of  nine  years,  had  taken  the 
bromide  of  sodium  two  years  in  two  doses  of  thirteen  and  twenty-six  grains 
with  complete  arrest  of  the  attacks,  when  she  had  symptoms  of  bromism. 
The  bromide  was  discontinued,  and  she  remained  well  for  some  weeks,  but 
finally  she  stated  that  the  furniture  at  times  seemed  to  move.  Half  the 
previous  dose  was  now  employed  for  a  month  or  two,  when  it  was  discon- 
tinued, and  she  has  remained  well  without  medicine  during  the  sis  or  eight 
months  which  have  since  elapsed.  In  slight  bromism  during  the  first  and 
second  years  of  treatment  it  is  usually  better,  I  think,  to  diminish  the  dose 
of  the  bromide,  but  not  to  discontinue  its  use,  and  at  the  same  time  to 
employ  a  vegetable  tonic  with  alcohol.  In  great  cerebral  depression  due  to 
the  bromide,  it  is  probably  better  to  entirely  discontinue  its  use  for  a  time, 
even  if  convulsions  occur. 

Occasionally,  the  bromide  employed  alone  does  not  cure  epilepsy.  It  may 
then  be  given  in  combination  with  another  drug  which  is  believed  to  exert 
some  controlling  influence  upon  the  disease,  as  digitalis,  belladonna,  cannabis 
indica,  or  zinc.  These  remedies  were  prescribed  with  apparent  benefit  in 
certain  instances  before  the  bromides  came  into  use.  Digitalis  has  been 
employed  as  a  remedy  for  epilepsy  since  Parkinson  recommended  it  in  1640. 
It  is  not  very  efficient  when  used  alone,  but  in  some  instances  when  given 
with  the  bromide  it  evidently  increases  the  curative  power  of  this  agent. 
Growers  says :  "  In  many  cases  attacks  which  continued  on  bromide  only, 
ceased  entirely  on  bromide  and  digitalis."  He  observed  good  results  from 
the  use  of  this  combination,  especially  in  epileptics  who  had  cardiac  disease, 
as    dilatation,  valvular  insufficiency,   hypertrophy,   and   a   too   rapid    pulse. 


632  LOCAL  DISEASES. 

Benefit  also  occurred  in  some  instances  in  wbich  the  heart's  action  was  nor- 
mal, as  in  the  following  case :  Jesse ,  aged  twelve  years,  was,  when  an 

infant,  rachitic,  backward  in  teething  and  the  use  of  his  limbs.  He  had  the 
first  epileptic  fit  at  the  age  of  sixteen  months.  The  attacks  occurred  at 
intervals  of  one  week,  and  were  preceded  by  a  visual  aura,  a  red  ball  of  fire, 
that  approached  the  eye.  Fifteen  grains  of  the  bromide  of  ammonium,  with 
five  minims  of  the  tincture  of  belladonna,  were  prescribed,  to  be  given  twice, 
and  subsequently  three  times,  daily.  With  this  treatiuent  the  intervals 
between  the  fits  were  lengthened  to  one  month,  but  they  still  occurred  after 
six  months'  treatment.  Five  minims  of  the  tincture  of  digitalis  were  then 
substituted  for  the  belladonna,  and  no  fit  occurred  for  eleven  months.  On 
diminishing  the  dose  of  digitalis  one  fit  occurred,  but  on  resuming  its  use  in 
five-minim  doses  seven  months  elapsed  without  an  attack.  A  girl  of  eighteen 
years  had  a  convulsion  at  the  age  of  two  years,  another  at  seven  years,  and 
confirmed  epilepsy  since  her  tenth  year.  The  attacks  occurred  about  every 
second  day,  without  an  aura.  The  bromide  alone  and  bromide  with  bella- 
donna were  employed,  with  slight  diminution  in  the  frequency  of  the  attacks. 
Digitalis  with  the  bromide  was  then  employed.  Immediately  the  fits  were 
reduced  to  four,  then  to  two,  in  the  month,  and  then  four  months  elapsed 
without  a  fit.  A  girl  aged  eleven  years,  greatly  frightened  by  a  thunder- 
storm, began  to  have  nocturnal  epileptic  attacks.  At  the  age  of  fourteen 
years,  when  treatment  was  commenced,  the  attacks  occurred  nearly  every 
night.  One  scruple  of  the  bromide  of  potassium  and  ten  minims  of  tincture 
of  belladonna  reduced  the  attacks  to  one  in  ten  days.  Then  the  treatment 
was  changed  to  two  scruples  of  bromide  of  ammonium  and  five  minims  of 
tincture  of  digitalis,  taken  once  daily  at  night,  and  two  months  passed  with- 
out an  attack,  when  she  was  lost  sight  of.  These  cases,  to  which  more  might 
be  added,  show  that  digitalis  combined  with  the  bromide  increases  the  efficacy 
of  the  latter  in  certain  cases. 

Belladonna  has  been  employed  in  the  treatment  of  epilepsy  during  the 
last  two  centuries.  It  was  recommended  by  Mardorf  in  1691,  and  by  Hufe- 
land,  Stoll.  and  others  in  the  eighteenth  century.  Its  proper  use  is  in  com- 
bination with  one  of  the  bromides,  when  the  latter  is  inadequate  to  arrest  the 
attacks.  Used  alone,  it  does  not  cure  epilepsy,  though  occasionally  it  renders 
the  attacks  less  frequent.  But  Gowers  relates  cases  which  show  that  it 
increases  the  efficiency  of  the  bromides  in  certain  cases  when  combined  with 
them.  It  is  believed  to  first  stimulate  and  then  depress  the  functions  of  the 
nervous  system,  acting  not  upon  one  part  only,  but  upon  various  parts  of  the 
brain  and  spinal  cord,  affecting  their  functional  activity.  To  show  the  effect 
of  the  combination  of  belladonna  with  the  bromide,  Gowers  relates  the  case 
of  a  boy  in  whom  epilepsy  commenced  at  the  age  of  thirteen  years  without 
known  cause.  The  attacks  began  usually  in  the  morning  without  an  aura, 
at  intervals  of  three  weeks.  Fifteen  grains  of  the  bromide  administered 
night  and  morning  reduced  the  attacks  to  one  a  month.  After  three  months 
of  treatment  twenty  grains  of  the  bromide  and  five  minims  of  tincture  of 
belladonna  were  given  three  times  daily,  and  two  months  elapsed  without  an 
attack,  when  two  occurred.  Subsequently,  he  took  the  same  medicine  four- 
teen months  without  an  attack,  when  treatment  was  discontinued.  Sis 
months  later  he  was  still  well.  Other  cases  have  been  related  in  which 
belladonna,  combined  with  the  bromide,  produced  a  more  decided  curative 
action  than  the  bromide  employed  alone ;  but  in  some  instances,  as  we  have 
seen,  when  these  two  agents  fail  to  cure,  this  result  is  accomplished  by  the 
bromide  and  digitalis.  The  liquor  atropiae,  one  minim  of  which  contains 
T"2"o  of  a  grain  of  atropine,  may  be  used  in  place  of  the  tincture  of  bella- 
donna. 


EPILEPSY.  633 

Stramonium,  cannabis  indica,  and  gelsemium  sempervirens  have  been  pre- 
scribed with  some  apparent  benefit  in  certain  instances,  but  it  is  the  common 
belief  with  those  who  have  employed  them  that  they  are  no  more  efficacious 
than  digitalis  and  belladonna,  and  they  seldom  if  ever  cure  the  disease  when 
used  alone.  When  employed  with  the  bromide,  good  results  have  followed, 
but  the  improvement  has  probably  been  due  almost  entirely  to  the  bromide. 

Zinc  has  been  recommended  in  the  treatment  of  epilepsy  for  more  than  a 
century  by  good  observers.  In  experiments  on  animals  it  has  been  found  to 
diminish  reflex  action,  and  it  exerts  some  controlling  effect  on  the  functions 
of  the  hemispheres  and  the  medulla  oblongata.  It  diminishes  the  frequency 
of  the  epileptic  attacks  in  many  patients,  but  not  usually  so  certainly  as  the 
bromides,  or  to  such  an  extent.  In  exceptional  instances  zinc  prevents  the 
epileptic  attacks  to  a  greater  extent  than  the  bromide,  especially  when  they 
present  the  hysteroid  form.  The  oxide,  lactate,  and  citrate  are  commonly 
prescribed,  and  a  child  of  eight  years  can  take  from  one  to  two  grains  three 
times  daily.  It  should  be  gi^^en  after  tbe  meals,  since  it  sometimes  ii'ritates 
the  stomach  and  causes  nausea.  It  is  believed  by  Gowers  to  be  slowly  con- 
verted into  the  chloride  in  the  stomach.  He  relates  the  case  of  an  adult 
epileptic  who  took  five  grains  of  the  oxide  of  zinc  morning  and  evening,  and 
had  no  attack  during  the  five  months  in  which  he  was  under  observation.  A 
girl  of  eight  years  having  inherited  epilepsy,  after  four  months  of  treatment 
with  the  bromide  was  still  having  two  fits  each  week.  Oxide  of  zinc  in 
doses  of  three  grains  was  ordered,  and  in  two  months  the  fits  ceased.  Nine 
months  elapsed  with  only  one  attack,  when  the  patient  was  lost  sight  of. 
Gowers  also  relates  the  following  case,  showing  that  the  addition  of  the  zinc 
to  the  bromide  sometimes  plainly  increases  the  efficiency  of  the  latter :  A 
boy  of  eleven  months,  belonging  to  an  epileptic  family,  had  a  fit  at  the  age 
of  eleven  months.  At  the  age  of  fourteen  years,  when  he  was  presented  for 
treatment,  the  convulsions  occurred  every  two  weeks.  One  scruple  of  bro- 
mide of  ammonium  administered  three  times  daily  caused  some  improvement, 
as  did  the  bromide  with  digitalis,  but  the  disease  was  not  cured  until  the 
zinc  was  employed  with  the  bromide.  In  obstinate  cases,  therefore,  zinc  is 
-sometimes  useful  as  an  adjuvant  to  the  bromide. 

Opium,  or  its  alkaloid  morphia,  has  been  long  employed  in  the  treatment 
of  epilepsy,  but  its  use  has  now  given  place,  for  the  most  part,  to  that  of 
other  remedies.  Occasionally,  especially  in  the  hysteroid  forms  of  epilepsy, 
morphia  given  at  the  commencement  of  the  warning  has  apparently  pre- 
vented the  fit. 

The  effect  of  iron  in  epilepsy  is  equivocal  and  uncertain.  Brown-Sequard 
and  Jackson  discountenance  its  use,  and  they  think  it  increases  the  frequency 
■of  the  attacks.  Gowers  says  that  he  has  given  iron  to  several  hundred 
epileptics,  and  that  it  only  rarely  increases  the  severity  of  the  fits.  In  most 
instances  it  produces  no  ill  effect,  and  it  sometimes  improves  the  general 
health.  He  states  that  occasionally  bromide  with  iron  arrests  the  attacks, 
when  the  bromide  alone  has  little  effect. 

A  considerable  number  of  remedies  which  we  have  not  mentioned  have 
been  employed,  but  they  have  been  for  the  most  part  discarded  by  recent 
observers,  either  because  they  have  been  found  to  be  inert  or  have  been  use- 
ful only  in  rare  cases,  and  less  useful  than  other  remedies. 

According  to  my  observation,  the  treatment  which  has  been  found  ade- 
quate to  arrest  the  fits  should  be  continued  at  least  two  years  after  the  last 
paroxysm,  being  omitted  for  a  few  days  or  its  quantity  reduced  if  symptoms 
of  bromism  occur.  Even  after  a  cure  for  two  years  occasional  symptoms  of 
the  petit  mcd  may  occur,  so  that  it  will  be  necessary  to  resume  the  use  of  the 
medicine  in  smaller  doses. 


634  LOCAL  DISEASES. 

Hi/gienic  Treatment. — It  is  necessary  that  an  epileptic  cliikl  should  lead  a 
quiet  and  regular  life,  free  from  excitement  and  all  perturbating  influences. 
The  diet  should  be  plain  and  easily  digested.  In  some  instances  a  diet  con- 
sisting almost  entirely  of  milk  has  seemed  to  be  a  very  important  remedial 
measure. 


CHAPTER    IX. 

INTERNAL  CONVULSIONS  (SPASM  OF  THE  GLOTTIS  ;  LARYN- 
GISMUS STRIDULUS). 

Young  children  are  liable  to  temporary  suspension  of  respiration,  induced 
by  violent  emotions,  especially  by  anger.  In  the  midst  of'their  excitement, 
while  they  are  crying  or  screaming,  their  breath  is  suddenly  held,  as  if  from 
tonic  spasm  of  the  respiratory  muscles.  In  a  few  seconds  respiration  returns 
and  is  natural.  There  is  no  stridulous  inspiration  or  other  unusual  sound, 
and  there  is  no  apparent  ill-effect,  unless  occasionally  a  degree  of  languor. 
External  convulsions,  which  seem  to  be  threatening,  seldom  occur,  and  when 
they  do  are  ordinarily  mild.  Some  writers  consider  dentition  the  predispos- 
ing cause  of  this  arrest  of  respiration  by  inducing  a  sensitive  state  of  the 
nervous  system ;  such  an  efi'ect  is  possible,  but  certainly  many  infants  are 
affected  in  this  manner  before  the  age  of  dentition. 

A  much  more  serious  state,  and  one  which  is  recognized  as  a  true  disease, 
is  that  variously  designated  by  writers  as  internal  convulsions,  spasm  of  the 
glottis,  child-crowing,  laryngismus  stridulus,  etc.  Manifest  difiiculties  attend 
the  investigation  of  the  pathological  state  in  this  disease.  There  can  be 
little  doubt  that  it  is  not  precisely  the  same  in  all  cases.  That  there  is,  dur- 
ing the  paroxysms,  tonic  or  clonic  spasm  of  more  or  fewer  of  the  respiratory 
muscles  is  inferred  not  only  from  the  symptoms  pertaining  to  the  respiratory 
apparatus,  but  from  the  fact  that  in  severe  cases  spasms  of  the  external 
muscles,  as  those  of  the  limbs  and  face,  often  occur.  Usually,  also,  the 
movements  of  the  eyeballs  indicate  spasmodic  contractions  of  the  motor  mus- 
cles of  the  eyes.  The  fact  of  spasmodic  muscular  action  in  parts  that  are 
visible  justifies  the  belief  that  it  occurs  in  other  parts  which  are  concealed 
from  view,  especially  as  the  characteristic  symptoms  cannot  be  readily  ex- 
plained except  on  this  supposition.  Trousseau  says :  "  Internal  convulsions 
consist,  then,  principally  in  a  spasm  of  the  diaphragm  and  of  the  respiratory 
muscles  of  the  abdomen  and  chest ;  but  it  occurs  also  that  the  muscles  per- 
taining to  the  larynx  are  affected  with  spasm  at  the  same  time  with  these." 
Rilliet  and  Barthez  conclude  from  the  symptoms  that  the  "  heart  is  not 
always  a  stranger  to  this  internal  convulsion,  which  perhaps  prolongs  itself 
even  to  the  intestines."  The  muscles  of  the  pharynx  appear  to  be  involved 
in  some  cases,  as  well  as  those  of  respiration,  rendering  deglutition  diflacult. 
In  one  form  of  internal  convulsions — namely,  that  which  is  principally 
referred  to  by  writers — there  is  not  complete  arrest  of  respiration,  but  the 
inspirations  during  the  paroxysms  are  difficult  and  are  attended  by  a  stridu- 
lous noise.  Again,  the  respiration  may  cease  entirely,  but  when  it  com- 
mences it  is  stridulous  and  difficult  during  a  few  inspirations.  In  still 
another  form  of  the  disease  respiration  ceases,  but  there  is  no  symptom  or 
sign  indicative  of  glottic  spasm  or  of  an  obstacle  to  the  ingress  of  air ;  the 
inspirations  which  succeed  the  paroxysm  are  easy  and  noiseless.  It  has  been 
suggested  that  in  these  cases  there  is  paralysis  rather  than  spasmodic  con- 


INTERNAL   CONVULSIONS.  635 

traction  of  the  respiratory  muscles ;  but  the  symptoms  may  be  explained  in 
accordance  with  the  commonly  accepted  opinion — namely,  that  there  is  spasm 
of  the  diaphragm  and  perhaps  of  certain  muscles  of  the  chest  and  abdomen, 
while  the  laryngeal  muscles  are  not  affected.  M.  Herard,  indeed,  who  has 
written  one  of  the  best  monographs  on  internal  convulsions,  describes  three 
forms  of  the  disease  according  to  the  supposed  location  of  the  spasm — 
namely,  laryngeal,  diaphragmatic,  and  another  which  consists  of  a  blending 
of  the  two. 

Internal  convulsions  are  not  frequent  in  this  country ;  they  are  rare  in 
France,  more  frequent  in  Germany,  and  quite  common  in  England.  They 
occur,  with  few  exceptions,  before  the  age  of  two  years.  Dr.  West  observed 
31  cases  under  the  age  of  two  years,  and  only  6  above  that  age.  The  fact 
has  been  established  by  many  observations  that  the  rachitic  are  especially 
liable  to  spasm  of  the  glottis. 

Causes. — Spasm  of  the  glottis  has  been  attributed  to  enlargement  of  the 
thymus  gland,  and  also  to  enlargement  of  the  cervical  and  bronchial  glands. 
It  is  presumed  that  this  effect  is  due  to  the  pressure  of  these  glands  on  the 
par  vagum  or  the  recurrent  laryngeal  nerve.  It  is  certain,  however,  that 
there  is  no  such  enlargement  of  the  thymus  gland  which  could  possibly  pro- 
duce glottic  spasm  or  any  other  form  of  internal  convulsion  at  the  age  at 
which  these  convulsions  commonly  occur.  This  gland  is  largest  in  the  new- 
born, and,  having  no  function  after  birth,  it  gradually  becomes  atrophied.  If 
an  enlarged  thymus  could  produce  glottic  spasm,  it  would  certainly  occur 
most  frequently  in  the  new-born.  Abnormal  development  of  the  thymus 
gland  seemed  to  be  the  cause  of  atelectasis  in  two  infants  who  died  soon  after 
birth  in  my  practice,  but  I  have  not  seen  a  case  in  which  a  convulsive  attack 
was  referable  to  this  cause.  M.  Herai'd  examined  the  thymus  gland  in  6  chil- 
dren who  died  of  internal  convulsions  and  in  60  who  died  of  other  affections, 
and  was  not  able  to  discover  in  its  condition  any  causal  relation  to  this  dis- 
ease. Indeed,  cases  have  been  reported  in  which  the  thymus  had  undergone 
more  than  its  usual  atrophy  at  the  time  when  the  convulsions  occurred 
(Haase).  Enlargement  of  the  lymphatic  glands  in  the  vicinity  of  the  pneu- 
mogastric  or  recurrent  laryngeal  nerve  may  possibly  give  rise  to  glottic  spasm, 
but  this  is  doubtless  an  infrequent  cause,  if  it  be  a  cause  at  all,  since  these 
glands  are  often  greatly  enlarged  in  strumous  and  tubercular  diseases  without 
such  a  result. 

The  cause  is  occasionally  located  in  the  cerebro-spinal  axis.  Thus,  Dr. 
Coley  relates  a  case  in  which  an  exostosis  arising  from  the  internal  surface 
of  the  occipital  bone  pressed  upon  the  cerebellum,  while  nothing  abnormal 
was  discovered  in  other  organs.  Examples  are  also  related  in  which  the 
cause  was  located  in  the  spinal  cord.  Thus,  Marshall  Hall  relates  the  case 
of  a  child  with  spina  bifida  who  was  attacked  with  croup-like  convulsions 
whenever  it  lay  so  as  to  press  on  the  tumor. 

Internal  convulsions  are  also  frequent  in  rachitic  softening  and  absorption 
of  the  calvarium,  since,  when  this  is  present,  undue  pressure  occurs  upon  the 
brain  by  the  weight  of  the  head  of  the  child  upon  the  pillow. 

In  some  patients  there  is  evidently  an  hereditai'y  predisposition  to  this 
disease,  those  affected  belonging  to  families  in  which  a  tendency  to  convul- 
sive maladies  is  manifested.  Thus,  Toogood  states  that  five  infants  of  the 
same  family  were  affected  with  spasm  of  the  glottis ;  and  Reid  relates,  on 
the  authority  of  Powel,  that  of  thirteen  infants  of  the  same  parents  only 
one  escaped  internal  convulsions. 

The  common  predisposing  cause  is  an  excitable  state  of  the  nervous  sys- 
tem, often  associated  with  impaired  general  health.  Hence  the  disease  is 
more  prevalent  in  cities,  where  antihygienic  conditions  abound,  than  in  the 


636  LOCAL  DISEASES. 

country.  Hence,  too,  the  frequent  improvement  when  the  patient  is  removed 
to  the  pure  and  bracing  air  of  the  country.  The  use  of  insufficient  food  or 
food  of  a  bad  quality  must  for  the  same  reason  be  considered  a  cause,  since 
it  leads  to  impoverishment  of  the  blood  and  renders  the  nervous  system  more 
impressible.  Facts  mentioned  by  Reid  and  others  show  conclusively  the  influ- 
ence of  premature  weaning  and  the  use  of  indigestible  or  otherwise  improper 
aliment  in  the  production  of  this  disease. 

The  causes  enumerated  above  are  for  the  most  part  predisposing ;  occa- 
sionally they  are  the  only  apparent  causes,  since  this  disease  sometimes  occurs 
when  the  child  is  tranquil,  even  in  the  midst  of  quiet  sleep  or  when  it  is  at 
rest  in  its  mother's  arms.  In  other  cases  and  more  frequently  there  is  an 
exciting  cause,  often  trivial.  Anything  that  requires  exertion  on  the  part 
of  the  Hifant  or  that  excites  strong  emotions  may  be  a  direct  cause,  as  anger 
or  any  of  the  violent  passions :  so  may  even  coughing,  or,  in  rare  instances, 
attempts  to  swallow.  One  author  has  known  it  to  occur  from  excitement 
produced  by  examinigg  the  throat  with  a  spoon.  In  a  case  in  my  practice, 
hereafter  related,  it  occurred  whenever  the  infant  cried  violently.  It  appears 
from  the  above  facts  that  the  etiology  of  internal  convulsions  is  very  similar 
to  that  of  eclampsia.  The  same  spasmodic  muscular  contraction  may  occur 
from  a  variety  of  causes. 

Anatomical  Characters. — While,  therefore,  structural  changes  in 
various  parts  of  the  system  may  give  rise  to  internal  convulsions,  this  dis- 
ease, so  far  as  ascertained,  presents  no  anatomical  characters,  and  must  conse- 
quently be  considered  one  of  the  neuroses.  The  lesions  of  the  respiratory 
apparatus  which  are  seen  at  post-mortem  examinations  are  due  to  the  convul- 
sions or  are  coincidences.  Emphysema  has  sometimes  been  observed  as  a 
result,  it  is  believed,  of  the  spasmodic  and  irregular  respiration.  It  was  pres- 
ent in  all  of  Herard's  cases,  and  Eilliet  and  Barthez  consider  it  common  in 
those  who  die  of  this  aff"ection,  although  they  did  not  observe  it  in  any  of 
their  cases.  Slight  emphysema  in  the  upper  lobes  is,  however,  a  common 
lesion  in  feeble  infants,  whatever  the  diseases  of  which  they  die.  Therefore 
its  occurrence  in  internal  convulsions  is  probably  due  more  to  molecular 
change  in  the  lungs,  since  these  patients  are  cachectic,  than  to  the  irregular 
breathing,  which  is  only  momentary. 

In  fatal  cases  of  internal  convulsions  the  blood  is  darker  than  usual,  from 
an  excess  of  carbonic  acid ;  and  in  some  cases  the  cavities  of  the  heart  and 
large  vessels  are  engorged  with  blood,  but  in  others  they  contain  no  more 
than  the  normal  amount.  More  or  less  passive  congestion  occurs  in  the  inter- 
nal organs  ;  and  congestion  of  the  cerebral  vessels  is  in  some  patients  so  great 
that  transudation  of  serum  occurs. 

Symptoms. — I  have  said  that  the  symptoms  vary  according  to  the  seat 
and  function  of  the  muscles  which  are  affected.  There  is  generally  previous 
ill-health.  The  child  is  drooping,  and  is  sometimes  restless,  for  days  before 
the  disease  appears.  Finally,  if  the  muscles  of  the  glottis  become  affected, 
the  peculiar  crowing  sound  is  heard  now  and  then  during  inspiration.  It  is 
observed  especially  when  the  child  is  crying  or  is  agitated.  It  may  be  loud 
and  well  defined  from  the  first,  but  in  most  patients  it  comes  on  gradually, 
so  that  several  days  elapse  before  its  full  stridulous  character  is  developed. 
The  attacks  are  more  frequent  and  severe  at  night,  in  or  after  the  first  sleep, 
than  in  day-time. 

Under  favorable  hygienic  conditions  the  malady  may  pass  off  without 
becoming  more  serious.  In  other  cases  the  paroxysms  gradually  increase 
in  frequency  and  severity.  The  dyspnoea  in  the  attack  is  such  that  the 
features  are  livid,  the  head  forcibly  retracted,  and  death  seems  imminent 
from  apnoea.     In  these  severe  paroxysms  respiration  often  ceases  entirely  for 


INTERNAL   CONVULSIONS.  637 

a  moment.  When  the  spasm  ends  a  deep  stridulous  inspiration  occurs,  after 
which  the  breathing  is  natural.  I  have  stated  also  that  internal  convulsions 
are  often  associated  with  those — usually  tonic,  but  sometimes  clonic — of  the 
external  muscles.  In  the  tonic  form  the  thumbs  are  flexed  across  the  palms 
of  the  hands,  and  sometimes  are  grasped  by  the  fingers ;  the  great  toes  are 
adducted  and  the  other  toes  flexed.  In  severe  cases  the  hands,  forearms,  feet, 
and  legs  are  also  somewhat  flexed  and  rigid.  At  first  the  contraction  of  the 
external  muscles  is  temporary,  either  corresponding  with  the  internal  spasm, 
or  it  is  most  intense  at  the  time  of  the  spasm,  though  commencing  sooner 
and  subsiding  later.  After  a  while,  however,  if  the  disease  continue,  the 
spasmodic  action  of  the  external  muscles  becomes  more  persistent.  In  severe 
cases  nearly  every  inspiration  is  accompanied  by  the  whizzing  sound,  and 
the  paroxysms  of  dyspnoea  are  excited  by  trifling  causes.  Anything  that 
suddenly  disturbs  the  mind  or  body  may  bring  on  the  attack,  as  anger,  the 
impression  of  cold,  or  currents  of  air.  Dr.  West  calls  attention  to  the  fact  that 
an  anasarcous  condition  is  sometimes  present,  accompanied  by  albuminuria. 

If  the  convulsions  afi"ect  other  muscles,  as  the  diaphragm  or  the  pectoral 
and  abdominal  muscles,  which  are  concerned  in  the  respiratory  function, 
while  those  of  the  larynx  escape,  respiration  is  irregular  or  even  suspended 
for  a  moment,  but  the  stridulous  laryngeal  sound  is  absent,  as  there  is  in 
the  larynx  no  obstacle  to  the  entrance  of  air.  In  this  form  of  the  disease  the 
inframammary  region  may  be  strongly  retracted  during  the  paroxysm  from 
tonic  contraction  of  the  diaphragm.  In  severe  paroxysms,  whether  the  spasm 
be  laryngeal  or  diaphragmatic,  consciousness  is  nearly  or  quite  lost,  the 
features  may  be  pallid,  or,  if  respiration  be  suspended,  may  be  more  or 
less  livid.  Relaxation  of  the  sphincters  of  the  bowels  and  bladder,  with 
involuntary  evacuations,  often  occurs  in  this  disease  during  the  attack. 

The  duration  of  the  paroxysm  may  be  a  quarter,  a  half,  or  even  a  whole 
minute.  Total  suspension  of  respiration  for  even  half  a  minute  involves 
danger.  In  mild  cases  there  may  be  but  few  paroxysms,  and  these  slight. 
In  other  instances  they  occur  in  a  severe  form  almost  daily  for  several  weeks 
or  even  months. 

The  general  health  in  internal  convulsions  is  more  or  less  impaired,  except 
in  mild  forms  of  the  disease,  in  which  the  convulsive  attacks  soon  cease. 
Pallor  or  a  sickly  and  cachectic  aspect,  irregular,  usually  constipated  bowels, 
poor  appetite,  and  moroseness  or  irritability  of  temper  are  common  symptoms 
of  severe  and  protracted  cases. 

Diagnosis. — This  disease  is  easily  diagnosticated,  unless  when  its  symp- 
toms are  masked  by  those  of  external  convulsions  ;  it  may  then  escape  notice. 
Spasm  of  the  glottis  may  be  mistaken  for  spasmodic  laryngitis,  and  vice  versa. 
In  some  of  the  published  cases  this  mistake  appears  to  have  been  made. 
Spasmodic  laryngitis  is,  however,  so  difi"erent  not  only  in  its  nature,  but  in 
its  clinical  history,  that  a  difi"erential  diagnosis  is  not  difiicult.  It  is  an 
inflammatory  disease,  and  is  attended  with  feeble  reaction  and  a  sonorous 
cough ;  it  commences  at  night  after  the  first  sleep  and  from  exposure  to 
cold — particulars  in  regard  to  which  it  contrasts  with  true  spasm  of  the 
glottis,  which  in  complicated  cases  is  not  attended  by  any  febrile  symptoms. 

Prognosis  ;  Modes  of  Death.— Statistics  show  great  mortality  in  this 
disease.  Dr.  Reid,  in  a  monograph  on  "  Infantile  Laryngismus,"  states  that 
of  289  cases  which  he  collated,  115  died.  Rilliet  and  Barthez  met  with  1 
favorable  case  in  9  unfavorable,  and  Herard  1  in  7.  If  the  paroxysms  be 
mild,  infrequent,  and  dependent  on  a  cause  which  can  be  easily  removed, 
recovery  is  probable  with  proper  treatment.  The  cause  may,  however,  be 
such,  even  when  the  spasm  is  mild,  that  the  case  is  necessarily  unfavorable, 
as  when  it  is  due  to  disease  of  the  cerebro-spinal  axis.    We  should,  not,  how- 


638  LOCAL  DISEASES. 

ever,  in  any  case  consider  the  patient  entirely  safe,  since  grave  symptoms 
may  suddenly  arise,  so  as  to  change  entirely  the  prognosis.  Long  and  severe 
paroxysms,  with  lividity  of  face  and  symptoms  of  suffocation,  indicate  an 
unfavorable  result.  The  same  should  be  predicted  also  if  the  infant  gradually 
lose  flesh  and  strength,  especially  if  the  face  be  pallid,  the  pulse  feeble,  and 
the  appetite  poor. 

There  are  three  modes  of  death  in  internal  convulsions.  The  first  is  by 
apncea.  The  infant  dies  suffocated  in  the  attack.  Respiration  is  first  arrested, 
and  then  the  pulse  ceases,  and  at  the  autopsy  the  lungs  and  the  cavities  of  the 
heart  are  found  engorged  with  dark  blood.  Death  may  also  result  from  the 
state  of  the  brain.  In  such  cases  passive  congestion  of  the  brain  occurs  from 
ob.struction  to  the  return  of  blood  from  this  organ  to  the  heart  and  lungs ; 
and  if  this  congestion  be  not  soon  relieved  serous  effusion  also  occurs.  Death 
results  from  the  congestion  and  consequent  oedema  or  dropsy. 

The  third  mode  of  death  is  from  exhaustion.  Repeated  and  severe  attacks 
undermine  the  constitution  ;  the  infant  gradually  grows  pallid  and  thin,  and 
dies  of  inanition  or  of  some  disease  which  this  state  induces. 

Treatment. — The  treatment  of  internal  convulsions  has  varied  according 
to  the  theories  which  physicians  have  held  in  reference  to  its  cause.  Grland- 
ular  enlargement  is  no  longer  regarded  as  a  common  cause,  and  therefore 
treatment  directed  to  its  removal  is  less  frequent!}"  prescribed  than  formerly. 
The  causes  of  internal  convulsions  are  in  part  very  similar  to  those  of  eclamp- 
sia, and  the  remedies  employed  in  the  one  affection  are,  in  a  measure,  appro- 
priate in  the  other.  That  dentition  is  sometimes  a  cause  is  usually  admitted, 
and  two  cases,  one  of  which  occurred  in  my  practice  and  the  other  was  reported 
to  me,  appeared  to  .show  that  it  may  operate  as  a  cause.  The  effect  of 
dentition  is  especially  observed  in  weakly  infants  when  several  dental  fol- 
licles are  undergoing  active  evolution.  Thus,  in  one  of  the  cases  to  which  I 
refer  five  teeth  pierced  the  gums  in  the  course  of  two  weeks  ;  after  which  no 
convulsive  attack  occurred.  If,  therefore,  the  gums  are  swollen,  the  propriety 
of  scarification  should  be  considered,  especially  if  the  convulsions  be  so  severe 
as  to  endanger  life. 

In  all  cases  of  internal  convulsions  a  careful  examination  should  be  made 
in  order  to  detect  any  aberration  from  the  normal  state  which  might  cause 
nervous  excitation.  The  condition  of  the  digestive  organs  should  be  ascer- 
tained, and  evacuants  or  other  remedies  prescribed  if  there  be  evidence  of 
their  derangement. 

Sometimes  the  alimentation  of  the  infant  is  at  fault.  It  is  perhaps  bot- 
tle-fed and  the  stools  have  an  unhealthy  appearance.  Attention  should  be 
given  to  the  preparation  of  its  food  and  the  times  of  its  feeding,  or  if  it 
nurse  the  mother  or  wet-nurse  who  suckles  it  should  have  plain  but  nutri- 
tious diet,  live  with  regularity,  and  give  the  breast  to  the  infant  at  regular 
intervals.  If  there  be  a  torpid  state  of  the  intestines,  Dr.  Meigs  recommends 
'•  castor  oil  and  aromatic  syrup  of  rhubarb  rubbed  up  together,  three  parts  of 
the  former  and  five  of  the  latter.''  A  simple  enema  answers  well  in  such 
cases,  and  in  debilitated  infants  this  is  preferable  to  medicine  administered 
by  the  mouth.  If  diarrhoea  be  present,  and  it  persist  after  the  requisite 
changes  are  made  in  regard  to  the  diet,  remedies  calculated  to  relieve  it, 
which  are  mentioned  elsewhere,  should  be  employed.  3Iarshall  Hall  states 
that  he  has  ordinarily  succeeded  in  curing  the  disease  by  attending  to  the 
condition  of  the  gums  and  digestive  organs. 

Since  rachitis  is  a  not  uncommon  cause,  the  child  .should  be  examined  in 
reference  to  rachitic  manifestations,  and  if  they  appear  the  treatment  appro- 
priate for  rachitis  is  required. 

In  pallid  and  cachectic  infants  tonics  are  indicated.     The  elixir  of  call- 


ixTERXAL  coyruLsioxs.  639 

saya-bark  witli  iron,  in  half-teaspoonful  doses  three  or  four  times  daily  to  an 
infant  of  two  years,  is  an  eligible  preparation.  The  preparatiofis  of  iron  are 
frequently  to  be  preferred  to  the  vegetable  tonics,  as  the  citrate  of  iron  and 
bismuth;  citrate  of  iron  and  quinia,  the  syrup  of  iodide  of  iron,  or  the  wine 
of  iron.  To  an  infant  of  one  year  the  syrup  may  be  given  in  doses  of  three 
drops,  the  citrates  in  one-grain  doses,  and  the  wine  in  doses  of  one  teaspoonful, 
every  four  hours,  or  the  liquor  ferri  peptonati  may  be  employed. 

Antispasmodics,  as  asafoetida,  valerian,  and  oxide  of  zinc,  are  often  pre- 
scribed in  this  malady,  but  they  are  less  eiEcacious  than  the  general  tonic 
measures  which  I  have  mentioned.  The  salutary  effect  of  bromide  of  potas- 
sium in  eclampsia  and  epilepsy  certainly  justifies  the  trial  of  this  agent  in 
internal  convulsions  if  they  persist  after  the  employment  of  invigorating 
remedies. 

Hygienic  measures  are  of  the  utmost  importance.  The  infant  should 
reside  in  dry  and  airy  apartments,  and  should  be  kept  much  of  the  time 
through  the  day  in  the  open  air.  Remarkable  success  sometimes  attends 
this  simple  expedient  when  medicines  have  entirely  failed.  Mr.  Robertson  ^ 
of  3Ianchester  relates  five  severe  cases  in  which  this  disease  was  cured  by 
exposure  of  the  infants  several  hours  daily  to  a  cool  atmosphere.  These 
cases  were  treated  in  the  winter  months,  and  were  kept  outdoor  even  during 
strong  winds.  Mr.  Robertson  has  records  of  forty  cases,  all  occurring 
between  December  and  April,  while  he  has  seen  no  case  in  the  summer 
months.  As  the  result  of  such  extensive  experience  the  writer  recommends 
*'  the  free  exposure  of  the  infant  out  of  doors  for  many  hours  daily  to  a  dry, 
cold  atmosphere,  and,  if  the  air  be  dry,  the  colder  the  better."  Dr.  Marshall 
Hall's  experience  was  similar.  Says  he  :  "  The  curative  influence  of  the  air, 
and  especially  of  the  sea-breezes,  is  not  less  marked  in  this  afi"ection  than  in 
whooping  cough."  Mr.  Robertson  recommends  also,  as  part  of  the  tonic 
treatment,  '-free  sponging  of  the  body  every  morning  with  cold  water."  In 
February,  1867,  I  attended  a  nursing  infant  five  months  old  with  internal  con- 
vulsions, the  paroxysms  being  attended  with  lividity  of  the  face  and  at  times 
tonic  convulsions  of  the  limbs.  Among  the  remedies  employed  was  bromide 
of  potassium,  but  more  benefit  obviously  accrued  from  keeping  the  infant 
much  of  the  time  in  the  open  air  than  from  the  medicines  employed.  The 
disease  passed  ofi"  in  six  or  eight  weeks. 

Unless  the  cause  be  of  such  nature  that  it  cannot  be  removed,  the  above 
hygienic  and  therapeutic  measures  will,  in  a  large  proportion  of  cases,  be  fol- 
lowed by  a  satisfactory  result. 

The  mother  or  nurse  may  abridge  the  paroxysm  by  raising  the  infant, 
blowing  upon  it,  sprinkling  water  in  the  face,  or  gently  stroking  it.  Dr. 
Hall  recommends  tickling  the  nostrils  with  a  feather  to  produce  respiration, 
or  the  fauces  to  occasion  vomiting,  and  thereby  interrupt  the  paroxysm. 
Anj'thing  which  causes  a  sudden  and  profound  efi"ect  upon  the  system 
may  abridge  the  attack.  This  was  effected  in  one  case  in  the  practice  of 
Dr.  C.  C.  Meigs  by  applying  a  cloth  wrapped  around  ice  over  the  epigas- 
trium and  the  lower  part  of  the  sternum.  The  chief  danger  during  the 
attack  is  from  congestion  of  the  brain,  with  eff'usion  of  serum  or  extravasa- 
tion of  blood.  If  the  attack  be  severe  and  the  features  congested,  so  that 
there  is  evident  danger  of  such  a  result,  cold  applications  should  be  made  to 
the  head,  derivatives  applied  to  the  extremities — as  sinapisms  or  mustard 
foot-baths — and  the  bowels  should  be  speedily  opened  by  enemata. 

^  London  Med.  Gazette,  Jan.  14,  1865. 


640  LOCAL  DISEASES. 

CHAPTER    X. 

TETANY. 

The  disease  known  as  tetany  has  probably  always  existed,  for  its  recog- 
nized causes  are  of  common  occurrence,  but  the  attention  of  the  profession 
was  first  directed  to  it  by  a  memoir  bearing  the  title  "  Observations  sur  une 
Espece  de  Tetanos  intermittent,"  published  by  M.  Dance  in  the  Archives 
generaJes  de  Medecine  in  1831.  He  described  it  as  it  occurs  in  the  adult.  In 
the  following  year  (1832)  M.  Tonnele  published  in  the  Gazette  medicale  an 
essay  on  tetany,  which  he  designated  a  new  convulsive  disease  of  childhood. 
In  the  same  year  Constant  and  Murdoch  also  published  their  observations  on 
this  malady  in  French  medical  journals,  the  former  designating  it  "  Contrac- 
tures essentielles,"  and  the  latter  "  Retractions  musculaires  et  spasmodiques." 
In  1835  the  memoir  of  De  la  Berge  on  tetany,  bearing  the  title  "  Retractions 
musculaires  de  courte  duree,"  was  published  in  the  Journal  Hehdomadaire. 
From  this  time  the  disease  was  fully  recognized  in  France,  and  several  addi- 
tional monographs  relating  to  it  appeared  in  medical  journals  prior  to  1850, 
among  the  most  notable  of  which  was  the  thesis  of  Delpech  in  1846.  The 
term  tetany  (tetanic)  was  first  employed  by  Dr.  Lucien  Corvisart  in  an 
interesting  and  instructive  paper  published  in  1851. 

The  term  tetany  is  applied  to  a  disease  which  is  characterized  by  tonic 
contraction  of  muscles,  commonly  those  of  the  extremities,  but  sometimes 
also  those  of  the  face  or  trunk,  produced  by  causes  external  to  the  nervous 
system,  and  usually  of  temporary  duration.  The  exception  to  this  definition 
might  be  as  regards  such  causes  as  are  psychical  or  emotional,  if  such  exist. 
Following  this  definition,  we  would  exclude  cases  of  tonic  muscular  contrac- 
tion, however  close  the  resemblance,  which  arise  from  disease  of  the  brain, 
spinal  cord,  or  their  meninges,  or  from  disease  of  the  nerve  supplying  the 
affected  muscle.  The  contractions  in  these  cases  are  not  the  malady  itself, 
as  iu  tetany,  but  are  merely  symptoms  of  some  important  disease  located  in 
the  nervous  system  at  a  distance  from  the  affected  muscles. 

Causes. — Tetany  may  occur  at  any  age,  but  is  most  frequent  in  infancy, 
in  early  childhood,  and  in  early  adult  life.  Of  28  cases  observed  by  Rilliet 
and  Barthez,  1  was  at  the  age  of  nine  months,  13  between  the  ages  of  three 
and  fifteen  years,  5  at  the  age  of  three  years,  and  the  remaining  between  the 
ages  of  three  and  fifteen  years.  Eustace  Smith  says  that  the  period  during 
which  the  largest  number  of  cases  occur  is  between  the  first  and  third  years. 
In  142  cases  collated  by  Gowers  the  ages  were  as  follows :  Between  one  and 
four  years,  34 ;  between  four  and  nine  years,  8 ;  between  nine  and  nineteen 
years.  36 ;  between  nineteen  and  twenty-nine  years,  24 ;  between  twenty- 
nine  and  thirty-nine  years,  23 ;  between  thirty-nine  and  forty-nine  years,  13 ; 
and  between  forty-nine  and  sixty-one  years,  4.  Erb  remarks  that  a  strong 
tendency  to  tetany  is  exhibited  in  early  childhood,  and  the  next  most  common 
period  of  its  occurrence  is  at  the  age  of  puberty  and  early  youth.  The  statis- 
tics of  different  observers  show  that  tetany  is  more  common  in  males  than 
females.  Of  Rilliet  and  Barthez's  28  cases,  20  were  boys.  Of  the  142  cases 
embraced  in  the  statistics  of  Gowers,  76  were  males  and  66  females.  Accord- 
ing to  Gowers,  in  the  first  and  second  decades,  in  which  a  large  majority  of 
the  cases  occur,  more  males  are  affected  than  females,  but  between  the  ages 
of  twenty  and  fifty  years,  females  preponderate,  while  above  the  age  of  fifty 
years  all  the  recorded  cases  have  been  males.  It  is  seldom  that  the  most 
thorough  investigation  elicits  any  inherited  predisposition  in  cases  of  tetany 


TETANY.  641 

to  nervous  or  other  diseases.  Most  of  the  observed  cases  have  occurred 
singly  in  families,  and  in  families  which  exhibit  no  special  tendency  to 
nervous  or  other  ailments.  Rarely,  however,  multiple  cases  have  occurred 
in  families,  from  which  we  infer  that  there  may  be  an  inherited  neuropathic 
tendency.  The  only  instances  of  this  sort  which  I  have  been  able  to  find  in 
the  literature  of  tetany  were  two  cases  observed  by  Murdoch  in  one  family, 
and  cases  alluded  to  by  Abercronibie,  who  states  that  at  different  times  4 
eases  occurred  in  each  of  two  families,  and  2  cases  in  another  family. 

Although  in  many  instances  different  causes  appear  to  act  simultaneously 
in  causing  tetany,  nearly  all  writers  who  have  contributed  to  the  literature 
of  this  malady  assign  the  most  important  place  in  the  causation  to  diseases 
of  the  digestive  apparatus.  Trousseau  states  that  in  the  cases  which  have 
fallen  under  his  observation  diarrhoea  has  been  commonly  present.  He  says 
that  in  1854  he  met  many  cases  following  cholera,  but  in  one  instance  occur- 
ring in  his  practice  the  cause  seemed  to  be  obstinate  constipation.  The 
patient  at  the  age  of  seventeen  years  was  suddenly  seized  when  travelling. 
His  fingers  were  bent  and  he  could  not  extend  or  use  them.  The  tetany 
subsided  in  two  or  three  hours,  but  it  recurred  every  day  for  three  months. 
He  was  treated  by  bleedings,  but  the  tetany  was  uniformly  worse  after  each 
loss  of  blood,  the  contractions  becoming  more  severe  and  also  more  general. 
Not  only  were  the  muscles  of  the  extremities  in  a  state  of  tetanic  contrac- 
tion, but  also  those  of  the  face  and  trunk,  so  that  respiration  and  speech 
were  embarrassed.  Although  the  contractions  were  aggravated  by  bleeding, 
and  were  never  so  bad  as  after  the  fourth  venesection,  they  ceased  entirely 
for  a  period  of  ten  months  after  cupping  along  the  spine.  Subsequently 
they  recurred  every  year  at  the  close  of  winter  and  continued  two  months. 
The  patient  was  habitually  constipated,  and  the  torpid  state  of  the  bowels 
seemed  to  be  the  chief  factor  in  producing  the  tetany.  In  the  following 
case,  which  I  have  recently  had  under  observation,  constipation  appears  also 

to  have  been  the  chief  cause :  George  C ,  without  teeth  and  at  the  age 

of  seven  months  when  tetany  commenced,  was  taken  from  the  breast  at  the 
age  of  two  months.  He  lives  in  a  tenement-house,  and  from  the  time  of 
weaning  has  been  fed  with  condensed  milk,  one  heaped  teaspoonful  of  large 
size  to  fifty  of  water.  Besides  this,  he  has  taken  once  daily  a  tablespoonful 
of  Nestle's  food  in  ten  of  water.  With  this  diet  his  growth  has  been  about 
like  the  average,  but  he  has  been  habitually  very  constipated,  so  as  frequently 
to  require  assistance  in  obtaining  an  evacuation.  Recently,  groups  of  muscles 
in  all  the  extremities  have  undergone  tonic  contraction,  pi'oducing  deformities, 
as  shown  in  the  photograph  (Fig.  190),  and  brief  attacks  of  laryngismus 
stridulus.  These  attacks  of  spasm  of  the  glottis  occur  both  by  day  and  by 
night,  causing  for  a  moment  the  chai'acteristic  stridulous  respiration.  The 
mother  states  that  at  times  he  is  feverish,  probably  from  the  constipation, 
but  usually  he  seems  entirely  well,  except  as  regards  the  sluggish  state  of 
the  bowels  and  the  contractions.  Attempts  to  straighten  the  fingers  and  toes 
elicit  cries  from  the  pain.  The  mother  also  says  that  at  times  both  thighs 
and  both  legs  are  flexed,  and  he  resists  attempts  to  straighten  them  on 
account  of  the  pain.  The  treatment  employed  consisted  in  the  use  of  bro- 
mide of  potassium  and  measures  designed  to  relieve  the  constipation.  When 
these  remedies  were  perseveringly  employed,  the  contractions  aradually 
diminished  and  ceased,  but  they  returned  when  the  treatment  was  discon- 
tinued. Four  months  have  elapsed  since  the  commencement  of  the  disease, 
and  it  is  only  in  the  last  week  or  two  that  the  contractions  have  entirely 
ceased.  The  important  factor  in  producing  the  tetany  in  this  case  appears 
to  have  been  the  habitual  constipation.  One  tooth  pierced  the  gum  durino- 
the  four  months  of  tetany. 
41 


642 


LOCAL  DISEASES. 


Erb  says  that  all  forms  of  intestinal  diseases  may  cause  tetany,  but  it 
especially  occurs  after  "  protracted  and  exhausting  diarrhoea."  Gowers  also 
remarks  that  the  most  common  cause  of  tetany  is  diarrhoea,  usually  long- 

FiG.  190. 


Photograph  of  a  child,  showing  tonic  contraction  of  groups  of  muscles  of  the  extremities  as 

the  result  of  tetany. 

continued  and  exhausting,  but  sometimes  acute  and  brief."  Among  the  rarer 
intestinal  causes  of  tetany  may  be  mentioned  the  presence  of  worms.  I 
have  not  found  in  the  literature  of  teta,ny  any  instance  in  which  lumbriei  or 
ascarides  cavised  the  contractions,  but  Growers  alludes  to  three  cases  in  which 
they  were  produced  by  the  tape-worm. 

From  the  nature  of  tetany,  and  from  the  important  part  long  assigned  to 
dentition  in  producing  nervous  ailments,  it  is  perhaps  remarkable  that  the 
teething  process  has  so  seldom  been  regarded  as  a  factor  in  causing  tetany  in 
young  children.  But,  so  far  as  I  have  been  able  to  learn  from  memoirs  and 
recorded  cases,  those  who  have  made  special  study  of  tetany  agree  for  the 
most  part  with  Trousseau,  who  says  that  in  nearly  all  instances  pathological 
conditions  distinct  from  dentition  are  present,  "  on  which  tetany  would  seem 
rather  to  depend."  Nevertheless,  in  the  following  case  which  was  treated  by 
Professor  E.  Gr.  Janeway  and  myself,  after  repeated  and  thorough  examina- 
tions, teething  was  regarded  by  laoth  of  us  as  the  chief  cause  of  the  contrac- 
tions : 

Case. — B ,  aged  twenty  months,  well-nourished,  has  during  the  last  few 

days  been  unable  to  use  the  left  lower  extremity.  The  thigh  is  flexed  at  an  angle 
of  about  forty-five  degrees  and  the  leg  at  about  the  same  angle,  and  attempts  to 
overcome  the  rigidity  of  the  flexors  and  straighten  the  limb  are  resisted  and  are 


TETANY.  643 

painful.  The  muscles  in  the  other  extremities,  and  those  which  move  the  foot  and 
toes  of  the  affected  limb,  appear  to  have  their  normal  functional  activity,  as  do 
those  of  the  face,  neck,  and  trunk.  The  gums  were  swollen  and  congested  over 
the  crowns  of  five  advancing  teeth,  which  appeared  to  be  in  nearly  the  same  stage 
of  development,  and  were  evidently  soon  to  protrude.  It  is  possible  that  a  rather 
sluggish  state  of  the  bowels  may  have  been  a  factor  in  causing  the  tetany,  but  the 
chief  agent  was  apparently  the  cutting  of  so  many  teeth.  There  was  not  at  any 
time  any  notable  elevation  of  temperature,  loss  of  appetite,  or  derangement  of  the 
functions  of  important  organs,  but  the  contractions  continued  three  weeks,  when 
all  or  nearly  all  the  imprisoned  teeth  escaped  and  the  limb  was  quickly  restored 
to  its  normal  state.  There  has  been  after  the  lapse  of  two  years  no  return  of  the 
tetan}'. 

Tetany  is  more  liable  to  occur  in  those  whose  systems  are  enervated  by 
pre-existing  disease  than  in  those  who  are  robust.  Rilliet  and  Barthez  state 
that  in  cases  which  have  come  under  their  observation  the  patients  were  often 
in  poor  health,  resulting  from  disease  which  they  had  had,  as  pneumonia, 
bronchitis,  or  enteritis.  Bouchut  also  remarks  that  tetany  occurs  as  a  sequel 
of  various  enervating  maladies,  among  which  he  enumerates  cholera,  typhus 
and  typhoid  fevers,  and  dysentery.  Erb  mentions  the  following  diseases 
which  sustain  a  causal  relation  to  tetany  or  in  the  convalescence  from  which 
tetany  is  liable  to  occur :  typhoid  fever,  measles,  cholera,  Bright's  disease, 
febris  intermittens,  in  addition  to  the  diarrhoeal  maladies  which  have  been 
alluded  to  above.  Eustace  Smith  goes  farther,  and  states  that  tetany  is  rare 
in  robust  subjects — that  it  ordinarily  occurs  in  those  who  have  delicate  con- 
stitutions by  inheritance  or  disease  or  are  imperfectly  nourished.  Gowers, 
enumerating  the  maladies  which  are  followed  by  tetany,  mentions  "  typhoid 
fever,  cholera,  smallpox,  rheumatic  fever,  measles,  febricula,  catarrh,  and 
pneumonia ;  "  and  he  states  also  that  in  young  children  the  indications  of 
rachitis  are  rarely  absent. 

Another  recognized  cause  of  tetany  is  taking  cold.  Exposure  to  wet  and 
cold  has  in  numerous  instances  been  followed  by  tetany.  From  this  mode  of 
origin  the  opinion  arose  that  tetany  is  a  rheumatic  affection.  Hence,  Eisen- 
mann  applied  to  it  the  term  "  brachiotonus  rheumaticus,"  and  Benedict  desig- 
nated it  "  rheumatische  contractur."  Erb  says :  "Amongst  the  exciting  causes, 
catching  cold  is  both  the  most  important  and  the  most  common  ;  and  this 
statement,"  he  adds,  "  is  supported  by  the  fact  that  many  physicians  have 
regarded  it  as  an  exquisite  example  of  rheumatic  disease.  Working  in  the 
wet  or  cold  or  in  water,  sleeping  on  the  damp  ground,  have  very  often  been 
regarded  as  causes,  and  the  swelling  in  the  joints  which  occurs  in  many 
instances  indicates  that  this  disease  has  a  somewhat  close  relation  to  true 
rheumatism."  It  must  be  recollected  that  Erb's  observations  have  been 
chiefly  with  adults.  As  regards  infancy  and  early  childhood,  other  causes 
of  tetany  are  apparently  more  common  than  taking  cold.  Adults  with 
tetany  often  attribute  the  attack  to  exposure  in  wet  and  inclement  weather, 
and  probably  correctly.  At  the  present  time,  in  Charity  Hospital,  a  female 
aged  thirty-nine  years  is  under  treatment  for  tetany.  She  said  that  her  sick- 
ness was  produced  by  exposure  in  wet  and  cold  weather.  She  was  employed 
as  a  seamstress,  and,  being  insufficiently  clothed,  sat  at  her  work  with  feet 
chilled  and  wet.  At  the  same  time  her  menstruation  had  been  irregular,  and 
she  had  diarrhoea,  apparently  produced  by  the  exposure.  Tonic  contractions 
occurred  in  the  muscles  of  the  fingers  and  toes  on  both  sides,  accompanied 
by  pain,  especially  in  the  alFected  muscles  of  the  lower  extremities.  Several 
months  have  elapsed  since  the  commencement  of  the  disease,  and  the  fingers 
have  regained  nearly  or  quite  their  normal  state,  but  the  toes  are  firmly 
flexed.  The  chief  cause  of  the  tetany  in  this  case  appeared  to  be  taking 
cold,  from  which  probably  the  diarrhoea  resulted,  which,  as  we  have  seen,  is 


644  LOCAL  DISEASES. 

one  of  the  most  common  causes  of  the  tonic  contractions.  Trousseau  also 
relates  cases  in  which  exposure  to  cold  was  apparently  the  exciting  cause. 
Growers  states  that  next  to  diarrhoea  the  most  common  causes  are  "  exposure 
to  cold,  acute  disease,  and  lactation." 

Among  the  other  recognized  causes  of  tetany  we  may  mention  suckling, 
pregnancy,  and  the  development  at  the  time  of  commencing  puberty.  The 
first  cases  seen  by  Trousseau  in  Necker  Hospital  occurred  in  women  recently 
confined  who  were  wet-nursing,  so  that  at  first  he  designated  the  disease 
rheumatic  contraction  occurring  in  nurses.  Gowers  says  that  the  frequency 
of  the  disease  in  adult  women  is  chiefly  due  to  maternity.  The  following  are 
occasional  causes  mentioned  by  various  writers :  anaemia,  prolonged  muscular 
effort,  alcoholism,  onanism  (Growers),  ergotism,  violent  excitement  (Erb),  irri- 
tation of  uric-acid  calculi  (Eustace  Smith). 

From  the  nature  of  tetany  it  would  seem  probable  that  it  might  occa- 
sionally result  from  preputial  irritation,  but  I  have  not  been  able  to  find  the 
history  of  any  case  in  which  this  cause  was  assigned,  either  in  the  literature 
of  tetany  or  in  monographs  relating  to  a  narrow,  irritated,  or  inflamed  pre- 
puce. Tetany  does  not  result,  or  very  rarely  results,  from  burns  or  ordinary 
wounds;  but  Weiss  in  1883  reported  13  cases  in  which  it  occurred  from 
excision  of  the  thyroid,  and,  according  to  Wolfler,  in  70  cases  of  this  opera- 
tion tetany  resulted  7  times. 

It  is  remarkable  that  this  disease  appears  to  occur  as  an  epidemic — a  fact 
not  easy  of  explanation,  unless  upon  the  supposition  that  the  rheumatismal 
cause  due  to  atmospheric  conditions,  or  the  psychical  or  emotional  cause 
giving  rise  to  imitation,  is  operative  at  the  time.  Bouchut  says  that  tetany 
occurred  as  an  epidemic  in  Germany  in  1717,  in  Belgium  in  1846,  and  in 
Paris  in  1855.  In  the  Paris  epidemic  it  occurred  equally  among  children 
and  adults,  and  was  the  occasion  of  interesting  observations  by  Aran  and 
Barthez.  Another  epidemic  occurred  in  Paris  in  1876  and  in  its  environs, 
especially  at  Gentilly,  where  in  a  school  the  teacher  and  thirty  pupils  were 
affected ;  but  some  of  the  pupils  afterward  confessed  that  they  had  feigned 
the  disease.  In  New  York  City,  in  the  first  quarter  of  1889,  I  saw  so  many 
cases  that  it  seemed  to  me  that  tetany  might  properly  be  regarded  as  an 
epidemic. 

Symptoms. — Ordinarily,  tetany  occurs  without  any  marked  premonitory 
symptoms,  but  in  some  instances  it  is  preceded  by  pain  in  the  head  or  spine, 
vomiting  without  any  previous  indigestion  or  gastric  derangement,  and  a 
general  feeling  of  indisposition.  Usually,  in  those  old  enough  to  express 
their  sensations,  tetany  begins  with  tingling,  burning,  or  other  unusual  sen- 
sory manifestations  in  the  limbs.  The  tonic  contractions  occur  suddenly, 
sometimes  in  the  upper  and  lower  extremities  simultaneously.  Rarely,  the 
contractions  occur  in  the  upper  extremities  alone  or  in  the  muscles  of  the 
trunk.  At  first  a  feeling  of  stiffness  is  experienced,  and  this  is  followed  by 
tonic  contractions,  with  the  fixing  of  the  affected  part  in  a  state  of  per- 
sistent flexion  or  extension.  Usually,  as  regards  the  upper  extremities,  the 
contraction  of  the  thenar  and  hypothenar  muscles  causes  hollo wness  of  the 
palms  of  the  hands ;  the  first  phalanges  of  the  fingers  are  flexed,  the  second 
and  third  phalanges  extended,  and  the  thumb  adducted  and  flexed  so  as  to 
press  against  the  index  finger  or  lie  underneath  it.  The  fingers  sometimes 
incline  toward  the  ulnar  side,  and  sometimes  are  pressed  against  each  other. 
Usually  the  hand  is  slightly  fiexed,  as  is  also  the  forearm.  The  muscles 
which  move  the  arm  usually  escape,  but  exceptionally  there  is  adduction  of 
the  arm  on  the  shoulder.  The  hand  may  be  extended  instead  of  flexed, 
and  all  the  joints  of  the  fingers  extended,  or  they  may  all  be  flexed  and  the 
fist  closed. 


TETANY.  645 

The  thighs  may  be  addueted  or  flexed,  the  legs  extended  or  flexed,  the 
foot  extended,  forming  a  talipes  equinus,  and  the  toes  flexed,  as  in  the  fol- 
lowing interesting  case  now  in  Charity  Hospital,  which  has  been  alluded  to 
above.  Though  the  patient  is  an  adult,  her  case  is  related  here  since  it  aids 
in  throwing  light  on  the  nature  of  the  disease : 

Case. — Mary  F.  0 ,  native  of  the  United  States,  seamstress,  married,  and 

of  apparently  healthy  parentage,  states  that  her  health  was  good  previously  to  the 
present  sickness.  She  says  that  she  has  never  had  venereal  disease  and  never  taken 
stimulants  in  excess,  though  in  the  habit  of  using  whiskey  at  breakfast.  She  had 
been  married  four  years,  and  three  years  ago  had  a  stillborn  child  at  the  seventh 
month,  but  has  had  no  other  miscarriage  and  has  had  no  confinement  at  term.  Her 
catamenia,  which  formerly  were  scanty  and  at  unusually  long  intervals,  have  dur- 
ing the  last  four  months  been  normal  in  regard  to  time  and  quantity.  She  has  been 
subject  to  afternoon  headaches  for  years.  She  has  had  the  average  appetite,  has 
partaken  largely  of  rye  bread  at  her  meals,  and  her  stools  have  been  normal. 

In  -January,  1888,  the  patient,  being  employed  as  a  seamstress  in  a  shop  at  a 
distance  from  her  residence,  began  to  experience  unusual  fatigue,  and  on  returning 
from  her  day's  work  she   frequently 

noticed  a  painful  burning  sensation  -p^^    jgj 

in   her  feet,  the  pain    extending  up- 
ward  along  the   calves  of  her  legs.  \ 
This  pain  in  the  feet  and  legs  gradu-  \ 
ally  increased  until  March  12,  1888,      ,.,.  \ 
at  the  time  of  the  deep  snow  accom-     ^fc,  \ 
panying  the  ''  blizzard."    After  walk-       ^^^&  J®^.                 ,,.A 
ing  through  the  snow  she  sat  all  day            ^^feji^'            ;;;=;;"=*ssiafe„,__^^ 
at  her  work  with  wet  feet,  and  at  this                   ^^;  ""'ss^.-^ 
time  she  began  to  experience  a  dull                        ^\-J                        »:-      ;%.       \ 
intermittent  pain  extending  from  both                          ^fe                %^    "^^    ^      \ 
ankles  to  the  knees,  and  accompanied                            W!         ^     ^       i      \        \ 
by  great  lassitude,  so  that  walking  re-                             p|^     \  fy^^yL  <f-\  /f    \] 
quired   an   effort.     In  July  the  pain                              |^B^'>-y-^''^;=5i^*^i=i^ji^^ 
became  more  constant,  but  at  the  time                             W                .*  ^^ — 
of  her  admission  into  Charity  Hospi-                               ^^  ^,,j^^ 
tal  (August  17th)  it  was  not  so  con-                                  ^»®««»iB»»^ 
stant  or  severe.     Soon  after  her  ad- 
mission the  feet  became  strongly  extended,  forming  a  talipes  equinus,  and  the  toes 
of  both  feet  were  also  strongly  flexed.     Sensation  in  the  toes,  but  not  in  the  feet, 
was  almost  completely  lost.     A  few  days  subsequently  the  fingers  on  both  sides 
were  similarly  flexed,  but  without  pain  or  loss  of  sensation.     In  about  six  months 
the  flexion  of  the  finger  ceased,  and  she  can  now  use  them  nearly  as  well  as  before 
the  attack.     The  toes  also  are  not  so  strongly  flexed  as  at  first,  and  they  have  re- 
gained sensation.     The  bladder  has  never  been  affected,  but  the  sphincter  ani  was 
paralyzed  for  a  time  in  August,  so  that  the  feces  escaped  involuntarily  in  bed.    The 
patient's  memory  was  considerably  impaired  after  the  exposure  at  the  time  of  the 
"  blizzard,"  but  is  now  (.June,  1889)  apparently  nearly  or  quite  normal.    Otherwise 
no  impairment  of  the  mental  faculties  has  been  observed. 

The  tetany  in  this  case  has  been,  as  usual,  bilateral  and  for  the  most  part  equal 
on  the  two  sides,  with  a  little  more  acuteness  of  sensation  in  the  right  than  left 
limbs.  The  feet  continue  in  the  position  of  talipes  equinus,  with  toes  flexed,  and 
the  contracted  muscles  hard  to  the  feel,  almost  like  cartilage.  No  oedema  has  been 
observed,  but  perspiration  occurs  from  the  extremities  during  sleep. 

In  mild  cases  or  those  of  ordinary  severity  the  contractions  are  limited  to 
the  muscles  of  the  extremities,  and  are  more  marked  and  persistent  in  those 
that  move  the  hands,  feet,  fingers,  and  toes  than  in  other  muscles ;  but  in 
severe  cases  the  muscles  of  the  trunk  and  head  participate.  Contraction  of 
the  abdominal  muscles  produces  rigidity  of  the  abdominal  walls.  Spasm  of 
certain  of  the  thoracic  muscles  occasionally  occurs,  causing  dyspnoea  and 
even  lividity.  In  some  of  these  cases  of  embarrassed  respiration  the  dia- 
phragm is  probably  involved.     Opisthotonos,  retention  of  urine,  anteflexion 


646  LOCAL  DISEASES. 

of  the  neck  from  contraction  of  the  sterno-mastoids,  fixation  of  the  jaws 
from  spasm  of  the  masseters,  retraction  of  the  angles  of  the  mouth,  stiftness 
of  the  tongue,  and  indistinct  articulation  are  occasional  symptoms  in  severe 
cases  of  tetany. 

The  contractions  render  the  aifected  muscles  hard  and  unyielding,  and 
the  child  cries  from  pain  when  attempts  are  made  to  straighten  the  limb.  If 
the  spasm  be  slight  some  voluntary  movement  of  the  affected  muscles  is  pos- 
sible, but  it  is  restrained  and  difficult.  In  severe  cases,  with  the  muscles 
tense  and  unyielding,  voluntary  motion  is  impossible.  Except  in  the  mildest 
forms  of  the  disease  pain  is  felt  in  the  contracted  muscles,  such  as  all  people 
experience  when  a  spasm  occurs  in  the  calf  of  the  leg,  and  the  pain  may  pass 
upward  along  the  limb.  The  pain  may  occur  in  paroxysms  with  distinct 
intermissions,  or,  without  ceasing,  it  may  vary  in  severity  at  different  times, 
probably  from  some  variation  in  the  degree  of  spasm.  Certain  subjective 
symptoms,  such  as  numbness  and  tingling,  which  sometimes  occur  in  tetany, 
may  continue  during  the  intermission  or  remission.  After  some  hours  or 
days  the  rigidly-contracted  muscles  relax  and  the  disease  disappears,  except 
perhaps  that  a  degree  of  stiffness  remains.  But  the  respite  is  usually  not 
long.  The  spasms  recur,  and  several  successive  recurrences  and  intermis- 
sions take  place,  running  over  months,  before  the  disease  is  permanently 
cured.  During  the  intervals  in  the  contractions  the  affected  nerves  and 
muscles  are  in  ordinary  cases  unduly  excitable,  so  that  sudden  pressure  or 
percussion  causes  some  contraction. 

Trousseau  was  perhaps  the  first  who  noticed  and  called  attention  to 
the  fact  that  compression  of  the  artery  and  nerve  supplying  the  contracted 
muscles  in  tetany  causes  or  increases  the  contraction.  Occasionally  this 
result  cannot  be  obtained. 

It  is  an  interesting  fact  that  in  cases  which  I  have  observed  the  spasms 
do  not  cease  in  sleep,  though  the  contraction  of  the  muscles  may  not  be  as 
great  as  when  the  patient  is  awake. 

The  electrical  excitability  of  the  nerve  which  supplies  the  contracted 
muscles  is  increased.  Growers  states  that  he  has  obtained  contractions  in  the 
muscles  of  the  face  by  the  voltaic  current  from  a  single  cell.  The  increased 
excitability  of  the  nerves  is  apparent  if  either  the  direct  or  induced  current 
be  used.  According  to  Erb,  when  the  circuit  is  closed  the  earliest  contrac- 
tions occur  at  the  point  of  application  of  the  positive  pole.  Both  opening 
and  closing  the  circuit  cause  a  more  prolonged  contraction  of  the  muscles  in 
tetany  than  in  health.  When  the  contractions  are  strong,  oedema  sometimes 
occurs,  especially  upon  the  dorsal  surfaces  of  the  hands.  It  was  present  in 
cases  treated  by  Henoch,  who  attributes  it  to  compression  and  consequent 
passive  congestion  of  the  veins,  produced  by  contraction  of  the  interossei 
muscles,  the  congestion  giving  rise  to  serous  transudation.  When  the  parox- 
ysms are  severe,  perspiration  sometimes  occurs,  and  an  erythematous  redness 
may  appear  over  the  affected  muscles.  Occasionally  in  acute  attacks  the 
temperature  is  moderately  increased,  but  ordinarily  it  is  normal.  Tetany 
does  not  usually  affect  the  functions  of  the  internal  organs,  but  in  a  case 
related  by  Kussmaul  and  another  by  Nonchen  albuminuria  was  for  a  brief 
period  present,  and  in  one  recorded  instance  the  urine  exhibited  traces  of 
sugar  during  the  paroxysms.  Occasionally  in  long-continued  tetany  the  con- 
tracted muscles  undergo  a  degree  of  atrophy  which  is  attended  by  dimin- 
ished electrical  irritability.  Gowers  states  that  "  general  muscular  atrophy  " 
has  also  been  observed  following  tetany. 

The  following  may  be  regarded  as  typical  cases  in  tetany  in  infancy 
as  I  have  observed  it  in  New  York.  The  first  case  occurred' in  the  New 
York  Infant  Asylum  during  my  term  of  service,  and  the  resident  physician, 


TETANY.  647 

Dr.  Virginia  M.  Davis,  has  kindly  furnished  me  the  history  from  her  note- 
hook  : 

Case  1. — Gertrude  A ,  born  in  the  New  York  Infant  Asylum,  April  30, 

1888,  was  well  except  a  mild  attack  of  pertussis  until  March  9,  1889,  when  she 
had  a  prostrated  appearance,  and  the  thermometer  indicated  a  temperature  of  105°, 
and  a  little  later  1U5.5°.  During  the  following  sis  hours  she  had  five  large,  watery, 
and  yellow  stools.  She  was  restless,  her  features  sunken,  extremities  cool,  her  sur- 
face covered  with  a  clammy  perspiration,  and  her  pluse  feeble.  Her  diarrhoea  was 
checked,  and  she  slept  during  the  following  night.  From  March  9th  to  14th  she 
had  slight  fever  (100.4°-100.6°)  and  her  stools  were  normal,  but  during  the  week 
ending  with  the  14th  she  lost  one  pound  in  weight.  The  following  are' the  subse- 
quent notes  of  the  case : 

March  14th.— Is  restless;  temperature  in  the  morning  100.4°,  in  the  evening 
103°  ;  has  had  no  stool  in  the  last  twenty-four  hours.  To-day  has  had  for  the  first 
time  contraction  of  the  flexor  muscles  of  the  hands,  feet,  fingers,  and  toes,  so  that 
in  the  evening  all  the  fingers  and  toes  are  firmly  flexed.  The  dorsal  surface  of  the 
hands  and  feet,  and  the  fingers  and  toes  as  far  as  the  articulations  of  the  first  and 
second  phalanges,  are  cedematous.  The  flexions  can  be  overcome  by  the  employ- 
ment of  considerable  force,  but  the  attempt  is  painful.  An  erythematous  eruption 
has  appeared  over  the  upper  part  of  the  chest  and  upon  the  back. 

March  15th. — Temperature  100.6°  ;  thumbs  extended,  voluntary  movement  of 
fingers  returning  ;  toes  still  fiexed  ;  oedema  as  before  ;  rash  fading  ;  stools  normal. 
March  16th.  Temperature  99°-99.8°.  The  contractures  have  entirely  disappeared 
during  the  day.  Had  four  stools.  17th.  Bowels  constipated ;  slight  contractures 
of  the  fingers.  18th.  Morning  temperature  103° ;  evening,  101°.  In  the  evening 
contractures  of  both  extremities  disappearing ;  stools  normal;  gums  swollen.  From 
this  time  the  constipation  was  relieved  by  small  doses  of  calomel,  and  the  tetany 
ceased.  Some  elevation  of  temperature  was  a  prominent  symptom  previous  to 
and  during  the  tetany,  and  on  one  day  (May  17th)  an  attack  of  general  clonic  con- 
vulsions or  eclampsia  occurred.  The  tetany  ceased  on  the  18th  or  19th,  but 
between  the  20th  and  30th,  maculae  and  papules  appeared  on  the  surface,  due  per- 
haps partly  to  the  medicines  employed,  which  were  chiefly  the  bromides  and 
chloral. 

Case  2. — Edward  McI ,  aged  fifteen  months  (practice  of  Dr.  Vineberg,  but 

examined  by  myself),  has  healthy  parentage,  and  no  other  child  in  family  has  had 
any  nervous  ailment,  except  a  single  attack  of  eclampsia  during  measles  in  one  of 
the  children.  Edward  is  nourished  in  part  at  the  breast  and  in  part  from  the 
table.  He  has  four  teeth,  all  having  cut  the  gum  since  the  age  of  twelve  months. 
He  has  had  diarrhoea  much  of  the  time  since  birth,  and  during  the  last  two  months 
has  had  free  perspiration  from  the  head.  The  mother  states  that  during  the  first 
months  of  his  life  he  occasionally  held  his  breath,  especially  at  night,  but  with  this 
exception  no  symptoms  resembling  a  convulsive  attack  were  observed  until  recently, 
when,  during  an  attack  of' coughing,  his  face  grew  red,  his  eyes  turned  upward, 
and  his  respiration  ceased  for  a  moment.  When  he  was  at  the  age  of  twelve 
months  the  mother  first  noticed  that  the  toes  were  flexed  and  the  feet  extended  as 
in  talipes  equinus.  Considerable  force  was  required  to  overcome  the  tonic  contrac- 
tion of  the  affected  muscles,  and  when  the  pressure  was  relaxed  the  feet  imme- 
diately assumed  the  former  position  of  talipes.  The  thumbs  were  strongly  flexed 
across  the  palms  of  the  hands,  the  index  and  middle  fingers  forcibly  extended  and 
separated  from  each  other,  and  the  ring  and  little  fingers  were  flexed  against  the 
palm.  These  abnormal  flexions  and  extensions  continued  more  than  three  months, 
with  occasional  intervals  of  two  or  three  days,  during  which  the  action  of  the 
aifected  muscles  was  nearly  normal.  The  child  presents  evidences  of  rachitis  in 
the  shape  of  its  head  and  enlargement  of  the  epiphyses  of  the  extremities. 

The  treatment  employed  by  Dr.  Vineberg  consisted  in  change  of  diet  and  in 
the  use  of  the  following  prescription  : 

R.   Zinci  sulphat.,  gr.  J ;  ' 

Atropise  sulphat.,  gr.  ^ii^ — Misce. 

To  be  taken  three  times  daily. 

With  this  treatment  the  spasms  of  the  muscles  entirely  disappeared  within  a  week, 
and  two  weeks  later  had  not  returned. 


648  LOCAL  DISEASES. 

The  following  case,  related  by  Trousseau,  gives  a  clear  and  vivid  idea  of 
the  symptoms  of  severe  tetany  as  it  occurs  in  the  adult.  A  dissipated 
younff  man  was  found  one  morning  lying  in  the  street,  "  stiff  as  a  poker  " 
from  the  occurrence  of  tetany  during  the  night.  He  was  conscious  and 
complained  of  great  pain,  but  spoke  indistinctly  from  the  clenched  state  of 
his  jaws.  Muscles  in  his  extremities  were  rigidly'  contracted,  and  being- 
unable  to  walk,  he  had  fallen  down  and  could  not  rise.  The  rigidity  of 
the  muscles  of  the  chest  and  abdomen,  and  probably  of  the  diaphragm, 
rendered  respiration  difficult.  His  face  was  livid,  and  he  had  paroxysms 
of  dyspncea  that  threatened  suffocation.  The  tetany  finally  abated,  and  he 
was  able  to  walk  and  attend  to  light  duties,  but  at  intervals  he  had  recur- 
rence of  the  spasms,  and  finally  died  of  phthisis. 

Adults,  unlike  young  children,  give  a  clear  description  of  their  subjective 
symptoms.  Frequently — probably  in  a  majority  of  instances  in  the  adult, 
as  in  the  child — tetany  is  preceded  by  certain  sensory  symptoms,  as  formi- 
cation, a  sensation  of  weight  or  dragging,  of  heat  or  cold,  or  even  of  pain. 
Soon  afterward  in  using  the  limbs  the  patient  observes  some  stiffness  or  that 
the  movements  are  not  so  free  and  easy  as  previously.  The  spasms  succeed, 
and,  as  in  children,  their  duration  and  severity-  vary  greatly  in  different 
patients.  In  the  adult,  as  in  the  child,  in  mild  tetany  the  contractions  are 
limited  to  the  muscles  of  the  hands,  feet,  fingers,  and  toes,  and  the  severe 
disease  usually  attacks  first  these  muscles,  and  afterwards  extends  to  the 
muscles  of  the  head,  face,  neck,  and  trunk.  Cases  might  be  cited  from  the 
literature  of  tetany  in  which  the  contractions  occurred  in  the  muscles  of  the 
face,  cau.sing  unsightly  visage,  the  motor  muscles  of  the  eye,  causing  strabis- 
mus, the  pharj'ngeal  and  laryngeal  muscles,  the  muscles  of  the  tongue  and 
diaphragm,  causing  embarrassment  of  speech,  respiration,  and  deglutition, 
sterno-cleido  and  other  muscles  of  the  neck,  changing  the  position  of  the 
head,  and  in  the  various  muscles  of  the  trunk.  In  a  case  observed  by 
Dr.  Herard  the  recti  muscles  in  the  abdominal  walls  stood  out  like  two  tense 
cords.  However  severe  the  disease  may  be,  a  marked  remission  or  distinct 
intermission  soon  occurs,  the  progress  of  tetany  being  characterized  by 
intervals  of  complete  relief.  In  not  a  few  of  the  reported  adult  cases  tetany 
has  reappeared  at  varying  intervals  during  a  series  of  years,  being  due  to  the 
recurrence  of  the  causes  which  first  produced  it. 

Pathology. — Since  tetany  in  itself  is  rarely  fatal,  only  a  few  post-mortem 
examinations  have  been  made,  and  in  these  no  lesions  have  been  discovered 
which  appeared  to  sustain  a  causal  relation  to  the  disease.  In  the  spinal  cord 
minute  hemorrhages,  points  of  apparent  myelitis,  lymphoid  cells,  hyperemia 
of  the  spinal  meninges  and  of  the  cords  in  their  upper  portions  (Bouchut), 
and  softening  of  the  cord  in  the  cervical  region,  have  been  observed  in  certain 
cases,  but  these  lesions  are  believed  to  result  from  the  excessive  functional 
activity  of  the  cord.  The  exaggerated  excitation  of  the  motor  nerves  is 
probably  also  attended  by  some  change  in  their  nutrition.  G-owers  says  that 
change  in  their  nutrition  consequent  on  their  excited  action  is  undoubtedly 
present.  He  states  that  a  nutritive  change  in  the  motor  nerve-fibres  is 
usually  consequent  on,  and  secondary  to,  a  similar  change  in  the  motor  cells 
of  the  spinal  cord,  the  axis-cylinders  of  the  nerves  being  prolonged  processes 
of  these  cells.  Slight  changes  have  been  observed  in  these  cells  in  those 
who  have  had  tetany  severely,  and  the  fact  that  this  disease  is  bilateral 
indicates  that  it  has  a  central  origin.  Growers  adds  that  the  sensory  nerves 
are  also  probably  implicated,  from  the  fact  that  sensory  symptoms  often 
precede  the  spasm  of  tetany.  As  to  the  seat  of  the  disease,  nothing  fur- 
ther is  at  present  known ;  but  Gowers  after  a  careful  survey  of  the  facts 
relating  to  the  pathology  of  tetany,  remarks  :  "  On  the  whole,  our  present 


TETAJS^T.  649 

knowledge  of  the  pathology  of  the  disease  points  to  the  nerve-cells  of  the 
spinal  cord  and  medulla  as  the  parts  chiefly  deranged,  and  the  way  in  which 
the  cells  in  rare  cases  seem  to  undergo  subsequent  atrophy  suggests  that  the 
disturbance  is  a  primary  one  of  the  cells  themselves,  and  is  not  produced  by 
the  agency  of  any  vaso-motor  mechanism.  It  is  difficult  to  conceive  that 
symptoms  of  such  definite  and  uniform  character  can  be  the  result  of  any 
vascular  spasm.  The  occasional  wasting,  with  diminished  irritability,  is 
especially  important  as  suggesting  that  the  nutritional  changes  in  the  motor- 
cells  and  fibres,  causing  the  increased  excitability,  may  sometimes  go  on  to 
structural  degeneration." 

Diagnosis. — It  may  assist  in  the  diagnosis  to  ascertain  that  the  attack 
has  immediately  followed  the  occurrence  of  one  of  the  recognized  causes  of 
tetany,  as  diarrhoea  or  other  intestinal  ailment  or  exposure  to  cold.  We  may 
diagnosticate  tetany  from  tetanus  from  the  fact  that  it  is  very  rare  under  the 
age  of  one  month,  if  indeed  it  ever  occur  in  the  newly-born,  whereas  tetanus 
almost  never  occurs  in  infancy  after  the  first  month  or  in  childhood,  nearly 
all  cases  occurring  during  the  first  three  weeks  after  birth.  It  is  also  dis- 
tinguished from  tetanus  by  the  fact  that  it  begins  in  the  extremities,  has 
periods  of  cessation  or  intermittence,  and  the  masseters,  which  in  tetanus 
early  undergo  the  peculiar  tonic  contraction,  are  not  aff"ected  or  are  affected 
only  at  a  late  stage  and  in  the  most  severe  cases. 

In  organic  disease  of  the  brain  the  contractions  do  not,  as  a  rule,  intermit, 
and  they  are  frequently  limited  to  one  side  ;  besides,  other  symptoms  clearly 
referable  to  the  brain  are  usually  present.  The  bilateral  and  symmetrical 
nature  of  tetany,  the  occurrence  of  the  contractions  in  corresponding  groups 
of  muscles  on  the  two  sides,  distinguish  the  disease  from  those  contractions 
which  occur  from  lesions  in  the  course  of  the  nerves. 

Prognosis. — Tetany,  whether  intermittent,  remittent,  or  occurring  with 
little  variation  in  the  spasms,  soon  ceases  in  some  eases  and  never  returns. 
In  other  instances  it  does  not  cease  entirely  for  months,  though  varying  in 
severity  at  different  times.  Certain  patients  have  attacks  of  it  at  intervals 
during  a  series  of  years,  their  health  being  good  when  not  affected  by  it. 
Thus  the  ease  of  a  woman  is  related  whose  first  attack  was  at  the  age  of 
twenty-two  years,  and  who  had  a  recurrence  of  the  disease  every  winter,  and 
was  still  having  it  at  the  age  of  thirty-four  years.  This  appears  to  have  been 
one  of  those  eases  which  have  been  attributed  to  a  rheumatismal  cause  inci- 
dent to  cold  weather.  Lussana  relates  a  similar  case  in  which  tetany  occurred 
each  winter  during  ten  successive  years.  In  some  instances  years  elapse 
between  the  attacks,  as  in  a  case  related  by  Choostek.  Maccall  states  that 
a  woman  had  tetany  five  times  when  wet-nursing  five  successive  children,  and 
was  well  in  the  intervals. 

During  infancy  and  childhood  tetany,  when  uncomplicated,  ends  favor- 
ably, with  possibly  now  and  then  a  rare  exception.  In  this  respect  it  con- 
trasts with  tetanus,  which,  whatever  the  age,  is,  with  few  exceptions,  fatal. 
The  few  cases  found  in  the  literature  of  this  disease  in  which  death  appar- 
ently resulted  directly  from  tetany  have  been,  so  far  as  I  have  been  able  to 
ascertain,  adults.  Dr.  Blondeau  states  that  in  Lourcine  Hospital,  Paris,  a 
young  woman  whose  health  had  been  greatly  impaired  by  syphilis  and  a  mis- 
carriage had  an  obstinate  diarrlnjea.  Tetany  set  in  with  great  violence.  The 
muscles  of  the  face,  neck,  and  chest  were  rigidly  contracted.  The  face  was 
livid,  the  eyes  fixed,  the  pulse  could  not  be  counted,  and  the  breathing  was 
labored  and  stertorous.  She  was  bled  from  the  arm.  and  subsequently  twelve 
leeches  were  ordered  to  be  applied  behind  the  ears,  but  during  their  appli- 
cation she  died.  The  post-mortem  examination,  conducted  with  great  care, 
revealed  an  apparently  healthy  state  of  all  the  organs  except  "  trace  of  con- 


650  LOCAL  DISEASES. 

gestion  in  the  meninges,  the  veins  of  which  contained  a  little  more  dark 
blood  than  usual."  Gowers  states  that  death  may  occur  in  consequence  of 
pulmonary  congestions  and  a  low  form  of  pneumonia  which  result  from 
repeated  attacks  of  tetany.  Tetany  following  excision  of  the  thyroid  is  more 
likely  to  be  fatal  than  when  it  occurs  from  other  causes.  But,  we  repeat,  so 
rarely  is  tetany  fatal  that  most  of  those  who  have  contributed  to  the  litera- 
ture of  this  disease  have  never  observed  a  fatal  case.  Muscular  weakness 
for  a  time,  and  even  more  or  less  muscular  atrophy,  occasionally  follow  an 
attack  of  tetany. 

Treatment. — The  cause  or  causes  of  the  attack,  so  far  as  they  can  be 
ascertained,  should  obviously  be  promptly  treated,  and  if  possible  removed. 
Especially  should  diarrhoea  or  any  other  abnormal  state  of  the  digestive  sys- 
tem receive  appropriate  treatment.  If  the  patient  have  been  exposed  to  cold, 
and  the  cause  be  apparently  of  a  rheumatismal  nature,  warm  baths  and 
diaphoretics,  such  as  are  employed  in  breaking  up  a  cold,  may  be  advantage- 
ously employed. 

In  the  treatment  of  the  tetany  of  children  the  bromide  of  potassium  is  a 
most  useful  remedy.  Four  grains  dissolved  in  cold  water  or  any  convenient 
vehicle  may  be  given  every  third  or  fourth  hour  to  a  child  of  from  one  and 
a  half  to  two  years.  It  is  a  safe  remedy,  and  it  usually  causes  a  diminution 
or  cessation  of  the  spasms.  Cannabis  indica,  chloral,  and  hypodermic  in- 
jections of  morphia  which  have  been  employed  in  adult  cases  with  apparent 
benefit  should  not  be  recommended  for  young  children.  It  will  be  recollected 
that  in  the  case  treated  by  Dr.  Vineberg,  related  in  a  preceding  page,  the 
infant  at  the  age  of  fifteen  months  took  one-quarter  of  a  grain  of  sulphate 
of  zinc  and  y^-g-  of  a  grain  of  sulphate  of  atropia  three  times  daily,  and  with 
this  treatment  and  a  change  of  diet  recovered  within  a  week.  Chloroform 
inhalation  has  been  used,  and  during  the  narcosis  produced  by  it  active 
massage  treatment  of  the  aifected  limbs  has  been  employed  with  apparent 
benefit.  Gowers  states  that  faradism  is  contraindicated,  and  that  the  best 
results  have  been  obtained  from  the  voltaic  current,  either  with  both  poles 
applied  to  the  spine  or  with  the  negative  pole  to  the  spine  and  the  positive 
over  the  affected  muscles.  But  the  treatment  by  electricity,  by  chloroform, 
and,  we  may  add,  by  ice  over  the  spine,  as  practised  by  Trousseau,  is  more 
applicable  to  adult  cases  than  to  children. 

A  large  proportion  of  children  having  tetany  exhibit  rachitic  symptoms, 
and  when  such  symptoms  are  present  cod-liver  oil  and  iron  should  be  pre- 
scribed, and  at  the  same  time  that  the  bromide  of  potassium  and  other  reme- 
dies designed  to  relieve  the  tetany  are  employed. 


CHAPTER    XI. 

CHOREA. 

Chorea,  St.  Vitus's  or  St.  Gruy's  dance,  is  a  neurosis  which  is  charac- 
terized by  irregular  and  involuntary  muscular  movements,  without  loss  of 
consciousness.  The  movements  occur  in  the  muscles  of  volition,  and  there 
is  probably  no  one  of  them  that  may  not  be  engaged,  though  some  are  more 
frequently  affected  than  others.     It  is  not  known  that  any  involuntary  mus- 


CHOREA.  651 

cle  is  ever  involved,  though  Sir  William  Jenner  has  expressed  the  opinion 
that  occasionally  the  papillary  muscles  of  the  heart  are,  so  that  by  their 
spasmodic  contractions  they  produce  insufficiency  of  the  mitral  valve.  This, 
according  to  him,  affords  explanation  of  the  fact  that  in  certain  instances  a 
mitral  regurgitant  murmur  is  heard,  which  disappears  about  the  time  that 
the  external  movements  cease.  It  is  rare,  however,  that  a  mitral  regurgitant 
murmur,  heard  during  chorea,  ceases  when  the  latter  terminates,  and  it  is 
not  improbable  that  in  such  cases  there  is,  after  all,  a  lesion  of  the  valve, 
due  to  recent  endocarditis,  whether  of  a  rheumatic  or  other  origin ;  for  a 
valve  may  be  so  thickened  by  recent  inflammation  as  to  cause  a  murmur,  and 
after  a  few  weeks  or  months  the  infiltrating  substance  be  so  absorbed  that 
the  murmur  is  no  longer  audible.  If  we  admit  the  fact  that  cardiac  bruits 
occasionally  appear  and  disappear  with  chorea,  this  explanation  seems  to  me 
more  plausible  than  that  of  Jenner.  Hillier  says  in  reference  to  this  sub- 
ject: "  My  own  experience  leads  me  to  doubt  the  existence  of  dynamic  apex- 
murmurs  in  chorea ;  that  is  to  say,  murmurs  produced  in  hearts  entirely  free 
from  organic  change.  If  such  murmurs  ever  occur,  they  are  certainly  rare. 
Organic  murmurs  of  the  heart,  on  the  other  hand,  are  common  in  chorea, 
and  I  am  inclined  to  believe  that  organic  disease  of  the  heart  often  exists  in 
chorea  when  there  is  no  murmur."  We  shall  see,  by  a  case  presently  to  be 
related,  that  this  opinion  is  correct.  Hillier  also  calls  attention  to  the  fact 
that  choreic  movements  are  irregular ;  but  a  cardiac  bruit  occurring  regu- 
larly and  uniformly,  if  not  due  to  organic  disease,  would  require  rhythmical 
contractions  of  the  papillary  muscles  to  produce  it.  We  infer  from  this  that 
the  bruit  does  not  have  a  choreic  origin. 

In  the  class  of  children's  diseases  in  the  Bureau  for  the  Relief  of  the  Out- 
door Poor  in  New  York  City,  16,986  children  were  ti'eated  in  the  two  years 
and  three  months  ending  with  March  31,  1877.  Of  these  cases  82,  or  1  in 
every  207,  had  chorea.  The  patients  were  all  under  the  age  of  fifteen  years. 
Statistics  published  by  observers  in  Europe  show  that  the  relative  frequency 
of  this  disease  is  probably  about  the  same  in  the  large  European  cities  as  in 
New  York.  Thus,  according  to  Hillier,  among  122,621  out-patients  treated 
at  the  Hospital  for  Sick  Children  in  London,  406,  or  1  in  322,  had  chorea, 
while  of  the  in-patients,  174  in  5585,  or  1  in  every  32,  were  choreic.  In  the 
Parisian  Hospital  for  Sick  Children,  of  84,968  admitted  in  twenty-one  years, 
531  had  chorea,  or  1  in  every  161. 

Age. — Chorea  may  occur  at  any  period  of  life,  but  a  large  majority  of  the 
cases  are  in  childhood.  It  is  rare  in  infancy  and  it  rarely  begins  after  puber- 
ty. Under  the  age  of  five  years  the  proportionate  number  diminishes  as  we 
approach  the  time  of  birth.  The  youngest  in  the  statistics  of  Hillier  was 
three  months.  In  1870,  in  the  Bureau  for  the  Out-door  Poor  a  child  was 
presented  for  treatment  who,  the  mother  said,  had  had  chorea  from  birth, 
and  in  1877,  I  treated  a  yoving  woman  with  severe  general  chorea  who, 
repeatedly  questioned,  uniformly  said  that  she  had  had  the  disease,  without 
any  assignable  cause,  from  the  first  week  of  her  life,  and  her  friends  corrobo- 
rated the  statement.  The  following  table  exhibits  the  relative  frequency  of 
chorea  at  difi'erent  ages  : 

6  years.         6  to  10         10  to  15 
and  under,      years.         years. 

Children's  Hospital,  London,  Hillier,  none  over  12  years 

admitted 81  237  104 

M.  Eufz ,10  61  118 

Bureau  for  Out-door  Poor  (prior  to  1875) 2  26  16 

At  and  under 
3  years. 

Bureau  for  Out-door  Poor  (since  January  1,  1875)     5 


3  to  5 

5  to  10 

10  to  15 

years. 

years. 

years. 

30 

337 

330 

652  LOCAL  DISEASES. 

M.  See  collected  the  statistics  of  531  cases  occurring  in  the  Children's 
Hospital.  Paris,  and  from  them  concludes  that  the  maximum  frequency  of 
chorea  is  between  the  sixth  and  tenth  years.  Only  28  of  his  cases  were 
under  six  years,  the  remainder,  503,  occurring  between  the  sixth  year  and 
puberty. 

Causes. — The  profession  are  nearly  agreed  in  regard  to  certain  causes  of 
chorea,  while  there  is  a  diversity  of  opinion  in  reference  to  others.  It  is 
admitted  that  in  a  large  proportion  of  cases  there  is  a  neuropathic  state 
which  antedates  and  predisposes  to  chorea.  This  state  is  often  manifested 
in  the  family  history  by  a  proneness  to  affections  of  the  nervous  system,  and 
in  the  individual  by  a  highly  excitable  state  of  the  emotions,  so  that  he 
evinces  joy,  grief,  or  anger  from  slight  causes. 

All  writers  admit  that  there  is  often  an  inherited  predisposition  to  chorea. 
In  27  of  48  cases,  Radcliffe  found  that  father,  mother,  brother,  or  sister  had 
been  or  was  the  subject  of  one  or  other  of  the  following  disorders :  paralysis, 
epilepsy,  apoplexy,  hysteria,  or  insanity.  The  children  of  parents  who  when 
young  had  chorea  or  who  exhibit  proneness  to  ailments  of  the  nervous  sys- 
tem are  more  liable  to  chorea  than  other  children.  Hence  the  fact,  some- 
times observed,  of  diffei'ent  children  in  the  same  family  becoming  affected 
with  chorea  when  they  attain  the  age  at  which  this  disease  ordinarily  occurs. 
In  one  family  in  my  practice  three  girls  at  different  times  were  affected. 

Sex. — The  emotions  are  strong  in  girls,  since  in  them  the  nervous  system 
predominates,  while  the  muscular  power  is  weaker  than  in  boys.  Hence  a 
partial  explanation  of  the  fact  which  statistics  fully  establish,  that  the  pro- 
portion of  choreic  boys  to  girls  is  about  in  the  ratio  of  one  to  two  and  a  frac- 
tion. I  have  remarked,  in  this  city,  the  large  proportion  of  cases  in  school- 
girls between  the  ages  of  six  and  twelve  years,  the  severe  discipline  and 
confinement  of  the  public  schools  no  doubt  increasing  the  strength  of  the 
emotions,  and  weakening  the  control  of  the  will  over  the  muscles. 

Proportion  of  Males  to  Females. 

27  to  73.  Hughes's  Digest  of  Cases  in  Guy's  Hospital,  1846. 

138  to  393.  M.  See. 

50  to  94.  Out-door  Department,  Bellevue. 

276  to  499.  Children's  Hospital,  London,  West  (Lumleian  Lectures). 

491  to  1059  =  1  to  2.15. 

The  cases  treated  in  the  Out-door  Department,  Bellevue,  since  those 
contained  in  the  above  table  occurred,  give  a  larger  percentage  of  females. 
Between  April,  1878,  and  December,  1883,  288  choreic  cases  were  treated 
in  this  department,  and  of  these  the  proportion  of  boys  to  girls  was  1  to  2.4 
(Chapin). 

Uterine  Irritation. — The  peculiar  changes  occurring  in  the  female  at 
puberty  constitute  an  important  cause.  Hence  another  reason  of  the  excess 
of  female  cases.  Dysmenorrhoea  and  pregnancy  are  causes  of  a  large  pro- 
portion of  cases  in  the  first  years  of  puberty.  In  the  male,  on  the  other 
hand,  the  changes  of  puberty  do  not  appear  to  increase  the  liability  to  the 
disease,  directly  or  indirectly,  and  male  cases  after  the  age  of  twelve  years 
are  comparatively  rare.  Radcliffe  ^  states  that  after  the  ninth  year  females 
are  more  liable  to  chorea  than  males,  in  the  proportion  of  5  to  2,  while  before 
the  ninth  year  the  two  sexes  are  equally  liable  to  it.  Carefully  prepared 
statistics,  however,  notwithstanding  the  high  authority  of  Radcliffe,  show  a 
preponderance  of  girls  under  the  age  of  nine  years,  though  not  so  great  as 
over  that  age.  In  the  Out-door  Department  at  Bellevue,  of  35  patients  under 
^  Reynolds'  System  of  Medicine. 


CHOREA.  653 

the  age  of  ten  years,  22  were  girls,  while  of  20  from  the  age  of  ten  years  to 
sixteen,  15  were  girls. 

According  to  West,^  in  775  children  with  chorea,  under  the  age  of  ten 
years,  treated  in  the  London  Children's  Hospital,  64:  per  cent,  were  girls. 

Ansemia. — Among  the  most  common  predisposing  causes  of  chorea  is 
anaemia.  It  is  present  in  so  large  a  proportion  of  cases,  exhibiting  itself  by 
pallor  of  the  countenance  and  other  characteristic  signs,  that  medicines 
designed  to  improve  the  quality  of  the  blood  are  among  the  most  efficient 
remedies.  The  peculiar  neuropathic  state  already  alluded  to,  which  needs 
only  a  slight  additional  cause  for  the  development  of  chorea,  is  no  doubt 
largely  dependent  on  impoverishment  of  the  blood,  if  it  be  not  sometimes  due 
entirely  to  it.  Among  the  poor  of  a  large  city  like  New  York  or  in  hospital 
practice  the  proportion  of  an^Bmic  cases  of  chorea  is,  for  obvious  reasons, 
much  larger  than  would  appear  from  the  general  statistics. 

jRheumatism. — Dr.  Copeland,  M.  Bouteille,  and  afterward  M.  Germain 
See  in  a  more  extended  monograph,  directed  the  attention  of  the  profession 
to  rheumatism  as  a  cause  of  chorea.  Subsequent  observations  have  estab- 
lished the  fact  that  rheumatism  or  the  rheumatic  diathesis  is  so  frequently 
present  that  it  obviously  sustains  an  important  relation  to  chorea,  though  in 
what  manner  is  not  fully  ascertained.  This  relation  between  the  two  is  more 
frequently  observed  in  some  countries  than  in  others.  In  England  and 
France  so  large  a  proportion  of  choreic  patients  present  a  history  of  rheu- 
matism, either  in  themselves  or  family,  that  certain  physicians  of  these  coun- 
tries believe  that  rheumatism  is  the  most  common  cause  of  the  disease.  In 
Germany,  on  the  other  hand,  according  to  Romberg,  in  the  majority  of  cases 
no  relation  can  be  traced  between  chorea  and  rheumatism.  Probably  the 
largest  number  of  choreic  cases  treated  in  one  institution  in  this  country  is  in 
the  Bureau  for  the  Relief  of  the  Out-door  Poor  in  this  city ;  and  it  has  been 
our  practice  during  the  last  few  years  to  examine  each  patient  for  heart  dis- 
ease and  question  the  parents  as  regards  rheumatism.  Without  referring  to 
the  exact  statistics,  I  should  say  that  at  least  one-third  give  the  history  of 
rheumatism  in  themselves  or  parents  or  had  unequivocal  signs  of  heart  dis- 
ease. One  of  the  physicians  of  the  class  found  that  22  in  38  consecutive 
cases  of  chorea  gave  the  history  of  rheumatism  or  of  heart  disease  in  them- 
selves or  parents. 

Various  theories  have  been  promulgated  in  explanation  of  the  relationship 
of  the  rheumatic  and  choreic  diseases.  It  has  been  suggested  that  chorea  is 
due  to  rheumatism  of  the  brain  or  spinal  cord.  This  is  simply  an  hypothesis, 
the  truth  or  falsity  of  which  can  only  be  ascertained  by  carefully-conducted 
necropsies ;  but  the  theory  appears  improbable  in  view  of  all  the  facts. 
Another  theory  attributes  chorea  to  the  state  of  the  blood  which  is  present 
in  those  having  rheumatism  or  the  rheumatic  diathesis,  as  well  as  in  certain 
other  conditions.  This  theory  is  enunciated  by  Dr.  Ogle  as  follows  :  ''  Recog- 
nizing the  frequent  existence  of  these  fibrinous  deposits  or  granulations  on 
the  heart's  valves  in  chorea,  I  should  be  much  inclined  to  look  upon  these 
post-mortem  appearances  rather  as  results  of  some  antecedent  general  con- 
dition of  the  blood  common  also  to  the  choreic  condition.  It  is  very  freely 
recognized  that  this  afi^ection  is  frequently  in  some  way  or  other,  connected 
with  that  condition  of  blood  which  obtains  in  what  we  call  anaemia  or  that 
existing  in  rheumatic  constitutions.  In  both  of  these  states  we  know  that 
the  fibrin  of  the  blood  is  much  in  excess  (as  also  it  is  in  pregnancy,  another 
condition  looked  upon  as  obnoxious  to  chorea)  ;  and  in  these  states  we  know 
that  the  fibrin  with  which  the  blood  is  surcharged  is  very  prone  to  be  readily 
precipitated,  either  owing  to  its  superabundance  or  from  other  obscure  and 

^  Lumleian  Lectures. 


654  LOCAL  DISEASES. 

acquired  properties,  ....  upon  the  heart's  walls  or  valves.  May  not  this 
hyperinosis  be  the  explanation  of  the  coincidence  alluded  to?"' — namely,  the 
occurrence  of  chorea  in  those  affected  with  rheumatism.  Others  still  hold 
that  chorea  is  the  result  of  the  heart  disease,  and  not  directly  of  rheumatism, 
occurring  when  the  heart  is  affected  from  other  causes  as  well  as  when  the 
lesion  has  a  rheumatic  origin.  This  theory  is  plausible,  and  probably  to  a 
certain  extent  correct.  Heart  lesions  observed  in  children  result  from  scarlet 
fever  in  a  considerable  proportion  of  cases,  though  it  is  true  that  the  endo- 
carditis and  pericarditis  of  scarlet  fever  are  believed  often  to  have  a  rheumatic 
origin,  occurring  in  some  instances  from  scarlatinous  rheumatism,  but  in  other 
cases  from  scarlatinous  uraemia.  Occasionally  also  the  heart  disease  appears 
to  have  occurred  independently  of  both  rheumatism  and  scarlet  fever.  Thus 
in  a  fatal  case  of  chorea  with  valvular  disease  related  to  the  London  Patho- 
logical Society,  April  6,  1869,  the  child  was  always  healthy  up  to  the  present 
illness  (chorea),  and  there  was  no  history  of  rheumatism  in  the  family.  The 
more  observations  accumulate  the  more  important  does  heart  disease  in  itself 
appear  as  a  cause  of  chorea.  In  nearly  all  recorded  cases  of  fatal  chorea 
which  were  supposed  to  be  due  to  rheumatism,  and  in  which  post-inortem 
examinations  were  made,  endocardial  and  usually  valvular  disease  has  been 
found.  We  shall  see  that  certain  eccentric  causes  of  irritation  aid  in  pro- 
ducing chorea,  and  may  not  the  valvular  disease  or  the  endocarditis  which 
causes  the  valvular  lesion  operate  in  a  similar  manner  as  a  cause?  We  know 
that  in  the  adult  severe  cardiac  disease  often  profoundly  affects  the  nervous 
system,  perhaps  in  consequence  of  the  irregular  and  embarrassed  circulation, 
and  certainly  in  the  child  a  similar  cause  would  be  likely  to  produce  a  more 
decided  effect. 

But  there  is  an  ingenious  theory  which  attributes  chorea  to  minute  emboli 
detached  from  vegetations  on  the  valves,  and  arrested  by  capillaries  in  the 
corpora  striata  or  other  portion  of  the  cerebro-spinal  axis.  Since  attention 
was  directed  to  this  matter,  emboli  have  been  found  in  one  case  in  the 
medulla  oblongata,  although  this  portion  of  the  spinal  axis  appeared  healthy 
to  the  naked  eye.  Further  observations  are  necessary  in  order  to  determine 
how  much  truth  there  is  in  this  theory ;  but  it  seems  probable,  for  reasons  to 
be  stated,  that  if  capillary  embolism  do  cause  chorea,  it  is  only  in  a  limited 
number  of  cases,  and  that  therefore  those  British  observers  who  regard  it  as 
the  common  cause  have  been  led  into  error  by  the  large  proportion  of  choreic 
cases  which  in  their  climate  are  complicated  by  valvular  lesions. 

That  embolism  is  not  a  common  cause,  if  indeed  a  cause  at  all,  appears 
probable  from  the  following  facts :  First.  In  many  cases  of  chorea  there  are 
no  vegetations  or  other  appreciable  lesions  which  could  give  rise  to  emboli. 
Secondly.  Most  patients  recover,  and  some  speedily,  by  treatment,  which  we 
would  not  expect  if  the  cause  were  embolism.  Thirdly.  Embolism  is  not 
infrequent  in  the  cerebral  vessels  of  the  adult  without  the  occurrence  of 
chorea.  Indeed,  the  conditions  which  produce  embolism  are  much  more 
common  in  adults  than  in  children,  while  the  reverse  is  true  as  regards  the 
liability  to  chorea.  Fourthly.  Dogs  sometimes  have  chorea,  but  the  injection 
of  minutely  divided  fibrin  or  other  substance  into  the  veins  of  the  dog  is  not 
followed  by  chorea  as  one  of  the  phenomena.  Fifthly.  Were  capillary  emboli 
the  cause,  we  would  expect  to  find  an  occasional  embolus  in  the  larger  vessels 
of  the  brain,  so  as  to  be  appreciable  to  the  naked  eye  ;  but  I  find  no  examples 
of  this  in  all  the  recorded  autopsies  which  I  have  been  able  to  consult. 
Moreover,  it  seems  improbable  that  capillary  embolism,  when  producing  no 
lesion  appreciable  to  the  naked  eye,  would  so  arrest  the  circulation  and  dis- 
turb the  function  of  the  brain  or  spinal  cord  as  to  cause  chorea,  for  the  ill- 
'  British  and  Foreign  Med.-Chir.  Rev.,  January,  1868. 


CHOREA.  655 

effects  of  sucli  an  obstruction  would  be  likely  to  be  obviated  by  the  numerous 
anastomoses. 

In  1877  the  unusual  opportunity  occurred  in  my  asylum  practice  of  deter- 
mining whether  there  are  any  fixed  anatomical  characters  in  the  cerebro-spinal 
axis  in  chorea ;  in  other  words,  whether  chorea  is  a  neurosis,  as  we  have 
designated  it  in  our  definition,  and  the  case  is  so  interesting  in  other  respects 
that  I  shall  relate  it  entire : 

Case. — Charles  ,  a  foundling,  born  October  15,  1874,  was  received  in  the 

New  York  Foundling  i^sylum  soon  after  his  birth.  "When  two  weeks  old  he  was 
removed  to  a  family  in  the  city  to  be  wet-nursed.  His  health  continued  good  till 
the  age  of  three  months,  when  he  had  bronchitis  and  keratitis,  the  former  mild 
and  lasting  only  a  few  days,  but  the  latter  continuing  nearly  two  months,  being 
attended  by  moderate  injection  of  the  conjunctiva,  with  some  purulent  discharge, 
which  caused  adhesion  of  the  eyelids  during  sleep.  From  this  time  he  remained 
well,  with  the  exception  of  a  slight  attack  of  dysentery,  till  the  age  of  about  nine 
and  a  half  months,  when  he  began  to  have  febrile  symptoms.  In  the  morning 
hours  he  seemed  in  tolerable  health,  but  at  mid-day  or  a  little  later  than  mid-day 
of  each  day  he  was  observed  to  have  slight  irregularity  or  embarrassment  of 
respiration  and  lividity,  with  coolness  of  the  extremities  ;  which  state,  supposed 
at  the  time  to  be  the  algid  stage  of  a  somewhat  irregular  intermittent  fever,  lasted 
from  one  to  two  or  three  hours,  and  was  succeeded  by  fever,  which  continued  during 
the  remainder  of  the  day ;  sometimes  the  fever  abated  in  perspiration. 

On  August  4,  1875,  a  few  days  after  the  commencement  of  these  irregular  febrile 
symptoms,  Charles  was  brought  to  the  dispensary  of  the  institution  for  treatment, 
and  Dr.  Reid,  who  was  on  duty  that  day,  carefully  examined  the  case  and  pre- 
scribed the  sulphate  of  quinia.  This  medicine,  continued  a  few  days,  relieved  the 
symptoms,  but  every  four  to  six  weeks,  for  more  than  a  year,  the  febrile  attacks 
returned,  and  were  uniformly  relieved  by  the  same  medicine.  In  other  respects 
the  patient  had  the  usual  health. 

On  or  about  February  1,  1878,  the  nurse  noticed  that  Charles  had  what  she 
designated  "spells  of  trembling,"  in  which  he  seemed  excited  and  feverish,  and 
which  were  sometimes  attended  or  followed  by  perspiration.  In  the  course  of 
another  week  the  irregular  muscular  movements  became  more  marked  and  constant, 
and  they  increased  in  severity  till  near  the  time  of  the  admission  of  the  patient  into 
the  asylum,  about  March  1st.  The  nurse  had  noticed  in  February  slowness  and 
some  difficulty  of  micturition,  and  Dr.  Reid  examined  him  with  a  catheter  for 
calculus,  and  also  his  prepuce  for  any  source  of  irritation,  but  nothing  abnormal 
was  discovered,  either  in  the  condition  of  the  bladder  or  the  external  organs.  In 
the  latter  part  of  April  the  chorea  had  become  so  severe  that  irregular  muscular 
action  occurred  in  all  the  limbs  and  in  the  muscles  of  the  eyes,  producing  such 
grimaces  and  contortions,  with  strabismus,  that  the  woman  with  whom  he  was 
boarding  became  alarmed,  and  returned  him  to  the  asylum,  stating  that  he  had 
become  crazy. 

On  March  12th  my  attention  was  first  called  to  this  child,  when  I  made  the  fol- 
lowing entry  in  my  note-book  :  Family  history  unknown  ;  no  history  of  rheumatism 
in  patient's  case ;  he  may  or  may  not  have  had  it ;  heart  sounds  normal ;  pulse  104 ; 
all  the  limbs  and  the  muscles  of  the  face,  eyes,  and  eyelids  involved  in  choreic 
movements,  which  continue  constantly  except  during  sleep.  The  patient  cannot 
walk  or  stand  without  support :  appetite  good,  apparently  better  than  in  health, 
for  he  eats  every  kind  of  food  handed  to  him,  and  carries  the  food  with  his  own 
hand  to  his  mouth,  although  these  movements  are  very  irregular  and  jerking. 
Three  drops  of  Fowler"s  solution  ordered  after  each  meal. 

3Iarch  17th. — Condition  not  much  changed,  but  perhaps  slight  improvement ; 
in  addition  to  other  choreic  movements  the  eyes  twitch  spasmodically;  pulse  84, 
temperature  98^° ;  bowels  irregular ;  no  cough  ;  appetite  good :  increase  medicine 
to  five  drops. 

30th. — The  urine  examined  since  the  last  record  was  found  very  pale  and 
abundant ;  its  specific  gravity  low,  1004,  without  albumen.  When  an  equal  quan- 
tity of  nitric  acid  was  added  to  it,  after  twelve  hours  crystals  of  nitrate  of  urea 
occupied  about  one-half  of  the  volume  of  the  urine.  The  patient's  sleep  is  quiet, 
but  the  choreic  movements  recommence  as  soon  as  he  awakens,  but  in  a  milder 


656  LOCAL  DISEASES. 

form  ;  is  able  to  walk  without  support,  but  with  unsteady  gait.  My  term  of 
service  ended  March  31st.  On  the  following  day  laryngo-tracheitis  was  suddenly 
developed,  ending  fatally  in  forty-eight  hours  at  the  age  of  two  years  five  and  a 
half  months. 

Autojjsy,  April  4th. — Slight  oedema  about  the  aperture  of  the  glottis;  general 
and  intense  redness  of  mucous  membrane  of  larynx,  trachea,  and  bronchial  tubes ; 
as  far  as  they  can  be  traced,  posterior  portions  of  lungs  greatly  congested.  The 
heart,  lungs,  brain  with  one  eye  attached  to  it  by  optic  nerve,  and  the  entire  spinal 
cord  were  sent  to  Prof.  Francis  Delafield,  for  microscopic  examination.  They  were, 
as  soon  as  removed,  placed  in  a  solution  of  bichromate  of  potassium.  The  follow- 
ing is  a  Ijrief  statement  of  the  examination  which  was  made : 

Microscopic  Appearances.  By  Prof.  Francis  Delafield. — Brain  presented  no 
change  apparent  to  the  naked  eye  except  a  considerable  degree  of  congestion.  It 
was  hardened  in  bichromate  of  potassium  and  chromic  acid.  Minute  examination 
of  the  convolutions  of  the  brain,  the  large  ganglia,  the  cerebellum,  the  pons  Varolii, 
and  the  medulla  oblongata  showed  nothing  except  a  uniform  filling  of  the  vessels 
with  blood,  as  if  they  were  injected.  There  were  no  apoplexies,  no  changes  in  the 
walls  of  the  vessels. 

Spinal  cord  appeared  to  be  entirely  normal. 

The  Heart. — The  auricles  and  ventricles  were  of  normal  size.  The  aortic  valves 
were  atheromatous  and  somewhat  rigid  ;  the  mitral  valves  were  thickened  and  insuf- 
ficient ;  the  endocardium  of  the  left  ventricle  was  thickened. 

The  Lungs. — The  capillaries  in  the  walls  of  the  air-vesicles  were  dilated,  and 
there  was  an  increase  of  epithelial  cells  within  the  air-vesicles. 

In  this  case  there  seemed  to  be  no  lesion  associated  with  the  chorea  except  the 
organic  disease  of  the  heart  and  the  changes  in  the  lungs  secondary  to  this  condition 
of  the  heart. 

The  above  microscopic  examination  was  made  with  sufBcient  minuteness,  and 
it  is  seen  that  no  emboli  were  discovered  and  no  lesion  of  the  cerebro-spinal  axis 
except  congestion,  which  was  attributable  to  the  mode  of  death — namely,  by 
obstructed  respiration.  Moreover,  it  will  be  recollected  that  there  were  no  cardiac 
bruits,  and  apparently  not  sufficient  roughness  of  the  edge  or  surface  of  the  valves 
to  cause  precipitation  of  fibrin,  which  would  be  necessary  in  order  that  emboli 
should  form. 

Fright. — A  not  infrequent  cause  of  chorea  is  sudden  and  profound  emo- 
tion, especially  fright.  All  statistics  give  fright  as  the  cause  of  a  certain 
proportion  of  cases,  though  there  are  usually  other  potential  co-operating 
causes,  as  anaemia  or  valvular  disease.  Fright  was  stated  as  the  cause  of 
chorea  in  31  of  the  100  eases  occurring  in  Guy's  Hospital  reported  by 
Hughes,  or  nearly  1  in  3.  But  the  statistics  of  other  observers  do  not  give 
so  large  a  proportion  of  cases  originating  in  this  way.  Chorea  may  commence 
within  a  few  hours  after  the  fright  or  not  till  the  lapse  of  several  days  (eight 
or  ten).  If  several  weeks  have  passed  since  the  fright,  as  in  some  reported 
cases,  the  chorea  is  probably  due  to  other  causes.  In  rare  instances  chorea  is 
said  to  have  been  caused  by  sudden  and  excessive  joy. 

Imitation. — Under  unusual  circumstances,  especially  in  a  state  of  great 
mental  excitement,  imitation  has  been  known  to  cause  a  form  of  chorea. 
Hecker  describes  an  epidemic  of  it  occurring  in  the  Middle  Ages  and  spread- 
ing through  villages.  In  modern  times  it  is  rare  that  chorea  originates  from 
this  cause,  nevertheless  occasional  examples  have  been  recorded. 

But  the  disease  which  occurs  from  imitation  diifers  from  the  ordinary  form 
and  has  been  termed  chorea  major,  while  the  chorea  which  is  the  subject  of 
this  article  is  sometimes  designated,  in  contradistinction,  chorea  minor. 

In  chorea  major  the  patient  leaps,  dances,  or  whirls  like  a  top.  It  has  its 
origin  commonly  in  religious  excitement,  and  spreads  by  imitation  almost  in 
the  manner  of  an  infectious  disease.  The  epidemic  of  the  Middle  Ages  was 
a  chorea  major.  I  have  not  been  able  to  find  any  account  of  cases  spreading 
by  imitation  in  modern  times  which  were  not  examples  of  the  same  form  of 
chorea.     Thus  in  the  Edinburgh  Journal  of  Medicine  and  Surgery,  for  July, 


CHOREA.  657 

1839,  there  is  a  clear  description  of  chorea  major  occurring  successively  in 
five  children  in  the  same  family.  Dr.  Dewar,  the  attending  physician,  states 
that  one  of  the  children  whom  he  was  called  to  see  was  sitting  near  the  fire- 
place, when  her  head  dropped  on  her  chest  and  she  appeared  to  doze  for  some 
minutes.  In  the  mean  time  the  respiration  became  a  little  accelerated,  the 
face  altered  and  flushed,  the  eyes  wild.  In  less  than  one  minute  she  bounded 
from  one  extremity  of  the  apartment  to  the  other,  leaping  over  chairs,  a  chest, 
and  then  throwing  herself  upon  the  floor ;  she  attempted  to  stand  upon  her 
head,  rolled  upon  the  floor,  and  then,  rising,  i-au  with  extreme  swiftness  in 
the  room,  till  she  finally  fell  again  upon  the  floor,  where  she  remained  motion- 
less some  minutes.  Then,  recovering,  she  noticed  those  who  surrounded  her, 
and  asked  of  her  sister  a  toy  which  she  had  allowed  to  fall.  The  whole 
paroxysm  lasted  twenty  minutes. 

Obviously,  the  symptoms  of  chorea  major  difi"er  materially  from  those  of 
chorea  minor,  and  it  is  a  question  whether  it  should  have  the  same  generic 
name.  It  is  a  curious  and  interesting  disease  in  its  psychical  and  pathologi- 
ical  aspect,  but  it  is  so  rare  in  modern  times  that  a  knowledge  of  it  is  of  little 
practical  importance. 

Intestinal  Irritation. — In  rare  instances  intestinal  worms  cause  chorea, 
though  in    these  cases  there    have  usually  been   some  co-operating  causes. 

The  following  is  an    example  related   by  Mr.  Ogle  :  ^  "  Ellen  L ,   nine 

years  old,  had  been  under  treatment  about  a  month  with  chorea,  rheuma- 
tism, and  worms.  She  had  not  slept  in  four  days,  and  there  was  constant 
spasmodic  movement  of  the  body  and  face.  Her  general  condition  was  very 
unpromising.  As  she  had  passed  portions  of  a  tape-worm  at  intervals  during 
the  last  three  months,  one  drachm  of  the  oleum  filicis  maris  was  administered  in 
mucilage,  which  caused  the  expulsion  of  the  entire  worm.  From  that  time  she 
fully  and  rapidly  recovered  from  the  chorea,  though  a  mitral  murmur  remained." 

Lesions  of  Brain  and  Spinal  Cord. — Although  we  reject  the  theory  that 
cerebral  emboli  are  the  common  cause  of  chorea,  and  believe  that  in  a  large 
majority  of  cases  there  are  no  cerebro-spinal  lesions,  nevertheless  experi- 
ments and  also  occasional  cases  establish  the  fact  that  if  not  true  chorea,  at 
least  choreiform  movements  now  and  then  result  from  a  structural  aff"ection 
of  the  nervous  centres. 

Experiments  on  certain  of  the  lower  animals  demonstrate  that  irregular 
muscular  movements  may  be  produced  by  traumatic  injury  of  certain  por- 
tions of  the  cerebro-spinal  axis,  as  the  corpora  quadrigemina,  crura  cerebri, 
pons  Varolii,  crura  cerebelli,  thalami  optici,  parts  of  the  medulla  oblongata, 
and  the  upper  portion  of  the  spinal  cord.  Pressure  on  the  pi'ojecting  part 
of  the  medulla  oblongata  of  an  acephalous  monster  also  causes  convulsive 
movements.  At  the  meeting  of  the  New  York  Academy  of  Medicine,  April 
20,  1871,  Professor  Post  related  the  case  of  a  child  who  was  struck  over  the 
occiput  with  a  billet  of  wood,  and  chorea  followed,  due,  in  all  probability,  to 
the  injury  of  the  brain  which  resulted. 

If  irregular  muscular  movements,  choreic  or  choreiform,  result  from  trau- 
matic injury  of  certain  portions  of  the  nervous  centres,  may  they  not  also 
occasionally  occur  from  lesions  of  the  same  parts  produced  by  disease  ?  Sir 
Benjamin  Brodie "  relates  the  case  of  a  choreic  girl  dying  in  St.  George's 
Hospital,  in  whom,  after  a  careful  post-mortem  examination,  the  only  morbid 
appearance  observed  was  a  tumor  the  size  of  a  hazlenut  connected  with  the 
pineal  gland.  Dr.  Broadbent^  described  another  case  before  the  London 
Pathological  Society  in  which  a  tumor  was  found  arising  from  the  centre  of 
the  spinal  cord  ;  and  Chambers  one  in  which  tubercles  were  imbedded  in  the 

^London  Medico-Chir.  Rev.,  Jan.,  1868.  '^London  Lancet,  Dec.  19,  1840. 

^  Transactions  London  Pathological  Society,  vol.  xiii.  p.  246. 

42 


658  LOCAL  DISEASES. 

cord.  Komberg  quotes  from  Frerichs  a  case  in  which  the  medulla  oblongata 
was  pressed  upon  by  an  enlarged  odontoid  process  ;  and  Dr.  Aitkin '  one  in 
which  the  specific  gravity  of  the  thalamus  opticus  and  corpus  striatum  was 
greater  on  one  side  than  on  the  other.  Ptilliet  and  Barthez  relate  other  simi- 
lar cases,  and  they  remark :  "  We  may  conclude  from  these  different  cases 
that  there  exist  two  species  of  chorea — the  one  essentially  a  simple  neurosis, 
while  the  other  depends  on  an  alteration  of  the  encephalo-rachidian  system. 
In  a  word,  it  is  of  chorea  as  of  convulsions,  that  it  is  sometimes  idiopathic, 
sometimes  symptomatic."  Still,  the  cases  in  which  it  is  symptomatic  are  so 
few  that  it  is  proper  to  consider  chorea,  as  it  ordinarily  occurs,  one  of  the 
neuroses  until  the  microscope  detects  some  anatomical  cause  in  the  cerebro- 
spinal system  of  which  we  are  now  ignorant. 

Anatomical  Characters. — We  have  seen  that  chorea  has  no  constant 
anatomical  characters.  Lesions  which  probably  sustain  a  causal  relation  to 
the  disordered  muscular  action  are  sometimes  present,  and  others  are  some- 
times observed  which  are  neither  a  cause  nor  a  result,  their  presence  being 
a  coincidence.  But  there  are  two  lesions  which,  though  often  absent,  have 
been  observed  in  so  large  a  proportion  of  fatal  cases  that  they  are  justly 
regarded  as  an  occasional  result  when  chorea  is  severe.  Dr.  Hughes  of 
London  collected  records  of  the  post-mortem  appearances  of  14  cases,  with 
the  following  result  as  regards  the  cerebro-spinal  axis :  Brain,  14  cases ; 
healthy,  4  cases  ;  only  congested,  3  cases ;  softened  in  part  or  entirely,  6 
cases  (some  of  these  6  also  congested).  In  some  of  the  14  cases  those  occa- 
sional results  of  congestion — to  wit,  transudation  of  serum  and  extravasa- 
tion of  blood  in  greater  or  less  quantity — were  also  observed.  Spinal  cord : 
healthy,  3  cases  ;  congested,  2  cases  (one  slightly,  in  the  other  the  engorged 
vessels  were  large  and  numerous)  ;  softening  in  medulla  oblongata,  1  case ; 
softening  opposite  fourth  and  fifth  vertebrae,  12  cases.  In  1  there  was  soft, 
in  another  firm,  adhesion  of  the  spinal  meninges,  and  in  1  it  is  stated  that 
the  rachidian  fluid  was  opaque.  Of  16  fatal  cases  of  chorea  occurring  in 
St.  George's  Hospital,  "  congestion  (more  or  less  complete)  of  the  nervous 
centres  (brain  or  spinal  cord,  or  both)  was  met  with  in  6  cases."  Softening 
of  certain  parts  of  the  brain  was  observed  in  1  case,  and  of  the  spinal  cord 
in  another."  Other  statistics  of  the  anatomical  character  of  fatal  chorea 
correspond,  in  the  main,  with  those  of  Hughes  and  Ogle.  The  lesions 
observed  by  them  are  probably  not  present  in  ordinary  cases,  occurring  only 
when  the  choreic  movements  are  so  severe  that  the  patient  is  deprived  of 
needed  repose  and  the  important  functions  of  the  economy,  as  circulation  and 
nutrition,  are  seriously  disturbed. 

The  post-mortem  examination  of  other  parts  besides  the  cerebro-spinal 
axis  furnishes  a  negative  result,  if  we  except  such  aff"ections  as  have  been 
ascertained  to  act  as  causes  of  chorea.  What  portion  of  the  nervous  centre 
is  chiefly  involved  in  chorea  is  uncertain.  Some,  as  Sir  Benjamin  C.  Brodie,^ 
consider  chorea  a  disease  of  the  nervous  system  generally,  while  others  have 
attributed  it  to  disease  or  disorder  of  a  certain  part,  as  the  corpus  striatum, 
cerebellum,  etc.  Finally,  it  is  stated  that  in  late  experiments  on  choreic 
dogs  the  movements  do  not  cease  when  the  spinal  cord  is  severed  from  the 
brain,  nor  also  on  division  of  the  posterior  roots  of  the  spinal  nerves.*  In 
these  cases,  therefore,  the  part  of  the  axis  which  is  in  fault  would  appear  to 
be  solely  the  spinal  cord. 

^  Glasgoiv  Medical  Journal,  vol.  i. 
^  Ogle  :  Brit  and  For.  Medicn-Chir.  Rev.,  Jan.,  1868. 
'  London  Lancet,  Dec.  19,  1840. 

*  Legros  et  Onimus  :  "  Rech.  sur  les  Movements  chor^iforms  du  Chien,"  Acad,  des 
Sci.,  9  Mai,  1870,  Lyons  Med.  Jour.,  June  5,  1870. 


CHOREA.  659 

Symptoms. — Chorea  is  partial  or  general.  It  is  partial  when  it  affects  a 
few  muscles  or  groups  of  muscles,  as  those  of  one  arm,  the  face  or  neck,  or 
of  one  eye.  It  is  designated  general  when  all  the  limbs  and  certain  of  the 
muscles  of  the  face  and  trunk  are  involved.  Statistics  show  that  partial 
chorea  occurs  more  frequently  on  the  left  than  on  the  right  side,  and  in  gen- 
eral chorea  the  movements  on  the  left  side  usually  predominate.  The  com- 
mencement is  in  most  cases  gradual.  Even  when  finally  chorea  becomes 
general,  certain  muscles  only  are  affected  in  the  commencement  in  ordinary 
cases.  The  child  in  whom  this  disease  is  about  to  begin  is  observed  to  be 
fretful  and  impatient  from  slight  causes,  and  the  irregular  muscular  action 
is  sometimes  misunderstood  by  the  parents,  who  reprimand  him  for  his  sup- 
posed fidgety  habit.  In  exceptional  instances,  especially  when  the  cause  is 
a  sudden  and  profound  emotion,  the  commencement  is  abrupt,  and  the  disease 
is  severe  and  general  from  the  first. 

In  a  majority  of  cases  the  muscles  which  are  primarily  affected  are  those 
of  the  face,  neck,  fingers,  or  hand  on  the  left  side.  Sydenham  erred,  unless 
the  clinical  history  of  chorea  has  changed  during  the  last  two  centuries,  when 
he  stated  as  the  common  fact  that  a  tottering  gait  is  its  first  manifestation, 
but  now  and  then  such  a  case  does  occur.  Whenever  choreic  movements 
appear  other  muscles  besides  those  first  affected  are  soon  involved,  so  that  in 
the  course  of  a  few  weeks,  sometimes  of  a  few  days,  all  the  muscles  that 
participate  are  engaged. 

A  muscle  affected  by  chorea  alternately  contracts  and  relaxes,  but  less 
forcibly  and  rapidly  than  in  eclampsia,  and  the  movement  is  partly  controlled 
by  volition.  This  produces  an  unsteady  and  tremulous  action  of  the  part, 
whether  a  limb,  the  neck,  or  the  face,  which  at  once  arrests  attention  and 
indicates  the  nature  of  the  disease.  The  result  is  similar,  as  regards  the 
muscular  action,  whether  the  patient  wills  a  movement  or  attempts  to  control 
those  which  chorea  produces. 

If  the  case  be  of  ordinary  severity,  the  movements  continue  with  but 
momentary  intermis.sions,  except  during  sleep,  when  they  ordinarily  cease. 
In  grave  cases  patients  are  often  deprived  of  the  proper  amount  of  sleep  in 
consequence  of  the  severity  and  persistence  of  the  muscular  action,  and  in 
exceptional  instances,  especially  when  the  result  is  fatal,  the  movements  con- 
tinue in  sleep,  but  the  sleep  is  not  sound  and  is  frequently  interrupted.  In 
profound  sleep  the  muscles  are  always  in  repose. 

The  older  writers  have  left  us  graphic  descriptions  of  those  diseases  which 
have  striking  external  manifestations,  though  often  with  somewhat  of  exag- 
geration. Sydenham  says  of  chorea  :  ''  The  patient  cannot  keep  it  (his  hand) 
a  moment  in  the  same  place  ;  whether  he  lay  it  upon  his  breast  or  any  other 
part  of  his  body,  do  what  he  may,  it  will  be  jerked  elsewhere  convulsively. 
If  any  vessel  filled  with  drink  be  put  into  his  hand,  before  it  reaches  his 
mouth  he  will  exhibit  a  thousand  gesticulations,  like  a  mountebank.  He 
holds  the  cup  out  straight,  as  if  to  move  it  to  his  mouth,  but  has  his  hand 
carried  elsewhere  by  sudden  jerks.  Then,  perhaps,  he  contrives  to  bring  it 
to  his  mouth,  and  if  so,  he  will  drink  the  liquid  off  at  a  gulp,  just  as  if  he 
were  trying  to  amuse  the  spectators  by  his  antics." 

In  severe  general  chorea  a  similar  description  is  applicable  to  the  move- 
ments of  the  legs  and  features.  Grimaces  and  distortions  of  the  features 
occur,  while  the  gait  is  halting  and  unsteady,  or  it  is  impossible  to  walk,  and 
the  patient  lies  or  sits.  The  speech  is  slow,  thick,  and  indistinct  in  conse- 
quence of  the  muscles  of  the  tongue  and  larynx  becoming  engaged,  and  even 
mastication  and  deglutition  are  rendered  difficult.  The  imperfect  speech  in 
chorea  is  attributed  partly,  however,  to  the  mental  state  in  severe  protracted 
cases.     Chorea,  except  when  mild,  is  accompanied  by  other  symptoms  refer- 


660  LOCAL  DISEASES. 

able  to  the  nervous  system.  More  or  less  impairment  of  the  mental  faculties 
occurs  in  chronic  cases  when  severe,  exhibiting  itself  in  dulness  or  apathy. 
The  countenance  sometimes  presents  in  aggravated  cases  almost  the  appear- 
ance of  idiocy.  The  muscles,  instead  of  becoming  hypertrophied  and  more 
powerful  by  their  frequent  contraction,  grow  softer,  more  flabby,  and  weaker. 
Indeed,  a  partial  paralysis  sometimes  results,  so  that  a  degree  of  numbness  is 
experienced  in  the  affected  part  and  the  limb  when  raised  cannot  be  sustained. 
Pain  is  not  a  symptom  of  chorea,  but  fugitive  rheumatic  or  neuralgic  pains 
are  sometimes  experienced.  Derangement  of  the  digestive  function,  exhibited 
by  a  poor  or  capricious  appetite,  constipation,  etc.,  are  common. 

In  rare  instances  chorea  affects  the  respiratory  muscles  so  as  to  produce  a 
peculiar  involuntary  barking  or  squeaking  voice  by  the  forcible  expulsion  of 
air  over  the  tense  vocal  cords.  In  a  case  treated  by  Dr.  L.  C.  Gray  in  the 
N.  Y.  Polyclinic  the  patient,  a  boy  of  fifteen  years,  had  been  choreic  since 
his  seventh  year,  and  chorea  in  its  usual  form  had  continued  one  year  when 
the  barking  sound  commenced,  and  this  has  continued  until  the  present  time. 
Dr.  French  of  Brooklyn  also  treated  a  similar  case,  having  the  following  his- 
tory :  A  boy  of  nine  years  had  choreic  twitchings  of  the  facial  muscles  at 
the  age  of  five  years.  After  continuing  several  months,  they  ceased  during 
an  entire  winter,  after  which  the  peculiar  sound  of  the  voice,  resembling  the 
squeak  of  a  young  turkey,  commenced.  It  occurred  at  the  beginning,  middle, 
or  end  of  respiration.  It  alternated  with  choreic  movements  of  other  parts 
of  the  system,  so  that  when  they  ceased  it  returned.  By  the  laryngoscope 
the  irregular  action  of  the  vocal  cords  was  observed,  but  the  expiratory  mus- 
cles of  the  chest  were  also  involved,  so  as  to  produce  the  peculiar  sound  by 
the  forcible  expulsion  of  air.  In  Dr.  French's  case  these  vocal  sounds  ceased, 
except  at  rare  intervals,  after  three  months  of  medicinal  treatment.^ 

The  urine  of  choreic  patients  has  been  examined  by  Drs.  Walsh,  Ford, 
Bence  Jones,  Handfield  Jones,  Radcliffe,  and  others,  and  its  elements  have 
been  found  in  most  cases  to  vary  from  their  normal  quantity.  Dr.  Handfield 
Jones  ^  read  a  paper  before  the  Clinical  Society  of  London  in  1871  on  two 
cases  of  chorea  in  which  he  had  made  careful  chemical  analysis  of  the  urine, 
with  the  following  result :  During  the  height  of  the  disease  the  amount  of 
the  urine  was  much  in  excess  of  what  it  was  when  the  disease  had  ceased ; 
the  urea  excreted  during  the  choreic  period  was  in  excess,  as  was  also  the 
phosphoric  acid  excreted  when  the  choreic  symptoms  were  at  their  maximum, 
but  the  quantity  of  this  acid  was  less  than  the  average  during  convales- 
cence ;  a  moderate  amount  of  uric  acid  during  the  disease  was  also  observed, 
but  none  upon  recovery. 

Prognosis  ;  Course. — Chorea,  though  obstinate  and  often  incurable  in 
adults,  usually  terminates  favorably  in  children  in  two  to  four  months. 
Bouchut  considers  its  ordinary  duration  at  from  thirty  to  fifty  days,  which  is 
certainly  shorter  than  the  average  duration  in  this  country,  except  when  the 
disease  is  materially  abridged  by  treatment.  The  same  author  states  that  it 
may  continue  only  a  few  days,  as  he  has  observed  in  cases  which  occurred 
during  convalescence  from  scarlet  fever.  But  tremulousness  of  the  muscles, 
occurring  in  the  state  of  weakness  following  a  grave  disease  and  abating  as 
the  general  health  is  restored,  I  should  not  consider  as  properly  choreic,  any 
more  than  that  occurring  from  over-fatigue.  As  the  choreic  movements 
gradually  increase  in  the  initial  period  till  a  certain  maximum  is  reached,  so 
their  decline  is  gradual.  Temporary  variations  also  occur  throughout  the 
disease  as  regards  the  extent  of  the  movements,  which  are  aggravated  by 
mental  excitement,  bodily  fatigue,  certain  functional  derangements,  especially 
of  digestion,  and  sometimes  from  causes  which  are  not  apparent. 
^  N.  Y.  Med.  Record,  Dec.  15,  1883  :  Dr.  Chapin.  ^  Londm  Lancet,  July,  1871. 


CHOREA.  661 

Though,  as  a  rule,  chorea  in  children  ordinarily  terminates  favorably 
under  different  and  even  injurious  modes  of  treatment  there  are  exceptional 
cases.  Romberg  relates  the  history  of  a  patient  who  died  at  the  age  of 
seventy-six  years,  having  had  chorea  since  the  age  of  six  years.  In  chorea 
limited  to  a  few  muscles  or  a  group  of  muscles  the  prognosis  is  more  doubt- 
ful than  when  it  affects  a  large  number,  since  in  the  former  case  the  cause  is 
more  likely  to  be  some  lesion  of  the  cerebro-spinal  axis.  Thus,  chorea 
involving  only  certain  muscles  of  the  neck  or  of  the  eyes  is  sometimes  due 
to  this  cause,  and  is  then  very  obstinate. 

Again,  observations  demonstrate  that  chorea,  when  at  first,  in  all  prob- 
ability, strictly  a  neurosis,  but  of  a  protracted  and  grave  character,  may  give 
rise  to  a  central  organic  disease.  This  is  the  course  of  most  of  the  fatal 
cases,  congestion,  softening,  or  other  lesion  occurring  over  a  greater  or  less 
extent  of  the  nervous  centres.  Radcliffe  has  known  cerebral  meningitis  to 
supervene  in  two  instances.  With  the  occurrence  of  a  lesion  of  the  cerebro- 
spinal axis  new  symptoms  arise,  such  as  headache,  convulsions,  delirium,  and 
paralysis,  and  the  choi'eic  movements  cease  or  continue  according  to  the 
nature  of  the  lesion. 

Chorea,  like  certain  other  diseases  either  of  a  nervous  character  or  having 
a  nervous  element,  is  more  or  less  modified  by  intercurrent  inflammatory  and 
febrile  affections.  The  oft-quoted  expression  from  Hippocrates, /e6m  acce- 
dens  solvit  spasmos,  observations  show  to  be  founded  on  fact,  the  most  frequent 
example  of  which  occurs  in  pertussis.  In  chorea  the  movements,  as  a  rule, 
are  either  rendered  milder  or  they  cease  as  long  as  the  febrile  excitement 
continues  ;  but  there  are  exceptions,  and  the  subsequent  course  of  the  disease 
is  not  modified. 

Diagnosis. — This  is  not  difficult  in  ordinary  cases.  The  irregular  move- 
ments with  consciousness  preserved  enable  us  to  make  a  diagnosis  at  sight. 
In  its  commencement  and  when  it  continues  in  an  unusually  mild  form 
chorea  may  be  overlooked  by  the  physician,  as  it  often  is  by  the  parents, 
the  movements  being  attributed  to  a  fidgety  habit ;  but  medical  advice  is 
seldom  sought  till  the  movements  are  so  pronounced  that  it  is  impossible  to 
err,  except  through  gross  ignorance  or  carelessness. 

It  is  important  to  determine  when  chorea  occurs  in  an  organic  disease, 
and  also  whether  there  is  a  local  cause  of  the  chorea.  A  careful  and  intel- 
ligent study  of  the  symptoms  and  history  of  the  case  is  requisite  in  order  to 
obtain  a  correct  diagnosis  in  these  particulars. 

Treatment. — Regimenal. — As  chorea  in  a  large  proportion  of  cases  occurs 
in  a  state  of  anaemia,  and  the  vital  forces  are  ordinarily  more  or  less  reduced, 
obviously  the  regimen  should  be  such  as  invigorates  the  system.  Fresh  air 
and  out-door  exercise,  active  or  passive  according  to  circumstances,  with  the 
avoidance  of  undue  excitement,  are  requisite,  and  the  diet  should  be  nutri- 
tious, but  plain  and  unirritating.  The  various  functions  should  be  preserved 
so  far  as  possible  in  their  normal  state.  In  exceptional  instances,  when  the 
choreic  movements  are  violent,  the  patient  should  lie  in  bed,  and  some  writers 
have  recommended  the  use  of  splints  to  restrain  muscular  action  in  such 
cases.  I  have  found  chloralamid  an  effectual  remedy  in  these  severe  cases, 
allaying  the  muscular  contractions  and  producing  quiet  sleep.  It  may  be 
given  in  the  following  formula : 

R.  Chloralamid,  .!^j  ; 

iSpts.  frumenti,  .5j  ; 

Syr.  rubi  idsei,  ^ij. — Misce. 

Give  one  teaspoonful  to  a  child  of  five  years  every  two  hours  until  the  desired 
effect  is  produced. 


662  LOCAL  DISEASES. 

Medicinal. — Sometimes  among  the  co-operating  causes  is  one  of  a  local 
nature  which  is  susceptible  of  removal,  as  a  carious  and  painful  tooth,  intes- 
tinal worms,  etc.,  and  measures  calculated  to  effect  this  are  obviously  required. 
Allusion  has  already  been  made  to  a  case  in  which  the  employment  of  the 
oleoresina  filicis  and  the  expulsion  of  a  tape-worm  effected  a  speedy  cure. 

The  remedy  which  has  been  most  employed  in  chorea,  and  which  in 
consequence  of  the  anaemia  is  plainly  indicated  in  a  large  proportion  of 
cases,  is  iron.  It  does  not  interfere  with  the  employment  of  other  remedies 
which  have  a  more  specific  effect.  Nearly  all  the  ferruginous  preparations 
have  been  prescribed  in  different  cases  with  benefit.  Radcliffe  gives  the 
preference  to  the  iodide  of  iron,  believing  that  iodide  as  well  as  iron  exerts 
a  curative  influence.  I  have  prescribed  the  ammonio-citrate,  since  it  is  easy 
of  administration  in  simple  syrup  and  is  well  tolerated ;  but  I  now  prefer 
liquor  ferri  peptonati  or  the  pepto-mangan,  recently  introduced  from  Germany. 
It  should  be  given  in  doses  of  one  to  three  teaspoonfuls  three  times  daily. 

But  iron  must  not  be  regarded  as  the  main  remedy,  but  rather  as  an 
adjuvant.  Observations  during  the  last  few  years  in  both  continents  have 
more  and  more  established  the  claims  of  arsenic  to  be  regarded  as  the  most 
efficacious  of  all  medicinal  agents  in  the  treatment  of  ordinary  chorea. 
Properly  administered,  it  abridges  the  duration  of  this  disease  more  certainly 
than  any  other  agent,  and  within  a  few  days  begins  to  modify  the  choreic 
movements  in  the  severest  cases.  It  is  conveniently  given  in  the  form  of 
Fowler's  solution.  It  is  better  tolerated  by  children  than  by  adults,  and 
should  be  administered  to  them  in  a  larger  proportionate  dose.  A  child  of 
eight  years  can  take  five  drops,  diluted  in  water,  three  times  daily  after 
eating,  and  the  dose  may  be  increased,  if  needed,  to  eight,  ten,  twelve,  or 
even  fifteen  drops.  I  seldom  observe  any  gastric  irritability  or  other  un- 
pleasant effect  from  its  use  when  it  is  administered  largely  diluted  and  after 
the  meals,  but  if  such  occur,  it  should,  of  course,  be  suspended  for  a  time. 

While  not  hesitating  to  recommend  iron  and  arsenic  as  superior  to  all 
other  medicines  in  the  treatment  of  chorea,  it  is  not  proper  to  ignore  the 
opinions  of  other  members  of  our  profession  who  have  had  ample  experience 
and  recommend  other  agents  instead. 

Trousseau  gave  the  preference  to  strychnine,  increasing  the  doses  in  some 
cases  until  it  began  to  produce  its  poisonous  effects. 

Professor  Hammond^  says:  "  My  main  reliance  is  on  strychnia,  which,  I 
think,  should  be  given  in   gradually  increasing   doses,  somewhat   after  the 

manner  recommended  by  Trousseau This  plan  of  treatment  certainly 

shortens  the  duration  of  the  disease  very  materially,  and  causes  great  improve- 
ment in  the  general  health  of  the  patient.  Sometimes  the  effect  is  so  well 
marked  and  is  so  immediate  that  it  is  not  necessary  to  increase  the  doses  to 
the  extent  of  causing  muscular  cramps,  but  generally  the  full  therapeutical 
effect  of  the  drug  is  not  obtained  till  the  calf  of  the  leg  or  the  nucha  has 
slight  tonic  spasm.  I  have  never  seen  the  slightest  ill-consequence  follow 
this  mode  of  treatment,  and  the  doses  are  increased  so  gradually  that  with 
careful  watching  danger  need  not  be  apprehended."  Dr.  Hammond  has 
treated  thirty-two  children  with  this  agent  without  a  single  failure. 

But  as  chorea  terminates  favorably  with  smaller  and  safe  doses,  even 
if  the  time  required  be  longer,  it  does  not  seem  proper  to  recommend  its 
employment  to  the  extent  of  producing  physiological  effects  for  general 
practice.  Bouchut,  speaking  upon  this  point,  says :  "  But  with  these  pre- 
cautions strychnia  is  extremely  dangerous,  for  I  have  seen  at  the  Hopital 
des  Enfants  Malades  a  young  girl  of  thirteen  years  die  in  tetanus  '  produced 
by  an  increased  dose  of  this  drug  (article  on  Chorea).  Dr.  West,  in  his 
^  Diseases  of  the  Nervous  System,  page  617. 


CHOREA.  663 

Lumleian  Lectures,  also  says :  "  I  have  seen  one  instance  in  which  its 
employment,  while  it  failed  to  benefit  a  somewhat  severe  case  of  chorea, 
was  followed  by  two  attacks  of  violent  tetanic  convulsions,  which  nearly 
proved  fatal ;"  and  he  adds  :  "  The  twitching  of  the  limbs  of  itself  prevents 
our  becoming  aware  of  the  dose  being  excessive."  Therefore,  Dr.  West  does 
not  favor  the  employment  of  this  agent.  Still,  any  agent  may  be  given  in 
an  overdose,  and  it  is  not  difiicult  to  prescribe  strychnia  in  a  dose  which  may 
be  efficient,  and  yet  safe  for  children,  at  the  age  at  which  chorea  ordinarily 
occurs. 

I  have  employed  bromide  of  potassium  in  a  few  cases,  but  with  so  little 
benefit  that  I  am  not  inclined  to  continue  its  use  for  this  disease.  Others 
have  not  been  more  successful.  However  efficacious  the  bromide  may  be  in 
epilepsy,  it  does  not  appear  to  be  a  remedy  for  chorea. 

Cimicifuga,  first  employed  by  Jesse  Young  of  this  country,  is  highly 
esteemed  by  Philadelphia  physicians  in  the  treatment  of  chorea.  I  have 
employed  the  fluid  extract  in  doses  of  half  a  drachm,  increased  to  one  drachm, 
for  a  child  from  six  to  ten  years  of  age,  and,  though  it  benefits  some  cases,  it 
has  no  appreciable  eff"ect  either  in  moderating  the  movements  or  abridging  the 
duration  of  others. 

Ether,  asafcetida,  valerian,  musk,  the  oxide  and  sulphate  of  zinc,  turpen- 
tine, tartar  emetic,  opium,  and  numerous  other  remedies  have  been  recom- 
mended, and  some  of  them  have  seemed  useful  in  certain  cases.  In  this  city 
sulphate  of  zinc  has  been  frequently  employed  as  a  remedy  for  chorea,  and 
in  gradually  increasing  doses  till  more  than  twenty  grains  were  administered 
three  times  daily  ;  but  it  has  not  appeared,  so  far  as  I  have  been  able  to 
ascertain,  to  exert  any  marked  influence  either  on  the  severity  or  duration  of 
the  choreic  movements.  Justice,  however,  requires  iis  to  state  that  Dr.  West, 
who  has  written  recently  on  the  nervous  diseases  of  children,  thinks  that  it 
has  been  beneficial  in  certain  cases  in  which  he  has  employed  it,  and  he 
regards  it  on  the  whole  as  the  best  remedy. 

Radclifi"e,  who  has  had  ample  experience  in  the  treatment  of  nervous 
affections,  writes  :  "  In  an  ordinary  case  of  chorea  the  plan  of  treatment 
which  I  have  now  adopted  as  a  rule  for  some  time  is  to  give  cod-liver  oil  in 
conjunction  with  hypophosphite  of  soda,  making  the  draught  containing  the' 
latter  salt  the  vehicle  for  the  administration  of  the  cod-liver  oil."  Sometimes 
camphor  or  the  sesquicarbonate  of  ammonia  is  added.  Of  more  than  thirty 
cases  treated  in  this  way,  the  average  dviration  was  under  three  weeks.  Rad- 
eliffe  began  to  prescribe  these  remedies  on  theoretical  grounds,  believing  that 
phosphorus  and  cod-liver  oil  were  required  to  restore  "  nerve-tone,"  and  the 
result  of  this  treatment  has  certainly  been  such  as  to  commend  it  to  the  pro- 
fession. To  children  he  gives  from  five  to  eight  grains  of  the  hypophosphite 
of  sodium  three  times  daily. 

In  those  severe  cases  in  which  choreic  movements  prevent  the  proper 
amount  of  sleep,  a  moderate  dose  of  hydrate  of  chloral,  or,  better,  as  stated 
above,  ehloralamid  may  occasionally  be  advantageously  administered. 

Electricity  has  been  many  times  employed  in  the  treatment  of  chorea, 
and  though  some,  chiefly  electricians,  believe  that  it  has  a  curative  efi"ect, 
others,  and  the  majority,  fail  to  see  any  material  benefit  from  its  use. 

Cold  general  baths,  the  shower-bath,  frictions  along  the  spine,  etc.,  have 
been  employed ;  but  the  local  treatment  which  has  so  far  been  most  success- 
ful, and  which  promises  to  supersede  all  other  local  measures,  consists  in  the 
application  of  ether  spray  over  the  spine.  About  two  ounces  of  ether  are 
employed  at  each  sitting,  the  spray  being  applied  from  an  atomizer  up  and 
down  the  whole  length  of  the  spine  if  the  chorea  be  general.  The  opera- 
tion, which  occupies  from  ten  to  fifteen  minutes,  should  be  repeated  daily  or 


664  LOCAL  DISEASES. 

every  second  day.  A  considerable  number  of  cases  have  been  reported  in 
which  the  spray  has  apparently  had  a  good  effect  in  controlling  the  disease. 
But  I  repeat  my  belief,  from  the  large  number  of  cases  seen  in  the  Bureau 
for  the  Relief  of  the  Out-door  Poor,  that  the  arsenical  and  ferruginous  treat- 
ment gives  more  satisfaction  than  any  or  all  other  measures. 


CHAPTER    XII. 

PAEALYSIS. 

Paralysis  in  young  children,  especially  infants,  is  in  most  instances  due 
to  causes  which  seldom  produce  it  in  adults.  The  principal  cause  of  it  in 
the  adult — namely,  cerebral  apoplexy — is  indeed  rare  in  children.  Paralj'sis 
in  children  has  the  following  recognized  causes  :  1st.  A  change  in  the  blood, 
not  fully  understood,  induced  by  certain  grave  diseases,  as  diphtheria,  typhoid 
fever,  measles,  scarlet  fever,  etc.  2d.  Reflex  influence.  The  function  of 
some  part  of  the  system  is  in  some  way  disturbed,  and  paralysis  occurs  in 
certain  muscles,  perhaps  at  a  distance  from  the  cause,  and  it  disappears  when 
that  cause  is  removed,  unless  it  have  continued  too  long.  The  only  rational 
explanation  is  found  in  the  fact  of  a  continuous  connection  between  the  local 
cause  and  the  paralyzed  muscles  through  the  afferent  and  efferent  nerves  and 
the  nervous  centres.  3d.  Compression  or  injury  of  a  nerve-trunk.  These 
cases  are  rare.  Pressing  of  the  portio  dura  liy  the  blades  of  forceps  during 
birth,  described  in  the  next  chapter,  is  an  example.  4th.  An  anatomical 
alteration  in  the  muscular  fibres,  the  nerves  and  nervous  centres  remaining 
unaffected.  This  has  been  designated  myogenic  paralysis.  This  form  of 
paralysis  is  probably  often  of  a  rheumatic  nature.  Paralysis  of  the  face  or 
other  portions  of  the  surface,  which  sometimes  occurs  in  children  and  adults 
from  prolonged  exposure  to  cold  winds,  is  of  this  nature.  5th.  Some  anatom- 
ical change  in  the  nervous  centres,  as  congestion,  hemorrhage,  inflammation, 
emboli,  compression  and  laceration  of  brain,  whether  by  tumors,  inflamma- 
tory products,  or  other  causes,  etc.  If  there  be  hemiplegia,  the  presumption 
is  that  the  disease  causing  it  is  cerebral ;  if  paraplegia,  that  it  is  spinal. 

Paralysis  occurring  as  a  symptom  or  sequel  of  some  obvious  local  or  gen- 
eral disease,  as  diphtheria,  lesion  of  the  nervous  centres,  etc.,  and  which  may 
occur  at  any  stage,  need  not  detain  us.  It  is  described  in  connection  with 
the  primary  diseases  on  which  it  depends. 


CHAPTER   XIII. 

POLIOMYELITIS   ACUTA   ANTERIOR. 

This  form  of  paralysis  occurs,  with  few  exceptions,  between  the  ages  of 
six  months  and  seven  years. 

Symptoms.— The  previous  health  of  the  patient  is  usually  good.  The 
paralysis  does  not  always  commence  in  the  same  manner.  In  a  few  instances 
it  begins  suddenly  in  the  day-time  when  the  child  is  apparently  in  perfect 
health.     In  others  it  begins  abruptly,  after  sound  sleep.     The  child  goes  to 


POLIOMYELITIS  ACUTA  AXTEBIOB.  665 

bed  well,  sleeps  through  the  night,  and  awakens  in  the  morning  paralyzed. 
I  have  known  it  to  occur  in  one  instance  after  sleep  in  the  middle  of  the 
day.  In  these  cases  there  has  sometimes  been  an  exposure  before  the  sleep 
to  wind  or  rain  or  from  sitting  on  a  cold  stone.  But  in  the  majority  of  cases 
the  paralysis  is  preceded  and  accompanied  by  a  very  decided  elevation  of 
temperature,  which  comes  on  suddenly  without  appreciable  cause,  and  after 
a  few  days  the  power  of  motion  is  found  to  be  lost  in  one  or  more  of  the 
limbs.  Xo  symptom  occurs  during  the  fever  indicative  of  disease  of  the 
brain ;  consciousness  is  retained,  and  the  headache  or  apparent  liability  to 
convulsions  is  no  greater  than  in  other  pathological  states  accompanied  by  an 
equal  amount  of  fever.  The  paralysis  is  at  its  maximum  in  the  commence- 
ment. Occurring  as  by  a  stroke,  the  full  extent  of  the  paralytic  state  is 
exhibited  at  once,  and  so  far  as  there  is  any  subsequent  change  it  is  an  im- 
provement as  regards  the  number  of  muscles  affected  and  the  degree  of  the 
paralysis.  Most  frequently  the  muscles  of  one  or  both  lower  extremities  are 
affected.  Occasionally  one  of  the  upper  extremities  is  also  paralyzed  in 
addition  to  the  lower,  but  paralysis  of  an  upper  extremity  is  less  in  degree, 
and  disappears  sooner,  than  of  the  lower.  The  bladder  and  lower  bowel 
remain  unaffected,  since  only  the  muscles  of  volition  are  involved.  Sensation 
is  unimpaired  in  the  affected  limbs,  and  in  the  commencement  there  is  even 
in  some  cases  a  state  of  hypera?sthesia  (West).  The  fever  which  precedes 
and  accompanies  the  paralysis  in  certain  cases  gradually  abates,  and  in  a  few 
days  nothing  abnormal  remains  except  the  loss  of  power  in  the  affected  mus- 
cles. These  muscles  are  flaccid  and  relaxed,  so  that  the  limb  falls  by  its 
weight  when  unsupported,  and  they  are  usually  free  from  pain.  The  number 
of  muscles  paralyzed  varies  greatly  in  different  cases.  Only  one  muscle  or 
a  single  group  of  muscles  may  be  affected,  or.  on  the  other  hand,  both  the 
extensor  and  flexor  muscles  of  two  or  more  limbs  may  be  paralyzed.  In  the 
opinion  of  3Ir.  Adams,  the  following  table  exhibits  the  groups  of  muscles 
and  single  muscles  most  frequently  involved,  and  in  the  order  stated : 

Groups. 

1.  Extensors  of  toes  and  flexors  of  the  foot. 

2.  Extensors  and  supinators  of  the  hand. 

3.  Extensors  of  leg,  and  with  them  usually  the  first  group. 

Single  3Iusdes. 

1.  Extensor  longus  digitorum  of  toes. 

2.  Tibialis  anticus. 

3.  Deltoid. 

4.  Stemo-mastoid. 

The  following  is  an  example  of  infantile  paralysis  as  it  not  infrequently 

occurs  when  the  result  is  favorable :  A.  K .  German,  female,  aged  three 

years  and  four  months,  fleshy  ;  had  been  in  the  habit  of  sitting  on  the  ground 
near  the  house  and  on  the  door-sill.  On  July  2,  1871,  she  had  a  sound  sleep 
in  the  afternoon,  having  been  entirely  well  previously,  and  awoke  trembling 
and  with  a  high  fever  at  3J  p.  m.  At  8  P.  M.,  the  febrile  excitement  con- 
tinuing, general  clonic  convulsions  occurred,  lasting  about  ten  minutes.  At 
this  time  I  was  called  to  see  her,  and  found  her  face  flushed,  surface  hot,  and 
pixlse  about  130.  Consciousness  returned  after  the  convulsion.  Her  intelli- 
gence was  good,  tongue  moist  and  slightly  furred,  bowels  rather  constipated, 
and  the  urine  freely  passed.  The  fever  continued  two  days,  when  it  grad- 
ually and  entirely  abated,  but  before  it  ceased  paralysis  of  the  left  lower 
extremity  was  observed.  No  weight  at  first  could  be  sustained  upon  this 
limb,  and  it  hung  powerless  when  we  endeavored  to  make  her  walk.     The 


666  LOCAL  DISEASES. 

attempt  roused  her  to  cry,  as  if  in  pain,  and  pressing  upon  the  thigh  or 
moving  it  had  the  same  effect.  The  thigh  of  this  limb  appeared  slightly 
swollen  on  inspection,  but  measurement  did  not  indicate  any  notable  enlarge- 
ment. The  difference  in  circumference  was  not  more  than  one-eighth  to  one- 
fourth  of  an  inch.  There  was  no  appreciable  increase  of  heat  in  the  thigh 
over  the  general  temperature  of  the  body.  Sensibility  remained  in  every 
part  of  the  limb,  and  the  loss  of  power  was  not  complete,  for  on  the  first 
day,  as  soon  as  the  paralysis  was  observed,  slight  and  imperfect  movements 
could  be  produced  by  pinching  the  limb.  In  three  weeks  the  use  of  the 
limb  was  fully  restored  by  mildly  stimulating  liniments  and  simple  medicines 
to  regulate  the  bowels.  The  tenderness  which  was  observed  in  this  case  is 
only  "occasionally  present,  and  has  been  attributed  to  hypersesthesia. 

Prognosis  ;  Progress. — The  paralysis  in  nearly  all  cases  soon  begins  to 
abate.  The  power  of  motion  returns  little  by  little,  and  whatever  improve- 
ment occurs  is  permanent.  There  is  no  retrogression  in  the  convalescence. 
The  sooner  improvement  commences  the  more  favorable  is  the  prognosis.  In 
the  most  favorable  cases  there  is  complete  restoration  in  from  three  to  four 
weeks.  In  other  patients,  while  certain  of  the  muscles  regain  the  power  of 
motion,  other  muscles,  oftener  those  of  the  lower  extremity  than  of  the 
upper,  do  not  recover  their  function,  and,  unless  proper  remedial  measures  be 
employed,  and  even  with  them  in  certain  instances,  atrophy  soon  commences. 
The  temperature  of  the  paralyzed  limb  falls  three,  five,  or  even  eight  degrees^ 
and  the  amount  of  blood  which  circulates  in  it  is  diminished,  so  that  the 
pulse  of  the  limb  is  feebler  and  its  vessels  smaller  than  in  health.  With  the 
atrophy  the  contractility  of  the  muscular  fibres  by  the  electric  current  dimin- 
ishes, and  in  unfavorable  cases  after  a  time  powerful  induced  and  even  pri- 
mary currents  have  no  appreciable  effect.  The  nutrition  of  a  paralyzed 
limb  is  always  imperfect,  and  if  the  paralysis  occur  in  a  child  its  growth 
is  retarded.  Therefore,  in  cases  of  contracted  or  permanent  infantile  paralysis 
of  one  limb  a  disproportion  occurs  both  in  diameter  and  length  between  it 
and  that  on  the  opposite  side.  If  the  paralysis  continue,  the  ligaments  of 
the  paralyzed  limb  become  relaxed  and  lengthened.  West  mentions  a  case 
of  paralysis  of  the  deltoid  in  which  the  humero-scapular  ligaments  were  so 
extended  that  the  humerus  dropped  from  the  glenoid  cavity,  so  as  to  increase 
the  length  of  the  limb  three-fourths  of  an  inch.  In  the  paralysis  of  certain 
muscles  of  the  lower  extremity  and  continuance  of  the  contractile  power 
in  others  we  have  the  conditions  which  give  rise  to  club-feet,  and  accord- 
ingly this  deformity  is  the  common  result  of  the  paralysis  when  it  is  not 
cured. 

Etiology. — As  this  form  of  paralysis  is  not  fatal,  opportunity  for  post- 
mortem examination  in  a  recent  case  seldom  occurs.  Hence  the  difficulty  in 
determining  the  exact  anatomical  change  in  the  nervous  system  which  pro- 
duces the  paralysis.  Medical  literature  contains  records  of  a  considerable 
number  of  cases  in  which  autopsies  have  been  made,  but  death  occurred  so 
long  after  the  commencement  of  the  paralysis,  usually  months  or  years,  that 
it  is  difiicult  to  determine  whether  lesions  which  have  been  observed  were  a 
cause  or  consequence.  In  a  majority  of  these  autopsies  a  spinal  lesion  of 
some  sort  was  detected,  but  in  some  instances  none  could  be  discovered. 

Mr.  Adams  in  his  treatise  on  club-foot  relates  a  case  in  which  the  spinal 
cord,  carefully  examined,  probably  only  with  the  naked  eye,  seemed  normal. 
Robin  examined  the  spinal  cord  microscopically  in  one  case,  but  discovered 
nothing  abnormal,  and  Elischer  made  autopsies  in  two  cases  of  this  paralysis 
in  which  death  had  occurred  from  variola,  but  with  a  negative  result  as 
regards  the  nervous  system.-^  The  examinations  by  Robin  and  Elischer, 
^  Jahrbuch  fur  Kinderh.,  1873. 


POLIOMYELITIS  ACUTA  ANTERIOR.  667 

since  they  were  microscopic,  have  been  justly  regarded  as  important,  and 
they  have  been  related  by  writers  in  order  to  sustain  the  theory  that  infantile 
paralysis  is  peripheral  and  not  centric. 

Very  little  was  effected  prior  to  1863  in  determining  the  cause  or  causes 
of  this  paralysis  by  post-mortem  examinations,  because  the  microscope  was 
so  little  used,  and  because  in  most  of  the  cases  reported  the  clinical  history 
or  microscopic  lesions  were  such  as  to  show  or  to  render  it  highly  probable 
that  the  paralysis  was  not  of  the  kind  which  we  have  been  describing. 
Thus,  Beraud  reported  a  case  in  which  tubercles  were  found  in  the  spinal 
cord ;  Hammond,  a  case  in  which  a  clot  was  found  in  the  spinal  cord ;  and 
Jaccoud,  one  of  spinal  arachnitis  with  thickening  of  the  meninges.  Since 
1863,  17  autopsies  have  been  recorded  in  which  the  spinal  cord  was  carefully 
examined,  and  upon  these  we  must  chiefly  rely  for  our  data  by  which  to 
determine  what  are  the  anatomical  changes  in  the  nervous  system  which 
probably  cause  this  paralysis.  The  reader  will  find  these  cases  tabulated  in 
a  lecture  by  B.  Gr.  Seguin,  M.  D.,^  and  the  most  important  of  them  narrated 
in  a  paper  on  infantile  paralysis,  showing  great  research,  published  by  Dr. 
Mary  Putnam  Jacobi.^  It  is  true  that  all  but  3  of  these  post-mortem 
examinations  were  made  many  years  after  the  occurrence  of  the  paralysis; 
but  in  the  3  cases  which  were  reported  by  Roger  and  Damaschino,  only  two, 
six,  and  thirteen  months  had  elapsed.  The  following  were  the  chief  lesions 
observed  in  these  cases  as  regards  the  spinal  cord : 

Cases. 

1.  Atrophy  of  motor-cells  in  anterior  comua 10 

2.  jS^erve-cells,  normal 2 

3.  Atrophy  (variously  recorded)  of  anterior  columns,  or  cornua,  or  part 

of  cord,  or  roots  of  anterior  nerves 8 

4.  Sclerosis 9 

5.  Myelitis,  recorded  as  diffused,  central,  or  slight 7 

6.  Central  softening  (the  three  most  recent  cases) 3 

7.  Small  clot  in  cord  (Hammond's  case) 1 

8.  Sciatic  neuritis ■ 1 

The  most  common  lesions  in  these  cases  were  those  of  inflammation  of 
the  anterior  cornua  of  the  spinal  cord,  or  such  as  are  known  to  result  from 
this  inflammation — to  wit,  atrophy  of  the  nervous  substance  and  sclerosis. 

With  the  data  furnished  by  these  post-mortem  examinations  and  the  clin- 
ical histories  of  cases  we  are  better  prepared  to  consider  the  theories  regard- 
ing the  etiology  of  this  malady.  The  views  of  MM.  Roger  and  Damaschino 
are  entitled  to  much  consideration,  since  the  autopsies  which  they  made  were 
in  cases  of  shorter  duration,  and  therefore  nearer  the  date  of  the  commence- 
ment of  the  paralysis,  than  those  which  have  been  reported  by  other  observ- 
ers. Roger  and  Damaschino  ^  published  a  series  of  papers  on  this  malady, 
which  they  conclude  with  the  following  propositions:  "1.  The  alteration 
peculiar  to  infantile  paralysis  is  a  lesion  of  the  spinal  marrow,  which  causes 
the  atrophy  of  muscles  and  nerves.  2.  The  seat  of  this  lesion  is  the  anterior 
part  of  the  gray  substance  of  the  medulla,  where  softened  portions  of  spinal 
substance  are  seen.  3.  This  softening  is  of  an  inflammatory  nature — in  fact, 
a  simple  myelitis.  4.  Infantile  paralysis  should  therefore  be  called  spinal 
paralysis  of  children,  and  be  classed  among  the  afl'ections  of  the  spinal 
marrow,  as  depending  on  myelitis." 

The  views  of  Roger  and  Damaschino,  expressed  above,  seem  to  harmonize 
more  closely  with,  and  to  aiford  a  more  satisfactory  explanation  of,  the  symp- 
toms, history,  and  lesions  thus  far  observed  in  ordinary  or  typical  cases  than 

1  N.  Y.  Medical  Record,  January  15,  1874.         ^  N.  Y.  Obst.  Jour.,  for  May,  1874. 
^  Gaz.  med.  de  Paris,  1874. 


668  LOCAL  DISEASES 

does  any  other  theory.  Many  neuropathists  regard  suddenly-occurring  active 
congestion  of  the  anterior  cornua  as  the  cause  of  infantile  paralysis ;  but 
there  is  that  affinity  between  active  congestion  and  inflammation  that  they 
may  be  regarded  as  having  the  same  pathological  effect  in  this  instance,  and 
therefore  the  two  theories  of  a  spinal  congestion  and  spinal  inflammation  may 
be  considered  as  one.  It  is  not  improbable  that  in  some  of  the  cases  which 
more  speedily  recover  there  is  simple  congestion ;  while  in  the  more  obstinate 
cases  and  those  with  inflammatory  symptoms  the  congestion  has  passed  into 
an  inflammation  or  inflammation  was  present  from  the  first.  According  to 
this  theory,  the  atrophy  so  generally  observed  in  the  twelve  cases  in  which 
autopsies  were  made  must  be  considered  a  degenerative  change  resulting  from 
the  inflammation.  That  so  accurate  an  observer  and  so  excellent  a  micro- 
scopist  as  Robin  could  detect  nothing  abnormal  in  the  case  which  he  examined 
was  probably  due  to  the  fact  that  the  inflammation  or  congestion  abated  with- 
out producing  any  degenerative  changes  in  the  nervous  substance. 

Professor  Charcot  regards  atrophy  of  the  motor-cells  as  the  cause  of  the 
paralysis,  but  it  is  much  more  in  consonance  with  the  facts  to  consider  the 
cellular  atrophy  a  result  than  a  cause.  For  how  could  atrophy,  which  always 
occurs  gradually  and  by  progressive  increase,  be  the  cause  of  a  disease  which 
begins  abruptly  and  is  most  intense  in  the  very  commencement  ?  Besides, 
atrophy  does  not  occur  without  some  antecedent  disease  to  cavise  it. 

In  a  report  to  the  International  Congress  at  Amsterdam,  Drs.  Damaschino 
and  Roger  give  the  following  summary  of  the  result  of  their  recent  study  of 
the  pathology  of  infantile  paralysis  :  ^ 

1.  The  anatomical  lesions  are  situated  in  the  motor  regions  of  the  spinal 
cord. 

2.  They  consist  of  a  central  myelitis,  with  a  stadium  of  softening  and 
atrophic  destruction  of  the  cells  of  the  gray  substance,  together  with  sclero- 
sis of  the  lateral  columns  and  considerable  atrophy  of  the  anterior  roots  and 
the  nerves  leading  to  the  paralyzed  muscles. 

3.  Atrophy  of  the  cells  is  not — as  Charcot  is  of  opinion — the  whole  pro- 
cess, as  it  is  in  progressive  muscular  atrophy. 

■4.  The  opinion  of  Leyden,  that  there  is  a  circumscribed  and  diffused  mye- 
litis in  children,  is  worthy  of  consideration. 

It  remains  for  future  examination  to  decide  whether  the  myelitis  begins 
as  interstitial  or  parenchymatous  in  the  connective  tissue  or  the  nerve-cells. 

Recent  observations  by  Drummond  (1885),  Gowei's  (1888),  and  othei's  have 
apparently  established  the  theory  of  Roger  and  Damaschino — to  wit,  that 
the  paralysis  which  we  are  considering  results  from  acute  inflammation  of 
the  gray  matter  of  the  spinal  cord,  and  entirely  or  chiefly  of  the  gray  matter 
in  the  anterior  cornua,  that  of  the  posterior  cornua  not  being  affected. 

All  muscular  fibres  which  are  in  a  state  of  disuse  begin  in  a  few  weeks  to 
atrophy  and  undergo  fatty  degeneration.  The  transverse  stride  in  the  primi- 
tive muscular  fasciculus  gradually  disappear,  and  are  replaced  by  granules 
of  fat,  and  later  still  by  small  oil-globules.  If  we  examine  with  the  micro- 
scope the  fibres  from  a  muscle  which  has  been  a  considerable  time  paralyzed, 
but  which  has  still  some  electric  contractility,  we  will  find  in  places  the  striae 
remaining,  but  numerous  opaque  granules  of  a  fatty  nature  within  the  sarco- 
lemma  wherever  the  striae  are  absent,  and  in  other  places,  where  the  degen- 
eration is  most  advanced,  oil-globules  occur,  always  small.  If  the  paralysis 
be  more  profound,  the  striae  have  all  disappeared.  At  a  later  stage,  usually 
after  some  years  in  cases  of  complete  and  incurable  paralysis,  the  fatty  mat- 
ter may  be  to  a  considerable  extent  absorbed,  and  the  fibrous  network  of  the 
muscle  which  remains  presents  a  tendinous  appearance.  There  is  a  great 
^  Le  Progres  medical,  No.  39,  1880. 


POLIOMYELITIS  ACUTA  ANTERIOR. 


669 


difference,  however,  in  different  cases  as  regards  the  rapidity  with  which 
these  changes  occur.  Hammond  states  that  he  found  the  striae  remaining  in 
two  cases  after  the  lapse  of  more  than  four  years  of  decided  paralysis.  The 
nerves  of  the  paralyzed  part  also  undergo  atrophy. 


Fig.  192. 


Figure  showing  displacement  of  the  humerus  in  poliomyelitis  acuta  anterior  which  came  on 
suddenly,  and  no  proper  treatment  was  employed  for  months. 

Diagnosis.— This  is  easy  as  soon  as  the  attention  of  the  physician  is 
directed  to  the  state  of  the  limbs.  In  a  large  proportion  of  cases  the  mother 
or  nurse  first  observes  the  paralysis  and  calls  the  attention  of  the  physician 
to  it.  A  knowledge  and  recollection  of  the  facts  in  relation  to  this  paralysis 
should  lead  the  physician  to  examine  the  state  of  the  limbs  in  all  cases  of 
fever  in  young  children  occurring  without  apparent  cause. 

Prognosis. — It  may  be  confidently  predicted,  if  the  child  be  seen  early 
and  correctly  treated,  that  the  paralysis  will  diminish,  if  it  cannot  be  entirely 
cured.  If  the  paralysis  have  continued  a  considerable  time,  and  there  be  no 
electric  contractility  of  the  muscles,  there  is  poor  prospect  of  any  improve- 
ment. The  induced  current  will  fail  sometimes  to  cause  muscular  contrac- 
tion, when  the  direct  current  may  produce  it ;  but  if  there  be  no  response  to 
the  direct  current,  there  is  no  therapeutic  agent  which  can  restore  the  use  of 
the  limb. 

In  cases  seen  soon  after  the  paralysis  commences  and  before  the  stage  of 
atrophy  the  prognosis  is  most  favorable  when  there  is  still  slight  voluntary 
motion,  and  improvement  commences  eai'ly.  In  most  instances,  even  when 
the  paralysis  has  been  mild  and  of  comparatively  short  duration,  the  extrem- 
ity, although  its  motion  be  fully  restored,  is  for  a  long  time  weaker  than 
before  the  attack. 


670  LOCAL  DISEASES. 

Treatment. — A  physician  called  at  the  commencement  of  the  paralysis 
should  endeavor  to  remove  every  cause  which  might  increase  the  irritability 
of  the  nervous  system.  The  bowels  should  be  kept  open  and  the  diet  be 
plain  and  unirritating. 

Local  treatment  is  very  useful  at  all  periods  of  the  paralysis.  In  the 
first  days  cold  applications,  as  by  an  India-rubber  bag  containing  ice,  should 
be  made  over  the  spine.  Stimulating  embrocations  over  the  spine  and  upon 
the  paralyzed  limb  are  appropriate  after  the  cold  has  been  discontinued,  and 
benefit  may  also  be  derived  from  dry  cups  along  the  spine.  Ergot,  the  bro- 
mide and  iodide  of  potassium,  which  may  be  administered  variously  combined 
or  singly,  are  the  appropriate  remedies  for  the  first  twelve  or  fourteen  days. 
Administered  every  three  or  four  hours  in  proper  dose,  they  are  the  most 
efi"ectual  of  all  internal  remedies  for  diminishing  spinal  congestion  and  pre- 
venting efiusion  and  permanent  structural  change  in  the  cord.  Unfortu- 
nately, this  first  stage  is  in  many  instances  far  advanced  before  proper  treat- 
ment is  employed  to  subdue  the  myelitis,  either  from  an  incorrect  diagnosis 
or  because  the  physician  is  not  summoned  until  structural  changes  have 
occurred,  which  constitute  the  second  stage. 

If  the  paralysis  continue  or  if  it  do  not  progressively  diminish,  we  should 
not  delay  more  than  two  weeks  from  the  commencement  of  the  disease  before 
employing  appropriate  measures  to  restore  the  use  of  the  limbs  and  arrest 
atrophy  of  the  muscles.  The  expectant  plan  of  treatment,  which  is  proper 
in  many  diseases  of  children,  is  unsuited  to  this.  Muscular  atrophy  may 
commence  in  three  weeks,  and  the  farther  it  has  advanced  the  more  dilficult 
and  tedious  will  be  the  cure.  Therefore,  by  the  close  of  the  second  week,  if 
the  paralysis  continue  or  be  not  rapidly  disappearing,  iron  as  a  tonic  with 
strychnia  should  be  prescribed.  There  is  probably  no  better  formula  for  the 
exhibition  of  these  agents  than  the  following  from  Professor  Hammond : 

R.  Strych.  sulphat.,  gr.  j  ; 

Ferri  pyrophosphat.,  ^ss ; 

Acidi  phosphorici  dilut.,  ^ss  ; 

Syr.  zingib.,  ^iijss. — Misce. 

One-third  of  a  teaspoonful  or  one-ninetieth  of  a  grain  of  strychnia  is  suffi- 
cient for  a  child  of  two  years,  administered  three  times  daily.  Hillier,  Bar- 
well,  and  others  have  employed  subcutaneous  injections  of  strychnia,  with,  it 
is  stated,  a  good  result.  While  in  the  first  and  second  weeks  the  child  has 
been  allowed  to  remain  quiet,  he  should  now  be  encouraged  to  use  his  limbs. 
Frequent  muscular  contraction  must,  if  possible,  be  produced,  and  the  volun- 
tary movements,  when  not  totally  lost,  aid  greatly  in  promoting  the  nutrition 
of  the  muscles  and  restoring  their  function.  Immersing  the  limb  for  half 
an  hour  in  water  at  a  temperature  of  110°  or  115°,  rubbing  the  limb  with  a 
coarse  towel,  and  kneading  the  muscles  aid  also  in  restorine;  nutrition  and 
tone  to  them. 

But,  fortunately,  we  have  an  invaluable  agent  in  the  electric  fluid,  which 
can  be  made  to  penetrate  the  muscles  and  cause  their  contraction  when  every 
other  measure  has  failed.  The  induced  current  should  be  employed  upon  the 
limb  every  day  or  second  day  if  it  cause  the  muscles  to  act,  but  if  the  loss  of 
power  be  of  long  standing  or  complete,  so  that  the  induced  current  is  not 
sufficiently  powerful,  the  direct  current  should  be  used  instead.  It  is  not 
regarded  as  important  which  way  the  current  passes,  provided  that  the  mus- 
cles contract. 

In  a  large  proportion  of  cases  a  cure  cannot  be  effected  until  the  lapse  of 
several  months,  so  that  the  patience  of  the  physician  and  friends  may  be  put 


FACIAL  FAB  A  LYSIS.  671 

to  the  test ;  but  if  muscular  atrophy  can  be  prevented  and  the  Hmb  kept  at 
nearly  the  normal  temperature,  this  mode  of  treatment  will  ordinarily  in  the 
end  be  successful.  The  primary  afiection  which  caused  the  paralysis  will, 
with  some  exceptions,  be  removed  by  the  treatment  indicated  above,  after 
which  the  state  of  the  muscles  and  their  nervous  supply  demand  the  whole 
attention.  Observations  show  that  by  treatment  perseveringly  employed 
fatty  degeneration  of  the  muscular  fibres  can  be  not  only  arrested,  but  the  fat 
which  has  already  been  deposited  within  the  sarcolemma  may  be  absorbed  and 
the  muscular  strias  restored.  In  those  cases  in  which  it  has  been  necessary 
to  employ  the  direct  current  the  induced  should  be  used  whenever  by  the 
improvement  of  the  case  it  is  found  sufficiently  powerful. 


CHAPTER    Xiy. 

FACIAL    PARALYSIS. 

Causes. — Facial  paralysis  in  the  new-born  commonly  occurs  from  pres- 
sure of  the  blade  of  the  forceps  upon  the  portio  dura  at  a  point  external  to 
the  stylo-mastoid  foramen.  It  may  also  occur  in  children  of  any  age  from 
exposure  of  the  face  to  a  cold  wind.  The  pressure  of  a  tumor  upon  some 
part  of  the  portio  dura,  or  even  of  the  fist  of  the  child  placed  under  the  face 
during  sleep,  may  cause  it.  It  may  also  result  from  disease  of  the  temporal 
bone,  producing  pressure  on  the  nerve,  as  caries,  periostitis,  suppuration,  or 
hemorrhage  into  the  aquseductus  Fallopii,  and  also  from  intracranial  disease 
afi'ecting  the  pons  Varolii  or  the  medulla  oblongata. 

Symptoms. — The  portio  dura,  which  is  a  nerve  of  motion,  supplies  the 
muscles  of  the  face,  and  therefore  its  loss  of  function  is  at  once  manifest  in 
distortion  of  the  features.  The  eye  of  the  aff'ected  side  remains  open  in  con- 
sequence of  paralysis  of  the  orbicularis  palpebrarum,  the  upper  lid  being 
raised  by  the  levator  muscle,  which  is  not  paralyzed,  since  its  nerve  is  derived 
from  the  third  pair.  From  the  inability  to  wink,  the  eye  becomes  irritated 
by  dust  and  constant  exposure,  and  in  children  old  enough  to  have  an  abun- 
dant lachrymal  secretion  the  tears  are  liable  to  flow  over  the  cheek.  On  ac- 
count of  the  paralyzed  and  relaxed  state  of  the  facial  muscles  the  mouth  is 
drawn  toward  the  healthy  side,  while  the  aff'ected  side  presents  a  swollen 
appearance.  Movement  of  the  eyebrow  or  the  anterior  portion  of  the  scalp 
on  the  paralyzed  side  is  also  impossible,  since  the  occipito-frontalis  and  cor- 
rugator  supercilii  are  supplied  by  the  portio  dura.  If  the  cause  of  the  dis- 
ease is  located  above  the  origin  of  the  chorda  tympani,  the  flow  of  saliva  and 
sense  of  taste  on  the  aff'ected  side  are  impaired.  If  the  injury  be  posterior  to 
the  gangliform  enlargement,  those  symptoms  are  superadded  which  are  due 
to  paralysis  of  the  petrosal  nerves. 

Figure  193  represents  a  case  which  was  under  observation  in  the  New 
York  Infant  Asylum.  The  age  of  the  infant  at  admission  was  about  five 
months,  and  its  previous  history  was  unknown.  The  paralysis  was  perma- 
nent. Death  occurred  some  months  later  from  an  intercurrent  disease,  and 
no  cause  of  the  paralysis  could  be  discovered  in  a  careful  examination. 

Prognosis. — This  depends  on  the  cause.  If  the  cause  be  peripheral,  as 
from  the  pressure  of  the  forceps  or  from  cold,  the  prognosis  is  favorable.  In 
case  of  deep-seated  lesion,  unless  syphilitic,  the  prognosis  is  usually  unfavor- 
able. A  syphilitic  lesion  can  often  be  removed  by  appropriate  remedies  and 
the  paralysis  be  cured. 


672 


LOCAL  DISEASES. 


Fig.  19c 


Treatment. — In  paralysis  of  the  new-born  from  pressure  of  the  forceps 
all  that  is  required  is  occasional  rubbing  or  gentle  kneading  over  the  affected 

muscles.  In  those  who  are  older  the  nature 
of  the  cause,  so  far  as  ascertained,  must  de- 
termine the  treatment.  If  there  be  glandular 
swellings  and  discharge  from  the  ear  from 
scrofula,  cod-liver  oil  and  the  syrup  of  the 
iodide  of  iron  are  required  internally,  with 
appropriate  external  treatment  of  the  glands 
and  ear.  If  syphilis  be  the  cause,  mercurials 
and  the  iodide  of  potassium  should  be  em- 
ployed. If  the  patient  do  not  soon  begin  to 
improve,  the  treatinent  recommended  for  in- 
fantile paralysis,  modified  somewhat  on  ac- 
count of  the  difference  in  location,  is  appro- 
priate. Iron  and  strychnia  may  be  admin- 
istered internally.  The  external  treatment 
should  consist  of  friction,  kneading,  hot  appli- 
cations, and  the  electric  current.  The  current  should  have  only  moderate 
intensity,  for  a  high  degree  of  it  might  injure  the  vision.  It  should  be  ap- 
plied every  second  day,  with  one  pole  over  the  mastoid  foramen  and  the 
other  moved  slowly  over  the  muscles. 


CHAPTER   XV 


PSEUDO-HYPEETEOPHIC  PAEALYSIS. 


This  is  a  rare  disease.  It  was  first  described  by  Duchenne  in  1861,  and 
since  the  attention  of  the  profession  was  directed  to  it,  cases  have  been 
observed  on  the  Continent,  in  Great  Britain,  and  in  this  country.  Though 
our  acquaintance  with  it  is  so  recent,  it  has  been  fully  and  accurately 
described  by  various  writers  in  our  language.  The  Transactions  of  the  Lon- 
don Pathological  Society  for  1868  contain  a  translated  paper  relating  to  it, 
communicated  by  M.  Duchenne,  with  photographic  views  and  remarks  by 
Lockhart  Clarke,  and  also  the  histories  of  two  cases  occurring  in  London  and 
exhibited  to  the  Society  by  Adams  and  Hillier.  In  this  country  an  elaborate 
paper  has  appeared  on  this  form  of  paralysis  from  the  pen  of  Dr.  Webber  ^ 
of  Boston,  who  succeeded  in  collecting  the  records  of  41  cases  ;  and  more 
recently  Dr.  Poore.^  physician  to  the  New  York  Charity  Hospital,  collected 
the  records  of  85  cases,  which  furnish  the  material  of  his  monograph. 

Weakness  of  the  legs  and  a  peculiar  waddling  gait  are  the  first  observ- 
able symptoms,  and  by  them  we  are  able  to  ascertain  approximately  the  date 
of  the  commencement  of  the  paralysis.  In  27  of  the  cases  collated  by  Dr. 
Poore  the  malady  began  so  early  in  infancy  that  they  were  never  able  ta 
walk  like  other  children ;  in  5  there  is  no  record  in  regard  to  the  time  when 
the  peculiar  gait  was  first  observed  or  whether  they  ever  could  walk  ;  52,  or 
about  two-thirds  of  the  cases,  walked  well  at  first,  having  no  symptoms  of 
the  paralysis  till  after  the  age  of  two  years.  In  15  of  these,  weakness  of 
the  legs  and  the  peculiar  gait  were  first  observed  between  the  ages  of  two 

^  Boston  Med.  and  Surg.  Jour.,  Nov.  17,  1870. 
^  Neiv  York  Medical  Journal,  for  June,  1875. 


PSE  UD  0-HYPEB  TR  OPHIC  PAPAL  YSIS. 


673 


Fig.  194. 


and  a  half  and  five  years  ;  in  23,  between  the  ages  of  five  and  ten  years  ;  in  6, 
between  the  ages  of  ten  and  sixteen  years ;  and  in  8,  over  the  age  of  sixteen 
years.  It  is  seen,  therefore,  that  this  malady  is  pre-eminently  one  of  infancy 
and  childhood. 

The  gait,  which  is  unsteady  and  waddling,  has  been  compared  to  that  of 
a  duck.  The  child  stands  with  the  legs  wide  apart,  and  from  the  weakness 
of  the  limbs  and  unsteadiness  of  the  gait  frequently  stumbles  and  falls.  In 
many  cases  this  muscular  weakness  and  difficulty  in  walking  occur  before 
there  is  any  perceptible  enlargement  of  the  muscles  beyond  the  normal  size. 

The  hypertrophy  occurs  without  tenderness,  pain,  or  other  nervous  symp- 
toms, and  without  fever  or  constitutional  disturbance.  Occasionally  the 
patient  complains  of  stifi"ness  or  aching  in  the  limbs,  especially  after  exer- 
cise, even  before  the  enlargement  is  observed,  and  exceptionally  there  is  pain, 
even  acute,  in  the  legs.  The  hypertrophy  is  ordinarily  observed  first  in  the 
calf  of  one  leg,  and  then  in  the  opposite  calf.  In  a  case  related  by  Nie- 
meyer  the  muscles  of  the  gluteal  region  were  first  aff"ected.  In  nearly  all 
cases  the  gastrocnemii  are  hypertrophied.  There  were  only  2  exceptions  in 
the  85  cases  collated  by  Dr.  Poore,  but  almost  any  of  the  other  muscles  or 
groups  of  muscles  may  also  be  involved.  The  muscles  which  are  most 
prominently  affected  and  which  produce  the  characteristic  deformities  are 
those  of  the  extremities  and  posterior  aspect  of  the  trunk.  Spinal  curvature, 
which  is  attributed  to  the  weakened  state  of  the  erector  muscles  of  the  spine, 
appears  early  and  is  seldom  absent.  The  bending  is  such  that  a  plumb-line, 
dropped  from  the  most  posterior  of  the  spinal  processes,  falls  behind  the 
plane  of  the  sacrum  ;  and  this  is  a  means  of 
distinguishing  this  disease  from  certain  other 
spinal  afi"ections.  Figure  194:  represents  a  case 
which  came  to  the  children's  class  at  Bellevue 
in  April,  1872.  The  boy  was  two  years  old. 
and  the  mother  stated  that  the  peculiar  gait 
and  the  enlargements  had  only  been  observed 
from  four  to  six  weeks,  and  yet  the  curvature 
of  the  spine  was  quite  marked.  He  did  not 
return  to  the  class,  and  his  subsequent  history 
is  therefore  unknown. 

Of  the  muscles  in  the  upper  extremities 
the  deltoid  and  scapular  are  most  frequently 
enlarged.  Hypertrophy  of  the  temporals  has 
been  observed  in  3  cases,  of  the  masseters  in 
2,  of  the  tongue  in  3,  and  of  the  heart  in  -4 
(Poore). 

"We  shall  see  presently  that  atrophy  occurs 
in  the  muscular  element  of  the  parts  which 
are  affected,  and  that  the  hypertrophy  is  due 
to  hyperplasia  of  the  connective  tissue.  Now, 
occasionally  this  hyperplasia  does  not  occur 
or  is  tardy  in  occurring,  while  the  atrophy  has 
taken  place.  Therefore,  certain  muscles  may 
have  less  than  the  normal  volume,  which, 
from  contrast  with  those  which  are  hypertro- 
phied, increases  the  deformed  appearance.  In 
ordinary  cases  the  enlargement  advances  more  rapidly  and  continues  greater 
in  the  gastrocnemii,  which  are,  as  we  have  stated,  the  muscles  first  afl'ected, 
than  in  other  muscles,  and  therefore  the  prominence  and  hardness  of  the 
calves  of  the  legs  are  greater  than  elsewhere.  In  advanced  cases  walking  is 
43 


674  LOCAL  DISEASES. 

impossible,  and  tte  patient  is  obliged  to  remain  in  a  reclining  posture.  Some- 
times from  the  unequal  muscular  action  the  feet  become  extended  and  the 
toes  flexed,  so  that  the  child  in  attempting  to  walk  steps  on  the  anterior  part 
of  the  sole  of  the  foot,  as  in  talipes  equinus. 

In  the  first  stages  of  the  disease  the  electric  contractility  of  the  muscles 
is  nearly  normal,  but  in  advanced  cases  response  to  the  galvanic  current 
becomes  more  and  more  feeble  according  to  the  degree  of  atrophy  of  the 
muscular  fibres.  The  skin  retains  its  normal  sensibility,  with  exceptional 
instances  in  which  there  is  numbness  either  general  or  in  places.  Reddish 
or  bluish  mottling  of  the  surface  of  the  extremities  is  sometimes  observed, 
which  is  attributed  by  some  to  obstructed  venous  circulation  in  the  hypertro- 
phied  muscles,  and  by  others  is  supposed  to  be  due  to  the  peculiar  neuro- 
pathic state.  The  bladder  and  rectum  are  not  involved.  The  mental  facul- 
ties are  more  or  less  blunted  and  feeble  in  certain  cases,  especially  when  the 
disease  begins  in  early  infancy,  but  in  some  patients  they  do  not  seem  to  be 
materially  impaired. 

Anatomical  Characters. — There  have  been  so  few  post-mortem  exam- 
inations of  those  who  died  having  this  disease  that  it  is  still  uncertain  whether 
there  is  any  centric  lesion.  Cohnheim  examined  the  spinal  cord  in  one  case, 
and  could  find  nothing  abnormal.  Recently,  Mr.  KeSteven  has  examined  the 
brain  and  spinal  cord  from  a  case,  and  found  dilatation  of  the  perivascular 
canals  both  in  the  brain  and  spinal  cord,  and  also  spots  of  granular  degen- 
eration, chiefly  in  the  white  substance,  "  caused  by  loss  of  cerebral  tissue 
replaced  by  morbid  matter."^  As  this  child  was  imbecile,  it  is  not  improba- 
ble that  these  lesions  were  connected  with  the  mental  state  and  not  the  mus- 
cular disease. 

Professor  Charcot '  reports  a  careful  microscopic  examination  of  the  spinal 
cord  and  of  the  nerves  in  a  case  which  had  continued  ten  years.  He  could 
discover  no  deviation  from  the  healthy  state.  More  recently,  Dr.  J.  Lockhart 
Clarke^  examined  a  case  and  found  the  encephalon  healthy,  but  in  the  spinarl 
cord  there  was  more  or  less  disintegration  of  the  gray  substance  in  each  lat- 
eral half,  and  in  places  dilatation  of  vessels  and  commencing  sclerosis. 

It  seems,  therefore,  that  central  lesions  are  not  essential  and  are  some- 
times absent.  When  they  do  occur  it  is  probable  that  they  are  consecutive 
to   the  paralysis. 

The  essential  lesions  in  this  malady  are  atrophy  of  muscular  fibres  and 
hyperplasia  of  the  connective  tissue  which  surrounds  these  fibres.  The 
hyperplasia  of  the  one  element  in  the  muscle  is  greater  than  the  atrophy  of 
the  other,  and  hence  the  increase  of  volume  above  the  normal  size.  The 
atrophy  is  probably  a  primary  lesion,  for  muscular  weakness  ordinarily  occurs 
for  a  considerable  time  before  there  is  any  evidence  of  the  enlargement,  and, 
as  we  have  seen,  certain  muscles  may  undergo  the  atrophy  without  the  hyper- 
plasia. Still,  the  mechanical  effect  of  the  newly-formed  connective  tissue 
doubtless  increases  the  atrophy  in  those  muscular  fibres  which  this  tissue 
surrounds,  and  the  comparatively  quiet  state  of  muscles  in  consequence  of 
paralysis  not  only  tends  to  promote  the  atrophy  and  degeneration  of  these 
muscles,  but  also  of  contiguous  healthy  muscles. 

The  muscles  which  are  involved  in  this  paralysis  present  a  pale  yellowish 
hue,  resembling,  says  Niemeyer,  the  appearance  of  lipoma.  Examining  by 
the  microscope,  we  find,  in  addition  to  a  large  increase  in  the  fibrous  tissue 
and  atrophy,  and  in  some  places  disappearance  of  the  muscular  element,  more 
or  less  fatty  matter,  granular  and  globular,  occupying  the  interstices.  Mr. 
Kesteven  describes  as  follows  the  appearance  of  the  muscles  in  the  case  which 

1  Jour,  of  Med.  Sci.,  Jan.,  1871.  ^  Archiv.  de  Physiol.,  March,  1872. 

3  Medico-Chir.  Trans.,  1874. 


PSEUD 0-HYPEETEOPHIC  PARALYSIS.  675 

lie  examined :  "  The  muscular  substance  is  pale,  almost  white,  and  very 
greasy.  The  superabundance  of  fat  is  evident  to  the  naked  eye.  The  mus- 
cular fibres   present  the   ordinary   striation,  but   less   distinctly   than  usual. 

Fig.  195. 


l.hf 


>  -  -  ,     /  Nil 


Beginning  changes  in  lipomatous  pseudo-liypertropiiy  of  tlie  muscles  after  Ebstein  and  Marr: 
increase  and  nuclear  proliferation  of  the  interstitial  tissue  and  increase  of  the  sarcolemma 
nuclei :  1  hf,  two  hypertrophic  fibres ;  2  af,  atrophic  fibres.    (Enlarged  400  times.) 

The  ultimate  fibres  are  pale,  and  separated  by  a  large  increase  of  areolar  and 
fibrous  tissue." 

Causes. — Why  there  is  this  strange  perversion  of  nutrition,  so  that  there 
is  an  exaggerated  development  of  the  connective  tissue  of  the  muscles  and 
atrophy  of  the  muscular  fibres,  is  unknown.  Boys  are  more  liable  to  be 
afi"ected  than  girls.  Of  the  85  cases  embraced  in  the  statistics  of  Dr.  Poore, 
73  were  boys,  and  there  was  a  similar  excess  of  males  in  the  cases  collated 
by  Dr.  Webber. 

There  is  in  a  considerable  proportion  of  cases  the  record  of  hereditary 
transmission,  and  in  almost  all  the  instances  the  predisposition  is  acquired 
from  the  mother's  side.  Thus  in  37  of  Dr.  Poore's  cases  "  2  or  more  belonged 
to  the  same  family."  In  some  instances  three  and  even  four  maternal  rela- 
tives had  this  form  of  paralysis.  In  one  case  observed  by  Duchenne,  and  in 
a  few  others  subsequently  observed,  this  malady  seemed  to  be  congenital,  for 
the  limbs  at  birth  were  unusually  large,  and  the  patients  when  they  came 
under  observation  were  unable  to  walk.  No  relation  has  been  observed 
between  this  paralysis  and  syphilis,  scrofula,  or  other  diathetic  diseases. 

Prognosis. — This  disease  is  in  most  instances  progressive,  terminating 
fatally  after  a  variable  period.  It  is  in  its  nature  chronic,  rarely  ending  in 
less  than  five  or  six  years.  A  considerable  proportion  live  longer,  some  even 
attaining  adult  age.  The  paralysis  may  be  stationary  for  a  time,  but  after- 
wai'd  continue  to  increase.  Duchenne  has  reported  one  case  of  recovery.  In 
two  or  three  other  instances  patients  appeared  to  improve  somewhat  under 
treatment,  but  the  writers  admit  they  may  have  become  worse  afterward. 
Death  usually  occurs,  not  directly  from  the  paralysis,  but  from  some  inter- 
current disease,  especially  of  the  lungs. 

Treatment. — The  treatment  thus  far  employed  has  been  chiefly  local, 
consisting  in   the  use  of  electricity  and  kneading  or  shampooing  over  the 


676  LOCAL  DISEASES. 

affected  muscles.  Both,  the  primary  and  induced  electric  currents  have 
been  employed,  but.  unfortunately,  without  any  appreciable  benefit  in  most 
cases.  Benedikt,  who  claims  a  better  result  from  electrization  than  any 
other  observer,  applied  the  copper  pole  over  the  lower  cervical  ganglion,  and 
the  zinc  pole  along  the  side  of  the  lumbar  vertebrae  by  means  of  a  broad 
metallic   plate. 


CHAPTER  XVI. 

DISEASES  OF  THE  SPINAL  CORD  AND  ITS  COVERINGS. 

The  diseases  of  the  spinal  cord  and  of  the  parts  which  cover  and  protect 
it  are  important,  but  they  are  less  understood  than  are  those  of  any  other 
portion  of  the  body.  This  is  partly  due  to  the  fact  that  in  many  cases  the 
spinal  disease  coexists  with  a  similar  pathological  state  of  the  brain  or  its 
meninges,  the  symptoms  of  which  predominate  and  mask  those  which  pertain 
to  the  spine ;  partly  to  the  fact  that  the  chief  symptoms  of  spinal  disease  are 
often  located  in  organs  or  parts  which  are  at  a  distance  from  the  spine  ;  and, 
lastly,  to  the  fact  that  it  is  difficult,  for  obvious  reasons,  to  deteriuine  the 
exact  state  of  the  spine  at  the  bedside,  while  post-mortem  inspection  of  the 
spine,  which  alone  can  give  accurate  pathological  knowledge,  is  less  frequently 
made  than  of  any  other  organ. 

Certain  spinal  diseases  occurring  in  childhood  are  the  same  as  in  adult 
life,  presenting  identical  symptoms  and  lesions  in  the  two  periods,  and  there- 
fore they  require  no  extended  notice  in  this  treatise.  Others  are  common  to 
childhood  and  maturity,  but  they  present  peculiarities  in  the  former  period 
which  require  to  be  pointed  out,  while  others  still  are  peculiar  to  childhood. 

The  so-called  spinal  irritation  or  anaemic  neuralgia  is  not  infrequent  in 
delicate  and  poorly-fed  children.  I  have  from  time  to  time  observed  marked 
cases  of  it  in  the  class  in  the  Out-Door  Department  of  Bellevue,  the  patients 
usually  being  above  the  age  of  three  or  four  years  and  exhibiting  evidences 
of  cachexia.  Most  of  them  have  been  spare  and  pallid,  some  affected  with 
a  nervous  cough  or  palpitation,  and  some  with  neuralgic  pains  in  the  chest, 
abdomen,  or  elsewhere,  which  pressure  at  a  certain  point  upon  the  spine 
intensified.  These  cases  recover  by  better  feeding,  out-door  exei'cise.  mild 
counter-irritation  along  the  spine,  and  the  use  of  tonics,  especially  of  iron. 

Primary  inflammation  of  the  cord  and  its  meninges  is  rare  in  children. 
Secondary  inflammation  of  these  parts  is,  on  the  other  hand,  more  common 
in  children  than  in  adults.  It  is  common  in  caries  of  the  vertebra?  and  in 
cerebro-spinal  fever.  The  preponderance  in  functional  activity  of  the  spinal 
cord  and  the  feeble  controlling  power  of  the  brain  render  infancy  and  child- 
hood more  liable  to  convulsions  and  reflex  paralysis  than  any  other  period  in 
life.  Cases  of  true  reflex  paralysis  occasionally  occur  in  children,  in  regard 
to  the  etiology  of  which  there  can  be  no  doubt.  Prof.  Sayre  of  this  city  has 
called  attention  to  the  fact  that  balanitis  and  preputial  adhesions  sometimes 
cause  paraplegia,  more  or  less  pronounced,  in  young  children,  and  which  is 
relieved  by  dividing  the  adhesions  and  restoring  the  mucous  surface  of  the 
glans  and  prepuce  to  its  normal  state.  Such  a  case  was  brought  to  the  chil- 
dren's class  in  the  Out-door  Department  at  Bellevue  in  April,  1875.  The 
child  could  not  walk  or  scarcely  stand  without  support,  but  after  the  division 
of  the  adhesions    and    subsidence  of  the  inflammation,  locomotion  rapidly 


CONGESTION  OF  THE  SPINAL   CORD  AND  ITS  MEMBRANES.   677 

improved/  In  another  instance  a  child  could  not  walk  properly,  having  a 
tottering  gait  and  dragging  one  foot.  The  preputial  and  urethral  orifices 
presented  an  irritated  appearance.  The  prepuce  was  stretched  and  separated 
from  the  glans  at  a  few  sittings,  the  instrument  used  being  an  infant's  catheter 
stifiened  with  a  wire,  so  that  it  served  as  a  probe.  Large  masses  of  smegma, 
nearly  as  far  forward  as  the  preputial  orifice,  were  found  underneath.  These 
were  removed,  and  the  parts  were  smeared  with  sweet  oil.  The  patient  rap- 
idly recovered  the  full  use  of  his  limbs,  and  was  soon  entirely  well.  It  is 
well  known  that  masturbation  sometimes  causes  a  similar  weakness  of  the 
lower  extremities.  Dr.  West  relates  the  case  of  a  child  "  between  two  and 
three  years  old "'  who  began  to  totter  in  his  gait,  and  finally  almost  ceased 
walking.  He  was  observed  to  practise  masturbation.  "  This  was  put  a  stop 
to,"  and  he  soon  recovered  his  health  and  his  power  of  locomotion.'-* 


CHAPTER    XVII. 

GONGESTIOiS^  OF  THE  SPINAL  COED  AND  ITS  MEMBRANES. 

Congestion  of  the  spinal  cord  and  meninges  occurs  both  as  a  primary 
and  secondary  malady,  the  latter  being  more  frequent  than  the  former.  It 
may  be  active  or  passive.  Active  congestion,  occurring  independently  of 
meningitis  or  myelitis,  is  in  most  instances  transient  and  subordinate  to  some 
graver  disease,  in  the  course  of  which  it  arises.  It  is  probably  often  over- 
looked. It  is  not  fatal,  and  its  symptoms  are  frequently  masked  by  those 
which  are  referable  to  the  brain  or  some  other  organ.  It  is  believed  to  be 
common  in  the  initial  period  of  certain  of  the  fevers  of  childhood.  It  is  not 
improbable  that  the  hyperaesthesia  observed  upon  the  thoracic  and  abdominal 
surfaces  and  along  the  thighs  in  the  commencement  of  remittent  and  certain 
other  febrile  diseases  has  its  origin  in  a  congested  state  of  the  spine.  To 
this  congestion  writers  attribute  the  lumbar  pain  and  occasional  paraplegia  in 
the  initial  stage  of  variola.  Active  spinal  congestion  may  also  result  from 
the  sudden  impression  of  cold,  and,  as  we  have  stated  above,  this  is  apparently 
the  most  frequent  cause  of  poliomyelitis  acuta  anterior. 

Certain  anatomical  circumstances  favor  the  occurrence  of  passive  con- 
gestion of  the  spinal  cord  and  meninges — to  wit.  the  tortuousness  of  their 
veins  and  the  absence  of  valves,  the  lack  of  muscular  support  in  them,  of 
the  vessels,  and  the  inferior  position  of  the  spine  in  sickness  as  the  patient 
lies  quietly  in  bed.  A  common  cause  of  passive  congestion  of  these  parts  is 
some  protracted  and  enfeebling  disease  which  diminishes  the  contractile  force 
of  the  heart  (cardiac  paresis),  producing  congestion  of  the  spinal  cord  in  the 
same  manner  as  under  similar  circumstances  hypostatic  congestion  of  the 
lungs  occurs.  Severe  convulsive  diseases,  as  tetanus  or  eclampsia,  when  pro- 
tracted or  occurring  at  short  intervals,  commonly  produce  spinal  congestion. 
In  tetanus  this  congestion  is  extreme,  so  that  extravasation  of  blood  is  liable 
to  occur  from  the  engorged  vessels,  especially  those  of  the  pia  mater. 

Anatomical  Characters. — It  is  often  impossible,  at  post-mortem  exami- 

^  Drs.  Holgate  and  Bosley,  formerly  attending  physicians  in  the  children's  class  at 
Bellevue,  made  many  examinations  of  the  state  of  thn  prepuce  in  young  children. 
They  report  that  they  found  preputial  adhesions  almost  daily,  in  most  instances  without 
symjptoms,  but  sometimes  with  dysuria,  and  occasionally  with  more  or  less  impairment 
of  the  use  of  the  legs. 

^  Diseases  of  Children,  p.  146,  4th  Amer.  ed. 


678  LOCAL  DISEASES. 

nations,  to  determine  how  much  of  the  congestion  of  the  spine  and  its  meninges 
is  pathological  and  how  much  cadaveric,  since,  if  the  corpse  be  placed  on  its 
back  at  death,  a  very  considerable  engorgement  of  the  spinal  vessels  occurs 
from  gravitation  of  blood.  If  the  body  have  been  placed  on  the  side  or  face, 
this  cadaveric  congestion  is  prevented.  Since  in  active  congestion  the  arterioles 
and  capillaries  are  distended  with  arterial  blood,  the  color  is  a  brighter  red 
than  in  passive  congestion,  in  which  venous  blood  predominates.  Active  con- 
gestion of  the  cord  usually  coexists  with  that  of  the  meninges,  but  it  may 
occur  without  it.  In  cases  of  considerable  congestion  the  "  puncta  vascu- 
losa  "  appear  upon  the  incised  surface  both  of  the  white  and  gray  substance. 
If  the  congestion  be  protracted  or  if  it  recur  frequently,  it  may  produce  per- 
manent dilatation  of  the  arterioles  and  capillaries  in  greater  or  less  degree, 
and  it  may  also  lead  to  sclerosis  of  the  cord.  Passive,  congestion  seldom,  per- 
haps never,  occurs  in  the  cord  without  being  equally  and  often  to  a  greater 
extent  present  in  the  meninges.  Continuing  for  a  time,  it  gives  rise  to  trans- 
udation of  serum  into  the  interspaces  over  the  cord,  and  even  softening  of 
the  cord  may  occur  to  a  limited  extent  from  imbibition  of  serum.  In  either 
form  of  congestion  extravasations  of  blood  are  frequent. 

Symptoms. — Spinal  congestion  is  announced  by  pain  in  the  region  of  the 
spine,  usually  in  the  lumbar  or  dorsal  and  lumbar  portions,  and  irradiations 
of  pain  and  tingling  in  the  legs.  In  addition,  more  or  less  paralysis  of  the 
bladder  and  legs  may  result.  The  paraplegia  may  occur  early  or  not  till  the 
lapse  of  several  days.  In  active  congestion  the  symptoms  are  rapidly  devel- 
oped, and  they  attain  their  maximum  intensity  sooner  than  in  the  passive 
form.  In  passive  congestion  the  development  of  symptoms  is  not  only  more 
gradual,  but  they  are  ordinarily  less  pronounced,  and  are  attended  by  more 
fluctuation,  than  in  the  active  form.  The  paralysis,  if  present,  comes  on 
slowly  after  several  days,  and  is  incomplete.  Spinal  congestion,  especially 
of  the  passive  form,  is  sometimes  associated  with  cerebral  congestion — as,  for 
example,  in  tetanus  and  severe  eclampsia — and  the  spinal  symptoms  there- 
fore coexist  with  those  which  have  a  cerebral  origin.  The  duration  and  the 
result  of  a  hypersemic  state  of  the  spinal  cord  and  its  meninges  depend 
largely  on  the  nature  of  the  cause.  If  it  be  not  relieved  within  a  few  days, 
there  is  strong  probability  that  some  other  serious  pathological  state  has 
supervened,  as  meningitis,  myelitis,  extravasation  of  blood,  or  serous  trans- 
udation, with  softening  of  the  nervous  substance. 

Treatment. — In  the  adult  spinal  congestion  sometimes  results  from  the 
sudden  cessation  of  the  hemorrhoidal  or  catamenial  flow,  and  the  application 
of  leeches  or  wet  cups  along  the  spine  is  indicated.  But  in  the  child  the 
abstraction  of  blood  is  seldom  required.  In  the  acute  stage  of  active  spinal 
congestion,  with  elevation  of  temperature,  cold  applications  along  the  spine 
are  often  beneficial,  as  by  an  India-rubber  bag. 

In  active  hypersemia  laxatives  are  useful,  and  rubefacient  applications 
should  be  made  along  the  spine,  as  by  mustard  or  by  friction  with  a  stimu- 
lating liniment.  In  the  inflammatory  spinal  congestion  of  cerebro-spinal  fever 
I  have  employed  with  a  very  satisfactory  result  a  liniment  containing  equal 
parts  of  camphorated  oil  and  turpentine.  In  both  active  and  passive  hyper- 
cemia  lateral  decubitus  should  be  prescribed  rather  than  dorsal.  The  tise  of 
ergot  in  order  to  diminish  the  turgescence  of  the  vessels  of  the  spinal  cord 
and  meninges  has  been  advocated  by  Brown-Sequard,  and  it  is  now  one  of 
the  recognized  remedies.  Bromide  of  potassium  is  also  a  remedy  of  value, 
but  it  is  more  useful  in  some  cases  than  in  others.  It  is  signally  beneficial 
in  those  cases  in  which  there  is  also  cerebral  congestion.  When  the  conges- 
tion is  increased  or  produced  by  clonic  convulsions  the  bromide  is  one  of  the 
most  reliable  remedies  which  we  possess  for  the  removal  of  the  cause.     Thus, 


CONGESTION  OF  THE  SPINAL    CORD   AND  ITS  MEMBRANES.    679 

it  should  be  employed  in  the  treatment  of  the  spinal  and  cerebral  congestion 
in  the  commencement  of  variola,  in  which  convulsions  are  so  common, "and  in 
the  convulsions  of  pertussis  or  pneumonia,  which  cause  extreme  passive  con- 
gestion of  the  cerebro-spinal  axis.  Passive  congestion  of  the  spine,  common 
in  exhausting  diseases  and  due  to  feebleness  of  the  circulation,  is  best  treated 
by  stimulating  and  sustaining  remedies  and  by  the  lateral  decubitus.  It  is 
hypostatic,  and  may  be  associated  with  a  similar  congestion  in  the  posterior 
part  of  the  lungs. 


SEOTIOI^  III. 

DISEASES   OF   THE   DIGESTIVE   APPARATUS. 


CHAPTER    I. 


SIMPLE  STOMATITIS,  ULCEROUS  STOMATITIS,  FOLLICULAR 
STOMATITIS. 

Diseases  of  the  digestive  system  are  very  frequent  in  infancy  and  child- 
hood. They  are  for  the  most  part  readily  recognized,  and  are  more  easily 
and  quickly  controlled  by  therapeutic  agents,  if  rightly  applied,  than  are  the 
diseases  of  any  other  system.  If  misunderstood  and  improperly  treated, 
they  may,  even  when  mild  and  very  manageable  in  their  commencement, 
become  chronic  and  obstinate,  or  even  fatal,  or  they  may  lead  to  other  and 
more  dangerous  diseases.  It  is  necessary,  then,  that  the  physician  should 
understand  thoroughly  the  pathology  as  well  as  the  therapeutics  of  the 
digestive  system,  that  he  may  make  timely  and  correct  use  of  the  required 
remedies. 

The  diseases  of  the  buccal  cavity  in  early  life  are  for  the  most  part  in- 
flammatory, one  of  the  most  interesting  of  which — to  wit,  sprue  or  thrush — 
we  have  already  treated  of  among  the  diseases  of  the  newly-born.  The 
mildest  of  these  diseases  is  that  known  as 

Simple  or  catarrhal  stomatitis,  which  is  more  common  in  infancy  than  in 
any  other  period  of  life  ;  it  occurs  over  the  whole  buccal  cavity  or  a  portion 
of  it,  according  to  the  nature  of  the  cause.  A  common  cause  is  the  use  of 
indigestible  food  or  food  not  suitable  for  the  age  or  development  of  the  infant, 
and  therefore  irritating ;  uncleanliness,  personal  and  domiciliary ;  in  fine,  all 
those  agencies  which  impair  the  general  health  and  enfeeble  the  digestive 
organs.  Therefore  stomatitis  is  more  common  among  the  city  poor,  who  are 
often  improperly  fed,  than  in  those  in  the  better  walks  of  life,  and  especially 
those  who  have  the  fresh  air  and  properly  prepared  food  of  the  country. 
Infants  deprived  of  the  mother's  milk,  and  given  a  diet  which,  with  all  care 
of  preparation,  is  a  poor  substitute  for  the  natural  aliment,  are  very  liable  to 
this  disease.  Beaumont  ascertained  from  his  experiments  on  St.  Martin  that 
irritative  changes  produced  in  the  stomach  by  indigestible  substances  were 
soon  followed  by  similar  changes  in  the  buccal  mucous  membrane.  Since  in 
young  infants  any  kind  of  artificial  food  is  less  digestible  than  breast-milk, 
it  is  evident  why  those  who  are  prematurely  weaned  or  are  carelessly  fed  are 
so  liable  to  stomatitis.  This  inflammation  is  also  sometimes  due  to  irritating 
substances  taken  into  the  mouth,  as  drinks  habitually  too  hot  or  too  cold. 
Stomatitis  is  also  present  in  measles  and  scarlet  fever  and  the  other  eruptive 
fevers.  It  then  corresponds  with  the  cutaneous  eruption,  and  disappears 
when  that  subsides. 

680 


SIMPLE  STOMATITIS,  ETC.  681 

Stomatitis  has  long  been  ascribed  to  dentition.  There  is  uniformly  some 
turgescence  of  the  gum  over  an  advancing  tooth,  but  in  the  normal  state 
there  is  not,  in  my  opinion,  any  decided  inflammation  from  this  cause,  but 
inflammation  may  be  produced  by  frequent  rubbing  of  the  gum  or  the  chew- 
ing of  an  artificial  nipple  or  other  hard  substance.  Mercury,  in  whatever 
form  introduced  into  the  system,  excreted  by  the  salivary  glands  and  flowing 
over  the  buccal  surface,  is  an  occasional  cause. 

Symptoms  :  Appearances. — Stomatitis,  like  other  mucous  inflammations, 
is  characterized  by  increased  redness  and  more  or  less  thickening  of  the 
inflamed  buccal  membrane,  by  rapid  proliferation  and  exfoliation  of  epi- 
thelial cells,  and  by  an  increased  functional  activity  of  the  muciparous  fol- 
licles. The  heat  of  the  mouth  is  sometimes  augmented  in  an  appreciable 
degree.  The  gums  in  severe  cases  are  swollen  and  spongy,  and  bleed  readily 
if  rubbed  or  pressed.  The  tongue  is  usually  covered  with  a  light  fur,  and 
the  salivary  secretion  is  frequently  augmented  to  such  an  extent  as  to  dribble 
from  the  corners  of  the  mouth.  Often  there  is  little  suff"ering,  but  in  other 
instances  the  patients  are  fretful,  experience  pain  from  the  contact  of  solid 
food,  and.  if  nursing,  may  even  wean  themselves  from  dread  of  pressure  of 
the  nipple. 

Simple  stomatitis  is  not  difiicult  of  detection,  provided  that  attention  be 
directed  to  the  mouth.  Inspection  informs  us  of  its  presence  and  extent. 
A  favorable  termination  may  be  confidently  predicted,  unless  there  be  a  state 
of  marked  cachexia  or  a  grave  coexisting  disease.  If  circumstances  are 
unfavorable,  simple  stomatitis  may  terminate  in  a  more  severe  form,  as  the 
ulcerous  or  diphtheritic. 

Treatment. — The  physician  should  endeavor  to  ascertain  the  cause,  and, 
if  possible,  should  remove  it  by  appropriate  medicinal  and  hygienic  measures. 
Sometimes  no  special  treatment  is  required,  as  in  measles  or  scarlet  fever. 
When  the  primary  aff"ection  terminates  the  stomatitis  disappears  of  itself. 
If  there  be  much  fever  and  fretfulness,  it  has  been  the  common  practice  to 
scarify  the  gums,  but  this  operation  is  harmful  instead  of  beneficial  by  in- 
creasing the  tenderness.  A  few  doses  of  bromide  of  potassium  relieve  the 
fretfulness,  and  mucilaginous  and  mild  astringent  lotions  suffice  for  the 
catarrh.  Borax  is  a  good  local  remedy  used  either  with  honey  or  with  gly- 
cerin and  water — one  part  of  borax  to  three  of  honey,  or  a  drachm  of  borax 
to  an  ounce  of  water  and  two  drachms  of  glycerin.  A  mixture  of  bismuth 
subnitrate  and  boracic  acid  is  also  a  useful  topical  remedy.  With  either  of 
these  agents,  in  a  favorable  condition  of  system,  and  without  any  serious 
coexisting  disease,  the  stomatitis  is  relieved. 

Ulcerous  Stomatitis. 

In  ulcerous  stomatitis  the  anatomical  characters  are  those  of  severe  simple 
stomatitis,  with  the  additional  element  which  gives  it  the  name  by  which  it 
is  designated. 

The  inflammation  usually  begins  upon  the  gums  and  extends  along  the 
buccal  surface.  Little  white  points  soon  appear  upon  the  under  surface  of 
the  mucous  membrane,  producing  slight  prominence  of  it.  These  points, 
which  are  inflammatory  exudations,  mainly  fibrinous,  gradually  enlarge. 
Some  unite  and  give  rise  to  large  irregular  ulcerations  ;  others  remain  isolated, 
producing  ulcers  which  are  smaller  and  of  more  regular  shape.  There  is, 
indeed,  no  uniformity  as  regards  the  size  and  form  of  the  ulcers.  In  the 
folds  of  the  buccal  membrane  they  are  usually  elongated,  while  inside  the 
lips  or  where  the  surface  is  smooth  the  circular  or  oval  form  predominates. 
It  is  a  noteworthy  fact  that  the  exudation  underlies  the  mucous  membrane, 


682  LOCAL  DISEASES. 

obstructing  its  nutrient  vessels,  so  that  the  ulcer  which  results  causes  destruc- 
tion of  the  mucous  layer  and  cure  is  effected  by  cicatrization. 

Ulcerous  stomatitis  is  usually  confined  to  that  part  of  the  buccal  surface 
which  covers  the  gums  or  is  in  their  immediate  vicinity,  but  in  some  instances 
it  aifects  nearly  every  part  of  the  cavity  of  the  mouth. 

If  the  disease  be  severe,  considerable  swelling  occurs  around  the  ulcers, 
but  the  swollen  part  is  soft  and  cushiony  and  not  very  tender  on  pressure. 
The  soft  and  yielding  nature  of  the  swelling  serves  as  a  means  of  diagnosis 
between  this  disease  and  the  premonitory  stage  of  gangrene,  since  in  the  latter 
affection  the  swollen  part  is  more  indurated. 

If  the  disease  grow  worse,  more  ulcers  appear,  and  those  already  present 
grow  deeper  and  wider  and  their  edges  more  vascular. 

If,  on  the  other  hand,  there  be  improvement,  the  swelling  subsides,  the 
ulcers  become  more  clean,  their  bases  approach  the  level  of  the  mucous  mem- 
brane and  present  a  granulating  appearance.  Finally,  the  mucous  layer  is 
reproduced.  A  considerable  time  after  the  ulcers  are  healed  the  new  mem- 
brane which  occupies  their  site  has  a  redder  hue  than  the  adjacent  surface. 

Causes. — Ulcerous,  like  simple,  stomatitis  is  most  frequent  in  the  families 
of  the  poor.  Personal  uncleanliness,  poor  food,  a  residence  in  apartments 
dirty,  humid,  or  in  other  respects  insalubrious,  favor  its  development.  In 
fine,  a  cachectic  condition,  however  produced,  is  a  common  predisposing 
cause.  Ulcerous  stomatitis  frequently  occurs  when  the  system  is  reduced  or 
enfeebled  by  acute  diseases,  as  after  the  essential  fevers  and  thoracic  and 
intestinal  inflammations.  In  protracted  entero-colitis  of  infants  it  is  some- 
times severe  and  obstinate,  and  a  case  in  which  this  complication  arises 
usually  ends  unfavorably.  The  abuse  of  mercury  is  an  occasional  cause  of 
this  form  of  stomatitis,  as  well  as  of  simple  catarrh.  Jaccoud  states  that 
Bergeron  established  the  fact  that  ulcerous  stomatitis  is  propagated  among 
soldiers  by  contagion,  and  he  adds,  "  it  is  very  probable  that  it  is  the  same  in 
infants." 

Symptoms. — The  symptoms  in  ulcerous  stomatitis  are  more  severe  than 
in  the  simple  form.  There  are  more  pain,  more  salivation,  and  more  fretful- 
ness.  The  ulcerated  surface  is  sometimes  very  tender,  so  that  there  is  but 
little  sleep.  Drinks,  unless  bland  and  lukewarm,  are  painful,  and  if  the  ulcers 
be  on  the  lips  or  the  front  of  the  mouth,  the  infant  nurses  less  eagerly  than 
usual,  and  even  with  reluctance,  sometimes  weaning  itself.  Occasionally 
the  submaxillary  glands  are  tumefied,  hard,  and  tender.  The  breath  has  an 
offensive  odor.  In  mild  cases,  in  which  the  stomatitis  is  of  limited  extent, 
this  odor  may  scarcely  be  noticed,  but  in  severe  cases  it  is  almost  like  that 
exhaled  from  putrid  substances.     The  fever  is  in  most  instances  slight. 

Prognosis. — A  favorable  prognosis  may  be  given  unless  the  patient  be  in 
a  decidedly  cachectic  condition  or  there  be  a  serious  coexisting  disease,  under 
which  circumstances  the  case  may  be  protracted.  If  death  occur,  it  is  due  to 
the  cachexia  or  to  some  pathological  state  quite  distinct  from  the  stomatitis, 
most  frequently  entero-colitis.  Ulcerous  stomatitis  when  the  ulcers  are  small 
and  the  inflammation  of  limited  extent,  is  of  course  more  easily  ciired  than 
when  it  is  extensive  and  the  ulcers  are  large. 

This  disease  is  very  liable  to  return  unless  the  general  health  be  good. 

Treatment. — The  physician  should  endeavor  to  ascertain  the  cause  of 
the  stomatitis,  and  so  far  as  possible  should  remove  the  patient  from  its  influ- 
ence. It  is  often  necessary,  in  order  to  ensure  speedy  recovery,  to  recommend 
a  change  in  regimen,  especially  as  regards  diet  and  cleanliness.  If  the 
patient  live  in  damp,  dark,  and  dirty  apartments,  the  family  should  seek  a 
better  residence,  and  he  should  be  taken  daily  into  the  open  air. 

Tonic   remedies   are   generally   required.     The   ferruginous    preparations 


SIMPLE  STOMATITIS,   ETC.  683 

may  be  advantageously  given,  or  the  vegetable  tonics,  or  the  two  in  combina- 
tion. In  selecting  the  internal  remedies  we  must  regard  the  antecedent  dis- 
ease, if  there  be  any,  which  the  buccal  inflammation  complicates  and  on 
which  it  depends.  For  that  large  proportion  of  cases  in  which  there  is  in- 
testinal catarrh  the  treatment  detailed  elsewhere  for  this  disease  is  indicated. 
Bismuth  subnitrate,  pepsin,  and  a  careful  selection  of  food  appropriate  for 
the  age  of  the  patient  are  needed.  The  following  mouth-wash,  applied  with 
a  eamers-hair  pencil,  has  seemed  to  me  more  serviceable  than  the  chlorate-of- 
potassium  mixture  which  has  been  commonly  employed  : 

R.  Bismuth  subnitrate,  ^ij  ; 
Acidi  borici, 

Sodii  borat.,  da.   5J  ; 

Mellis,  ^ss ; 

Aquge  destillat.,  q.  s.  ad  3iv. 

Aphthous  stomatitis  may  occur  at  any  age,  but  it  is  most  frequent  in 
childhood.  It  is  sometimes  designated  follicular  stomatitis,  but  the  disease 
affects  the  contiguous  mucous  surface  as  well  as  the  seat  of  the  follicles.  At 
first  a  vascular  injection  is  observed,  and  within  a  few  hours  a  whitish  exuda- 
tion occurs  immediately  under  the  epithelium  and  upon  the  corium  in  small 
round  or  oval  isolated  spots.  The  smallest  of  these  patches  are  not  larger 
than  a  pin  s  head,  but  most  of  them  have  a  diameter  of  one  or  two  lines, 
and  they  cause  slight  prominence  of  the  surface.  In  two  or  three  days  the 
exudation  softens,  and  the  epithelium  which  covers  it  is  thrown  ofi",  producing 
an  ulcer,  superficial,  without  induration  of  its  edges,  but  sensitive  to  the 
touch.  It  heals  in  one  or  two  weeks,  leaving  only  a  reddish  spot  or  stain, 
which  soon  fades.  Sometimes  two  or  more  aphthae  unite,  forming  a  patch 
and  an  ulcer  of  correspondingly  large  size.  The  seat  of  aphthous  stomatitis 
is  usually  the  internal  surface  of  the  lips  and  cheeks,  the  gums,  tongue,  and 
occasionally  the  roof  of  the  mouth. 

Causes. — Probably  in  most  instances  the  exciting  cause  is  some  derange- 
ment of  the  digestive  organs  which  may  not  be  appreciable.  We  sometimes 
observe  this  form  of  stomatitis  in  cases  of  diarrhoea.  Occasionally,  espe- 
cially in  spring  and  autumn,  two  children  in  a  family  are  alfected  at  the  same 
time,  or  two  or  more  in  a  school,  so  that  the  disease  presents  an  epidemic 
character.  Children  surrounded  by  bad  hygienic  conditions,  as  in  the  tene- 
ment-houses of  cities,  are  more  liable  to  this,  as  well  as  other  forms  of  stoma- 
titis, than  are  children  who  live  in  clean  and  airy  localities  and  have  nutri- 
tious and  wholesome  diet. 

Symptoms. — The  constitutional  symptoms  in  a  large  proportion  of  cases 
of  aphthae  are  slight.  In  twelve  children  afi"ected  with  the  disease  Billard 
found  the  pulse  from  sixty  to  eighty  beats  per  minute. 

The  iilcers  are  painful,  as  is  indicated  by  the  cries  of  the  child  when  they 
are  pressed,  and  its  fretfulness.  Solid  food,  and  even  drinks,  unless  bland 
and  unirritating,  are  badly  tolerated.  The  salivary  secretion  is  also  aug- 
mented. 

In  those  rare  cases  in  which  the  ulcers  become  confluent  or  gangrenous 
the  state  of  the  patient  is  really  serious.  There  is  then  often  gastro-intes- 
tinal  disease.  The  symptoms  indicate  prostration.  The  pulse  is  feeble,  the 
countenance  pallid,  and  the  body  and  limbs  become  wasted. 

Diagnosis. — This  is  easy.  The  only  disease  with  which  it  is  liable  to  be 
confounded  is  ulcerous  stomatitis.  In  the  ulcerous  form  there  is  antecedent 
and  accompanying  stomatitis  aff"ecting  a  considerable  part,  if  not  the  entire 
buccal  cavity,  while  in  the  follicular  form  the  inflammation  is  ordinarily  con- 
fined to  the  immediate  vicinity  of  the  ulcers.     The  character  of  the  ulcers 


684  LOCAL  DISEASES. 

serves  also  as  a  means  of  distinction.  In  ulcerous  stomatitis  there  is  great 
variety  as  to  size  and  form,  while  in  aphthous  stomatitis  there  is  great  uni- 
formity in  both  these  respects.  The  small  circular  ulcers  are  characteristic 
of  the  follicular  inflammation.  Before  the  ulcerative  stage  the  circumscribed 
character  of  the  eruption  serves  to  distinguish  this  form  of  stomatitis  from 
other  local  diseases  aifecting  the  cavity  of  the  mouth. 

Prognosis. — Aphthous  stomatitis  usually  ends  favorably,  but  if  the 
ulcers  became  concrete  or  gangrenous  the  health  is  seriously  affected,  and  a 
more  cautious  prognosis  should  be  expressed.  The  unhealthy  appearance  of 
the  mouth  and  the  real  danger  are  more  often  due  to  the  depressing  effect 
of  some  concomitant  disease  than  to  the  stomatitis. 

Treatment. — In  ordinary  aphthous  stomatitis,  which  is  discrete  and 
attended  by  little  or  no  constitutional  disturbance,  local  remedies  suffice  to 
cure  the  disease.  Demulcent  drinks  or  applications  to  the  mouth  should  be 
used,  as  the  mucilage  from  gum  acacia,  marshmallow,  or  flaxseed.  Mild 
astringent  lotions  with  the  demulcent  are  also  beneficial.  The  mel  boracis 
is  one  of  the  best  and  most  agreeable  applications.  It  may  be  placed  in  the 
mouth  with  a  spoon  or  applied  with  a  camels-hair  pencil.  If  there  be  much 
tenderness  of  the  ulcers,  with  restlessness,  a  small  quantity  of  some  opiate 
should  be  added  to  the  lotion  or  it  may  be  administered  separately. 

With  this  simple  treatment  the  ulcers  generally  soon  heal  and  the  health 
of  the  patient  is  restored.  If,  however,  the  ulcers  be  painful  and  not  dis- 
posed to  heal,  or  be  healing  tardily,  they  may  be  touched  lightly  with  a 
pencil  of  nitrate  of  silver,  or,  as  Barrier  recommends,  hydrochloric  acid  in 
honey  of  roses.  This  diminishes  the  tenderness  and  expedites  the  healing 
process.  A  better  remedy  is  iodoform,  two  drachms  to  one  ounce  of  ether, 
and  applied  to  the  ulcers  by  a  camels-hair  pencil. 

If.  as  may  in  rare  eases  occur,  the  ulcerations  be  numerous  and  accom- 
panied b}"  considerable  fever,  there  may  be  symptoms  indicative  of  cerebral 
congestion  or  even  premonitory  of  convulsions.  In  such  cases  laxatives  and 
the  soothing  eff"ect  of  one  of  the  bromides,  and  sometimes  of  the  warm  foot- 
bath, are  required. 

If  there  be  an  unhealthy"  appearance  of  the  ulcers,  if  they  gradually  en- 
large or  become  concrete  or  gangrenous,  indicating  a  cachectic  state,  tonics 
should  be  employed,  with  nutritious  and  easily-digested  diet,  and  antihygienic 
influences  should  so  far  as  possible  be  removed. 


CHAPTER    II. 

GANGEENE  OF  THE   MOUTH. 

The  diseases  of  the  mouth  which  we  have  been  considering  are  attended 
by  little  danger,  but  the  one  which  we  are  next  to  consider  is  among  the 
most  fatal  of  early  life.  It  is  gangrene  of  a  portion  of  the  cheek  or  gums, 
or  of  both.  It  is  described  by  writers  under  various  names,  as  cancrum 
oris,  noma,  necrosis  infantilis,  aqueous  cancer  of  infants. 

Anatomical  Characters. — G-angrene  of  the  mouth  is  sometimes  pre- 
ceded by  ulceration  of  the  mucous  membrane  at  the  point  where  it  is  about 
to  commence,  but  in  other  cases  this  membrane  is  entire.  The  tissues  at  the 
point  of  attack,  which  is  most  frequently  the  inside  of  the  cheek,  become 


GANGRENE  OF  THE  MOUTH.  685 

inflamed,  thickened,  and  indurated.  The  induration  extends,  and  soon  the 
purple  hue  of  gangrene  appears  and  increases.  The  next  stage  in  the  prog- 
ress of  gangrene  is  sloughing  of  the  portion  the  vitality  of  which  is  lost. 

The  slough  does  not  present  the  appearance  of  uniform  decay.  While 
the  color  is  generally  dark,  there  are  in  the  mass,  fibres  of  connective  tissue, 
or  even  blood-vessels,  which  remain  unchanged  or  are  but  partly  decomposed. 
After  separation  or  sloughing  of  the  part  where  the  vitality  is  first  lost,  the 
surface  of  the  excavation,  if  the  disease  be  not  checked,  has  a  dark,  jagged, 
and  unhealthy  appearance.  Commencing  with  the  mucous  membrane  and 
the  tissue  immediately  underlying  it.  the  disease  extends  on  the  one  side 
toward  the  skin  and  on  the  other  toward  the  deeper-seated  structures  of  the 
jaw.  According  to  Billard,  the  swelling  which  precedes  and  surrounds  the 
gangrene  is  in  great  part  oedematous. 

This  disease  is  occasionally  primary,  but  in  a  large  proportion  of  eases  it 
is  secondary.  Occurring  secondarily,  its  symptoms  are  often  masked  by 
those  of  the  antecedent  and  coexisting  afi"ection.  Under  such  circumstances 
attention  is  sometimes  first  directed  to  the  mouth  by  the  loosening  of  one  or 
more  of  the  teeth  or  the  appearance  on  the  skin  of  a  livid  circular  spot 
which  indicates  the  approach  of  the  disease  to  the  cutaneous  surface.  The 
mucous  membrane  presents  a  dark-red  appearance  to  the  distance  of  a  few 
lines  beyond  the  point  of  gangrene.  It  covers  tissues  which  are  inflamed 
and  indurated  and  about  to  become  gangrenous. 

The  tongue  is  usually  more  or  less  swollen,  unless  the  disease  be  mild; 
an  off"ensive  odor  arises  from  the  gangrene,  due  to  the  evolution  of  sulphur- 
etted hydrogen  and  other  gases.  There  is  great  difi'erence  in  the  extent  of 
the  destruction  and  the  gravity  of  the  disease  in  diiferent  cases.  It  may 
sometimes  be  arrested  by  proper  applications  and  a  favorable  change  in  the 
general  health  of  the  child  at  an  early  period,  when  there  is  little  loss  of 
substance.  In  other  eases  it  extends  till  it  perforates  the  cheek  or  even 
destroys  a  considerable  part  of  the  side  of  the  face,  and,  extending  inward, 
attacks  the  periosteum  of  the  maxillary  bone,  destroying  the  gum  and  teeth 
and  denuding  the  alveoli.  Kecover}-.  if  it  take  place  at  all  under  such  cir- 
cum.stances,  is  with  the  loss  of  a  portion  of  the  bone  and  with  deformity. 

The  duct  of  Steno  is  sometimes  included  in  the  gangrenous  portion,  but 
it  commonly  resists  the  destructive  process  and  remains  pervious. 

Age. — The  age  at  which  gangrene  of  the  mouth  occurs  is  usually  between 
two  and  six  years.  In  29  cases  collated  by  Killiet  and  Barthez.  21  were 
between  the  ages  of  two  and  six  years,  and  the  remaining  8  between  six  and 
twelve  years.  Of  the  cases  which  have  fallen  under  my  observation,  most 
were  between  the  ages  of  two  and  six  years.  It  is  seen  that  the  period  of 
greatest  frequency  of  gangrene  of  the  mouth  is  difi"erent  from  that  in  which 
the  ordinary  forms  of  stomatitis  occur. 

Gangrene  of  the  mouth  may,  however,  occur  under  the  age  of  one  year. 
Billard  reported  3  cases  under  the  age  of  one  month,  but  in  2  of  these  the 
disease  does  not  appear  to  have  been  sufficiently  marked  to  render  it  certain 
that  they  were  genuine  cases. 

Causes. — Gangrene  of  the  mouth  usually  occurs  in  those  whose  systems 
are  reduced  or  cachectic.  It  is  therefore  more  frequent  among  the  poor  than 
those  in  comfortable  circumstances — in  the  city  than  in  the  country.  It  is 
more  frequently  observed  in  asylums  for  children  than  in  private  practice. 
Most  of  the  cases  which  I  have  seen  have  been  in  these  institutions.  If  the 
constitution  be  good,  it  can  only  occur  in  those  long  deprived  of  pure  air  and 
wholesome  nutriment  or  those  enfeebled  by  disease. 

Among  the  diseases  which  have  been  known  to  terminate  in  or  be  followed 
by  gangrene  of  the  mouth  are  the  pulmonary  and  intestinal  inflammations. 


686  LOCAL  DISEASES. 

■whooping  cough,  and  the  fevers,  both  eruptive  and  the  non-eruptive.  Rilliet 
and  Bartliez  have  publi.shed  a  table  of  98  cases  in  which  gangrene  resulted 
from  various  diseases.  In  49  of  these  the  antecedent  disease  was  measles, 
in  5  scarlet  fever,  6  whooping  cough,  9  intermittent  fever,  9  typhoid  fever, 
7  mercurial  salivation,  and  5  enteritis.  It  is  seen  that  the  essential  fevers 
were  the  most  frequent  cause  of  the  gangrene.  Of  46  cases  collected  by 
MM.  Bouley  and  Caillaut,  the  antecedent  disease  was  measles  in  all  but  5. 
In  this  city  also  a  larger  number  result  from  measles  than  from  any  other 
disease. 

One  reason  why  so  many  cases  of  gangrene  occur  as  a  sequel  of  measles 
is  probably  because  this  disease  is  accompanied  by  stomatitis.  Simple  or 
ulcerous  stomatitis  often  precedes  gangrene. 

Diseases  sometimes  terminate  in  gangrene  of  the  mouth  in  consequence 
of  injudicious  treatment  which  has  lowered  the  vitality  of  the  system.  Ril- 
liet and  Barthez  mention  the  case  of  a  child  four  years  old  in  whom  gangrene 
commenced  at  the  twenty-ninth  day  of  primitive  pneumonia.  The  child  had 
been  reduced  by  the  application  of  twelve  leeches,  three  scarifications,  a  large 
blister,  and  by  a  poor  diet. 

The  misuse  of  mercury  was  once  a  much  more  frequent  cause  of  gan- 
grene than  at  present,  at  least  in  this  country,  since  this  agent  was  formerly 
much  more  employed  than  now.  In  fact,  most  of  the  affections  of  infancy 
and  childhood  in  which  mercurials  were  formerly  employed  are  now  treated 
without  it. 

Symptoms. — Gangrene  of  the  mouth  so  often  occurs  in  connection  with 
other  diseases  that  its  symptoms  are  in  a  large  proportion  of  cases  blended 
with  those  which  arise  from  a  distinct  pathological  state. 

There  is  usually  prostration,  more  and  more  pronounced  as  the  gangrene 
extends.  The  features  are  ordinarily  pallid,  but  occasionally  their  normal 
color  is  preserved  for  a  time  ;  the  expression  of  the  face  is  melancholy,  but 
composed.  Sometimes  the  child  is  fretful  if  disturbed ;  at  other  times  it 
will  quietly  consent  to  an  examination.  The  ,suff"ering  is  not  proportionate  to 
the  gravity  of  the  disease.  There  is  less  pain  often  than  in  some  of  the  forms 
of  stomatitis  which  are  unattended  with  danger. 

x\s  the  disease  advances  the  body  and  limbs  gradually  waste,  the  eyes  are 
hollow,  or,  if  the  gangrene  be  near  the  orbit,  the  eyelids  become  oedematous ; 
the  lips  are  infiltrated  ;  and  both  the  lips  and  nostrils  are  often  incrusted.  If 
the  cheek  be  perforated,  alimentation  is  rendered  difficult,  and  the  appearance 
of  the  child  is  melancholy  in  the  extreme. 

The  tongue  is  usually  moist ;  it  is  occasionally  swollen.  The  saliva  flows 
from  the  mouth,  either  pure  or  mixed  with  offensive  sanguinolent  matter. 
Unless  the  disease  be  slight  there  is  the  peculiar  gangrenous  odor.  The 
appetite  is  sometimes  poor ;  at  other  times  it  is  preserved  through  the  whole 
sickness.  There  is  no  vomiting  or  looseness  of  the  bowels,  unless  from  a 
complication.  The  thirst  is  usually  great,  and  the  pulse  is  accelerated  and 
feeble  except  in  mild  cases. 

The  skin  in  the  commencement  of  gangrene  is  hot.  When  the  vital  force 
is  much  reduced,  and  especially  as  the  disease  approaches  a  fatal  termination, 
the  face  and  limbs  become  cold  and  the  surface  generally  presents  a  waxen 
or  ashy  appearance.  No  derangement  occurs  of  the  respiratory  system. 
Those  cases  which  are  attended  by  a  cough  or  accelerated  respiration  are 
really  cases  of  bronchitis  or  pneumonia  coexisting  with  the  gangrene. 

Diagnosis. — Gangrene  of  the  mouth  is  easily  diagnosticated.  In  those 
cases  in  which  ulceration  precedes  the  gangrene  it  may  be  mistaken  in  its  first 
stage  for  that  form  of  ulcerous  stomatitis  in  which  the  ulcers  assume  an 
unhealthy  appearance.     The  following  are  the  distinguishing  features  of  the 


GANGRENE   OF  THE  MOUTH. 


687 


two  affections  :  Around  the  ulcer  where  gangrene  is  about  to  commence  the 
tissues  are  greatly  thickened  and  indurated  or  oedematous,  while  ulcerous 
stomatitis  begins  with  a  submucous  deposit  of  fibrin,  and  is  attended  by  little 
thickening  of  the  surrounding  parts  and  little  or  no  induration  or  oedema.  In 
ulcerous  stomatitis  the  skin  over  the  seat  of  the  disease  presents  its  normal 


appearance,  whereas  in  gangrene  it  presents  a  distended  and  shining  appear- 
ance. The  destructive  process  in  ulcerous  stomatitis  is  also  more  limited 
than  in  gangrene.  Deep  ulcerations  do  not  occur  or  are  rare.  Ulcerous 
stomatitis  is  more  readily  healed,  and  it  leaves  no  eschar,  contraction,  or 
deformity. 

The  differential  diagnosis  of  gangrene  of  the  mouth  from  those  cases  of 
follicular  stomatitis  in  which  the  ulcers  occupying  the  seat  of  the  follicles 
assume  a  gangrenous  appearance  must  be  made  by  a  consideration  of  the 
same  facts  or  particulars  which  serve  to  distinguish  it  from  ulcerous 
stomatitis. 

Malignant  pustule,  of  rare  occurrence  in  the  child,  resembles  this  disease 
in  some  of  its  features.  But  the  pustule  always  begins  on  the  skin,  while 
gangrene  is  a  disease  of  the  mucous  surface  primarily.  In  gangrene,  there- 
fore, the  chief  destruction  is  of  the  mucous  membrane  and  of  the  submucous 
tissue,  while  in  malignant  pustule  the  chief  destruction  is  of  the  skin  and  the 
subcutaneous  tissue. 

Prognosis. — This  depends  not  only  on  the  extent  of  the  gangrene,  but 
the  nature  of  the  disease,  if  there  be  one,  which  gave  rise  to  it,  and  the 
degree  of  cachexia.  If  it  occur  in  connection  with  or  as  a  sequel  to  one 
of  the  less  debilitating  diseases,  and  there  be  considerable  vigor  of  system, 
it  may  often  be  arrested  when  it  has  destroyed  only  the  mucous  and  sub- 
cutaneous tissues,  so  that  no  deformity  results.  The  friends  may  congratu- 
late themselves  if  the  ease  terminate  so  favorably.  In  the  graver  cases,  when 
the  gangrene  extends  until  it  destroys  the  periosteum  of  the  maxillary  bone 


688  LOCAL  DISEASES. 

on  the  affected  side,  and  perhaps  perforates  the  cheek,  if  the  child  recover  it 
is  with  the  permanent  loss  of  teeth,  tedious  separation  of  the  necrosed  bone, 
and  a  cicatrix  which  may  interfere  with  the  free  use  of  the  jaw.  Death  is, 
however,  the  more  common  termination  of  severe  cases.  Occasionally  the 
gangrene  destroys  the  continuity  of  a  blood-vessel,  causing  abundant  hem- 
orrhage and  accelerating  the  fatal  result.  In  most  cases,  however,  there  is 
little  or  no  hemorrhage  in  consequence  of  coagulation  in  the  vessels. 

Another  serious  complication  sometimes  arises — to  wit,  gangrene  of  other 
parts,  as  of  the  external  genital  organs.  The  English  editor  of  Bouchut's 
treatise  on  diseases  of  children  relates  the  following  interesting  case,  from 
the  Transactions  of  the  Edinhurgh  Medico-Chir.  Society:  An  infant  eight 
months  old  became  affected  with  gangrene  of  the  face,  head,  and  hands. 
"  The  right  ear  and  the  entire  hairy  scalp  were  of  an  intensely  black  color, 
and  on  both  cheeks  patches  existed  about  the  size  of  a  half-crown  piece. 
The  right  thumb  and  the  backs  of  both  hands  were  similarly  affected.  The 
child  was  noticed  to  have  been  restless  and  feverish  on  May  22d,  and  on  the 
23d  a  slightly  darkened  ring  was  found  to  have  formed  round  the  thumb, 
about  the  middle  of  the  first  phalanx  ;  in  a  few  hours  the  whole  thumb  was 
gangrenous,  and  the  dorsum  of  the  hand  became  involved.  On  the  ear  the 
gangrene  commenced  with  the  appearance  of  a  flea-bite,  and  subsequently 
extended  rapidly  to  the  scalp,  assuming  a  remarkably  regular  form  and 
giving  to  the  child  the  appearance  of  wearing  a  black  skull-cap.     The  pulse 

was  observed  to  be  very  feeble Death  took  place  in  twelve  hours  from 

the  first  appearance  of  gangrene  on  the  thumb,  the  child  being  sensible  and 
continuing  to  suck  well  up  to  a  few  minutes  before  death." 

Rilliet  and  Barthez  state  that  pneumonitis  frequently  occurs  in  the  course 
of  gangrene  of  the  mouth.  Such  a  complication  evidently  diminishes  materially 
the  chance  of  recovery. 

Whether  the  result  be  favorable  or  unfavorable,  it  is  evident  from  the  nature 
of  the  disease  that  the  duration  is  very  different  in  different  cases.  The  phy- 
sician's attendance  may  be  required  for  a  week  or  two  or  for  several  weeks. 

Treatment. — As  gangrene  of  the  mouth  is  eminently  a  disease  of  debility, 
all  antihygienic  influences  should  be  removed  and  the  most  nourishing  diet, 
together  with  tonics,  be  recommended.  The  ferruginous  preparations  or  the 
bitter  vegetables  are  required. 

As  soon  as  the  physician  is  called  he  should  endeavor  to  arrest  the 
gangrene,  accelerate  detachment  of  the  slough,  and  produce  a  healthy  and 
granulating  state  of  the  surrounding  tissues.  This  is  best  effected  by  apply- 
ing a  highly  stimulating  or  even  escharotic  agent  to  the  inflamed  surface 
underneath  and  around  the  gangrene.  For  this  purpose  a  great  variety  of 
substances  have  been  used  by  different  physicians,  such  as  acetic,  sulphuric^ 
nitric,  and  hydrochloric  acids,  nitrate  of  silver,  the  acid  nitrate  of  mercury, 
chloride  of  antimony,  carbolic  acid,  and  even  the  actual  cautery. 

A  safer,  less  painful,  and  in  many  cases  successful  treatment  is  that 
employed  by  many  British  and  American  physicians — to  wit,  the  use  of 
escharotic  agents  diluted,  or,  if  applied  in  their  full  strength,  such  as  are 
least  active  and  penetrating.  Some  employ  from  the  first  topical  treatment 
which  is  astringent  and  stimulating  rather  than  escharotic,  and  they  report 
satisfactory  results. 

Dr.  Gerhard  believes  "  the  best  local  applications  are  the  nitrate  of  silver, 
if  the  slough  be  small  in  extent ;  if  much  larger,  the  best  escharotic  is  the 
muriated  tincture  of  iron,  applied  in  the  undiluted  state.  After  the  progress 
of  the  disease  is  arrested  the  ulcer  will  improve  rapidly  under  an  astringent 
stimulant,  such  as  the  tincture  of  myrrh  or  the  aromatic  wine  of  the  French 
Pharmacopoeia." 


GANGRENE  OF  THE  MOUTH.  689 

The  local  treatment  recommeuded  by  Evanson  and  Maunsell  differs  from 
that  advised  by  any  of  the  writers  from  whom  I  have  quoted.  A  knowledge 
of  this  treatment,  from  which  I  have  myself  seen  good  results,  Vv'ill  be  best 
imparted  by  quoting  from  these  authors  :  ^  ''  The  lotion  which  we  have  found 
by  far  the  most  successful  is  a  solution  of  sulphate  of  copper  as  employed  by 
Coates  in  the  Children's  Asylum.     His  formula  is  as  follows  : 

R.  Cuprisulph.,  gij  ; 

Pulv.  cinchonEe,  ^ss ; 

Aquse,  giv.  — Misce. 

This  is  to  be  applied  twice  a  day  very  carefully  to  the  full  extent  of  the 
ulcerations  and  excoriations.  The  addition  of  the  cinchona  is  only  useful  by 
retaining  the  sulphate  of  copper  longer  in  contact  with  the  edge  of  the  gums. 
A  solution  of  the  sulphate  of  zinc,  gj  to  an  ounce  of  water,  by  itself  or  com- 
bined with  tincture  of  myrrh.  Dr.  Coates  found  to  be  also  useful  in  some 
cases." 

A  moment's  reflection  will  show  us  that  the  above  treatment  is  preferable, 
provided  that  it  is  equally  eff"ectual  in  arresting  the  gangrene,  to  the  treat- 
ment by  the  strong  acids  which  are  in  common  use.  and  the  efficiency  of 
which  cannot  be  questioned. 

The  purpose  in  applying  the  acid  is  to  establish  a  healthier  state  of  the 
tissues.  It  cauterizes  and  destroys  whatever  soft  tissues  it  comes  in  contact 
with  ;  besides,  it  produces  a  strong  corrosive  action  on  the  teeth  and  bone. 
Therefore  in  gangrene  affecting  the  jaw  there  is  great  danger  that  it  will 
destroy  the  periosteum,  and  consequently  increase  the  necrosis. 

Dr.  West,^  who  advocates  the  use  of  the  acid,  says  :  "  In  one  of  the  cases 
that  I  saw  recover  the  arrest  of  the  disease  appeared  to  be  entirely  owing  to 
this  agent,  though  the  alveolar  processes  of  the  left  side  of  the  lower  jaw, 
from  the  first  molar  tooth  backward,  died  and  exfoliated,  apparently  from 
having  been  destroyed  by  the  acid."  No  such  result  follows  the  use  of  the 
solution  of  sulphate  of  copper. 

In  one  of  these  severe  cases  in  which  the  disease  resulted  from  scarlet 
fever,  and  in  which  there  was  so  much  debility  that  an  unfavorable  prog- 
nosis was  made,  I  succeeded  in  arresting  the  disease  by  the  use  of  Dr. 
Coates's  prescription.  The  child  recovered  with  the  loss  of  two  teeth  and 
the  corresponding  portion  of  the  maxillary  bone.  From  the  good  effects 
which  I  have  observed  from  iodoform  as  an  application  for  gangrenous  vul- 
vitis following  measles,  it  has  occurred  to  me  that  it  may  also  be  useful  in 
gangrene  of  the  mouth. 

If,  after  employing  the  milder  treatment  for  two  or  three  days,  the  gan- 
grene continue  to  spread,  the  strong  muriatic  acid  should  be  cautiously 
applied  by  a  eamel's-hair  pencil  or  small  swab  in  such  a  way  that  it  comes  in 
contact  only  with  the  diseased  surface.  Its  use  should  be  immediately  fol- 
lowed by  an  alkaline  wash,  as  a  solution  of  sodium  bicarbonate. 

In  1881  an  epidemic  of  measles  occurred  in  the  New  York  Foundling 
Asylum  during  the  attendance  of  Drs.  O'Dwyer  and  Lee.  The  number  of 
children  affected  with  it  was  165.  and,  since  many  of  them  were  cachectic, 
we  were  not  surprised  that  gangrene  appeared  as  a  complication  or  sequel  in 
7  cases.  In  a  girl  of  three  and  a  half  years  it  appeared  upon  the  upper 
jaw  at  the  base  of  the  teeth  ;  in  two  girls  of  four  years  it  appeared  upon 
the  inside  of  the  cheek  and  upon  the  vulva,  and  not  upon  the  gums ;  in  a 
boy  of  three  years  it  attacked  the  lower  jaw,  destroying  four  teeth  with 
their  sockets,  and  the  upper  jaw,  destroying  five  teeth,  with  the  correspond- 

1  Diseases  oj  Children,  2d  Amer.  ed.,  p.  188.  '■^  Ibid.,  4th  Amer.  ed. 

44 


690  LOCAL  DISEASES. 

ing  portion  of  the  maxillary  bone,  so  that  all  the  incisors  and  one  canine 
were  lost,  as  well  as  the  cartilaginous  portion  of  the  nasal  septum.  Gan- 
grene also  occurred  in  the  groin  in  this  case.  Another  boy  of  three  and  a 
half  years  lost  two  incisors  from  gangrene  of  the  jaw.  .  The  treatment  by 
muriatic  acid  was  employed,  and,  according  to  the  house  physician,  Dr.  Kort- 
right,  there  was  no  further  extension  of  the  gangrene  after  the  first  applica-' 
tion  in  any  of  the  cases.  All  lived  except  the  first,  who  had  broncho-pneu- 
monia. The  remaining  two  patients,  aged  respectively  four  years,  died  of 
diphtheria  and  pneumonia  before  treatment  could  be  tested.  One  of  them 
had  commencing  gangrene  of  the  lower  jaw,  the  other  of  the  soft  palate. 
Recently,  in  the  Foundling  Asylum  carbolic  acid  has  been  used  as  an  eschar- 
otic  in  one  or  two  cases,  instead  of  the  strong  acid,  and  with  such  a  result 
as  to  encourage  its  further  use. 

The  gases  arising  from  the  gangrenous  mass  are  not  only  highly  offensive 
to  others,  but  they  are  doubtless  injurious  to  the  patient,  who  is  constantly 
inhaling  them.  To  remove  the  fetor,  chlorine  or  carbolic  acid,  properly  dilu- 
ted, should  be  occasionally  used  between  the  applications  of  the  sulphate  of 
copper.  Labarraque's  solution,  one  part  to  eight  or  ten  parts  of  water,  is  an 
eligible  form  for  its  use.  When  the  gangrene  is  removed  and  the  granula- 
tions present  a  healthy  appearance,  all  danger  is  usually  past  and  convales- 
cence is  fully  established.  Then  no  energetic  topical  treatment  is  required. 
A  mild  stimulating  lotion,  like  the  tincture  of  myrrh,  as  recommended  by 
Dr.  Gerhard,  suffices,  with  the  aid  of  tonics  and  nutritious  diet. 

Efflorescence,  Furring,  and  Eruptions  upon  the  Tongue. 

From  time  immemorial  the  physician  has  inspected  the  tongue  of  the 
patient  in  order  to  determine  his  or  her  physical  condition  and  obtain  aid  in 
diagnosis.  Elevation  of  temperature,  whatever  the  cause,  persisting  a  few 
hours,  indigestion,  as  Beaumont  has  shown,  and  many  maladies,  not  only 
those  located  in  the  digestive  system,  but  in  organs  distantly  connected  with 
this  system,  cause  a  fur  to  collect  on  the  tongue.  Hence  from  the  infancy 
of  medicine  until  the  present  time  the  tongue  has  been  inspected  by  the 
physician  before  he  announced  the  diagnosis.  The  fur  occurs  on  the  dorsum 
of  the  tongue,  and  not  on  its  under  surface,  and  scantily  or  not  at  all  on  its 
borders.  It  consists  of  epithelial  cells  of  varying  thickness,  brown  and  dry 
in  severe  and  malignant  diseases,  and  of  a  light-yellow  color  and  moist  from 
the  secretion  of  mucus  in  diseases  of  a  milder  type. 

An  occasional  "  circinate  eruption  "  upon  the  dorsum  of  the  tongue  has 
attracted  the  attention  of  various  observers  from  the  time  of  Gubler  (article 
"  Bouche,"  1869)  until  the  present  time.  It  begins  as  a  light-colored  patch 
and  enlarges  peripherally.  It  forms  a  ring  or  series  of  rings  resembling  the 
ringworm,  the  interior  of  which  presents  a  reddish  appearance,  contrasting 
with  the  thickened  epithelium  which  forms  the  rings.  In  some  instances, 
from  intersection  of  the  rings,  arches  are  formed.  As  the  circles  extend  the 
epithelial  layer  is  restored  in  their  centres  and  the  disease  gradually  disap- 
pears. Most  cases  occur  in  infants,  and  the  disease  is  of  little  clinical  im- 
portance. Cases  which  I  have  observed  are  without  pain  or  other  symptom, 
and  the  patients  recovered  without  treatment.  This  malady  has  the  appear- 
ance of  being  microbic,  but  its  origin  is  uncertain.  It  is  probably  best  treated 
by  antiseptic  washes  and  gargles,  as  a  wash  of  listerine  or  Seiler's  tablet. 


DENTITION.  691 

CHAPTEK    III. 

DENTITION. 

The  opinion  formerly  entertained  in  the  profession,  and  now  prevalent  in 
the  community,  that  many  infantile  maladies  arise  directly  or  indirectly  from 
dentition  is  erroneous.  Still,  there  are  physicians  of  experience  who  believe 
that  teething  is  a  common  cause  of  certain  maladies,  especially  of  functional 
derangements,  even  of  organs  remote  from  the  mouth.  On  the  other  hand, 
equally  good  observers — and  the  number  is  increasing — almost  wholly  ignore 
the  pathological  results  of  dentition.  They  say  that  as  it  is  strictly  a  phys- 
iological process,  it  should,  like  other  such  processes,  be  excluded  from  the 
domain  of  pathology. 

A  moment's  reflection  will  show  how  important  it  is  to  understand  the 
exact  relation  of  dentition  to  infantile  diseases.  Every  physician  is  called  now 
and  then  to  cases  of  serious  disease,  inflammatory  and  non-inflammatory,  which 
have  been  allowed  to  run  on  without  treatment,  in  the  belief  that  the  symp- 
toms were  the  result  of  dentition.  I  have  known  acute  meningitis,  pneumo- 
nia, and  entero-eolitis,  even  with  medical  attendance,  to  be  overlooked,  and 
the  symptoms  attributed  to  teething  during  the  very  time  when  appropriate 
treatment  was  most  urgently  demanded.  Many  lives  are  lost  from  neglected 
entero-eolitis,  the  friends  believing  the  diarrhoea  to  be  symptomatic  of  denti- 
tion, a  relief  to  it,  and  therefore  not  to  be  treated.  Such  mistakes  are  trace- 
able to  the  erroneous  doctrine,  once  inculcated  in  the  schools,  and  still  held 
by  many  of  the  laity,  that  dentition  is  directly  or  indirectly  a  common  cause 
of  infantile  diseases  and  derangements. 

I  shall  endeavor  to  point  out  what  is  really  ascertained  in  regard  to  the 
pathological  relations  of  dentition. 

The  first  dentition  commences  at  the  age  of  about  six  months  and  termi- 
nates at  the  age  of  two  and  a  half  years.  The  corresponding  teeth  of  the 
two  sides  pierce  the  gum  at  about  the  same  time.  The  two  inferior  central 
incisors  first  appear  at  about  the  age  of  six  or  seven  months,  followed,  in  the 
order  in  which  they  are  mentioned,  by  the  upper  central  incisors,  upper  lat- 
eral incisors,  lower  lateral  incisors,  the  four  anterior  molars,  the  four  canines, 
and,  lastly,  the  four  posterior  molars. 

The  incisors  usually  appear  in  rapid  succession,  so  that  all  are  in  sight  by 
the  age  of  one  year.  From  the  age  of  one  year  to  eighteen  months  the 
anterior  molars  appear,  and  from  the  age  of  sixteen  to  twenty-four  months 
the  canines,  and  from  twenty-four  to  thirty  months  the  posterior  molars. 
This  order  is  not  always  preserved.  Sometimes  the  upper  central  incisors 
appear  before  the  lower,  and  sometimes  the  lower  lateral  before  the  upper 
lateral.  In  rare  cases  there  have  been  teeth  at  birth.  I  have  seen  but  one 
or  two  infants  with  such  premature  dentition.  Retarded  dentition  is  much 
more  common.  Those  who  have  rickets  or  are  feeble  either  constitutionally 
or  by  disease  often  have  no  teeth  till  considerably  after  the  usual  period. 
In  such  the  first  incisors  may  not  appear  till  the  age  of  twelve  months,  or 
even  later. 

Pathological  Results  of  Dentition. — The  evolution  of  the  teeth  is 
commonly  attended  by  more  or  less  turgescence  around  the  dental  bulbs. 
This  is  greater  with  some  of  the  teeth  than  with  others.  Thus  the  superior 
incisors  cause  more  swelling  than  do  their  congeners  of  the  inferior  jaw.  The 
turgescence,  although  attended  by  more  or  less  congestion,  is  physiological 
within  certain  limits,  and  not  a  disease. 


692  LOCAL   DISEASES. 

But  exceptionally  there  is  an  unusual  amount  of  swelling  around  the 
dental  follicles ;  the  afflux  of  blood  to  them  is  greatly  augmented ;  they  are 
the  seat  of  such  a  degree  of  tenderness  and  pain  that  the  infant  is  fretful. 
It  carries  the  finger  often  to  the  mouth,  indicating  the  seat  of  its  suffering. 
The  surface  over  the  follicles  presents  greater  redness  than  in  ordinary  den- 
tition, and  the  salivary  secretion  is  considerably  increased.  There  may  now 
be  actual  gingivitis,  but  such  cases  are  rare. 

Occasionally  the  turgescence  affects  a  greater  extent  of  the  buccal  sur- 
face than  that  lying  directly  over  the  follicles,  so  that  most  writers  speak  of 
stomatitis  as  one  of  the  results  of  dentition.  In  a  few  cases  I  have  known 
such  a  degree  of  inflammation  over  the  advancing  tooth  that  a  small  abscess 
formed,  producing  pain  and  restlessness  till  it  was  opened  by  the  lancet. 

The  pathological  results  of  dentition  which  I  have  mentioned,  though  they 
may  interfere  more  or  less  with  nursing  or  feeding,  are  not  dangerous.  They 
are  easily  detected.  They  result  directly  from  the  rapid  growth  and  aug- 
mented sensitiveness  of  the  dental  follicles. 

There  are  other  supposed  accidents  of  dentition  occurring  in  distant  parts 
of  the  system  in  consequence  of  the  relation  and  interdependence  of  organs 
which  exist  through  the  system  of  nerves. 

Some  children  prior  to  the  eruption  of  the  teeth  are  affected  with  diar- 
rhoea, occasionally  accom23anied  b}'  irritability  of  the  stomach.  Certain  writers 
have  supposed  that  gastro-intestinal  catarrh  is  present  in  these  cases ;  others 
that  there  is  simply  a  hypersecretion,  an  increased  activity  of  the  intestinal 
follicular  apparatus — that  it  is.  in  other  words,  one  of  the  forms  of  non- 
inflammatory diarrhoea.  Barrier  believes  that  the  diarrhoea  of  dentition 
depends  usually  on  what  he  calls  a  "  subinflammatory  turgescence  limited  to 
the  gastro-intestinal  follicular  apparatus."  He  believes  that  in  occasional  cases 
it  is  due  to  defective  or  altered  innervation.  It  would  then  be  analogous  or 
similar  to  that  form  of  diarrhoea  which  occurs  in  the  adult  from  the  emotions. 
Bouchut  calls  the  diarrhoea  of  dentition  nervous  diarrhoea.  It  is  certain, 
however,  that  in  mo.st  cases  of  diarrhoea  which  are  attributable  to  dentition 
there  are  other  causes,  such  as  unsuitable  food  or  residence  in  an  insalubrious 
locality.  It  is  cei'tain,  as  regards  city  infants,  that  the  chief  causes  of  diar- 
rhoea during  the  period  of  dentition  are  strictly  antihygienic,  dentition  being 
quite  subordinate  as  a  cause,  and  probably  ordinarily  not  operating  at  all  as 
such.  But  when,  as  sometimes  happens,  at  each  period  of  dental  evolution 
the  infant  is  affected  with  diarrhoea,  the  influence  of  teething  is  apparent. 
Such  cases  give  rise  to  the  belief  that  teething  may  really  sustain  a  causal 
relation  to  certain  diseases  not  located  in  the  buccal  cavity. 

Among  the  more  common  pathological  results  of  difficult  dentition  are 
certain  affections  referable  to  the  cerebro-spinal  system.  Eclampsia  is  one 
of  the  admitted  results.  Barrier  attributes  convulsions  in  the  teething  infant 
to  excitement  of  the  nervous  system  arising  from  the  pain  which  is  felt  in 
the  gums,  and  to  a  determination  of  blood  to  the  dental  apparatus,  in  which 
afflux  the  whole  vascular  system  of  the  head  participates. 

In  most  eases  of  convulsions,  occurring  during  the  period  of  dental  evolu- 
tion, a  careful  examination  discloses  other  causes  in  addition  to  the  state  of  the 
gums.  Difficult  dentition  must  then  be  considered  not  so  frequently  a  direct 
as  perhaps  a  co-operating  or  predisposing  cause,  producing  a  sensitive  state 
of  the  nervous  system,  or  possibly  an  afflux  of  blood  to  the  head,  of  which 
Barrier  speaks,  and  which  by  an  additional  stimulus,  perhaps  trivial  in  itself, 
ends  in  convulsions.  The  belief  is  not  unreasonable  that  convulsions  may 
result  when  several  teeth  penetrate  the  gum  at  or  about  the  same  time.  In- 
fants who  are  burned  or  scalded  are  very  liable  to  clonic  convulsions.  This 
is,  in  fact,  the  chief  danger  as  regards  life  from  such   accidents.     So  the 


DENTITION.  693 

swollen  and  tender  gum,  if  several  teeth  are  about  emerging,  may  possibly 
affect  the  eerebro-spinal  system  like  the  burn  or  scald  and  produce  the  same 
nervous  phenomena.  Thus  in  a  case  already  alluded  to  in  the  chapter  on 
Convulsions,  five  incisors  pierced  the  gum  within  about  two  weeks,  and  in 
this  period  there  were  two  attacks  of  eclampsia  with  an  interval  of  a  few 
days.  The  attacks  were  not  severe,  and  the  most  careful  examination  could 
reveal  no  other  cause  than  the  simultaneous  development  of  so  many  den- 
tal follicles.     Previously  and  since  the  infant  has  been  well. 

Dentition  sometimes,  though  rarely,  occasions  also  tonic  contraction  of 
certain  muscles.  The  following  case  occurred  in  the  practice  of  the  late  Dr. 
A.  S.  Church  of  this  city,  the  history  of  which  he  communicated,  as  follows : 

Case. — •"  H ,  seven  months  old,  was  first  visited  April  3,  1863.     The  patient 

had  been  fretful  for  several  days,  but  about  daylight  on  the  morning  of  my  first 
visit  it  commenced  crying,  and  had  not  ceased  for  a  moment  at  the  time  of  my  visit, 
9  A.  M.  The  bowels  were  somewhat  constipated  and  tympanitic  ;  abdominal  mus- 
cles very  tense.  The  pain  was  supposed  to  be  in  the  abdomen,  and  a  brisk  cathar- 
tic, to  be  followed  by  an  anodyne,  was  ordered.  Some  relief  followed,  but  on  the 
ensuing  and  for  several  consecutive  mornings  the  pain  returned,  each  day  lasting 
longer,  until  the  child  only  ceased  crying  while  under  the  influence  of  a  full  ano- 
dyne. The  gum  over  the  upper  incisors  was  considerably  swollen,  hot.  and  dry, 
but  the  parents  would  not  consent  to  have  it  scarified.  For  the  first  week  there 
was  no  fever,  no  vomiting,  and  not  the  least  indication  that  the  nervous  system  was 
sufi'ering.  About  the  10th  the  thumbs  were  noticed  to  be  flexed  during  the  attack 
of  pain,  and  about  the  loth  the  flexors  of  the  toes  were  contracted  and  the  hands 
were  turned  backward  and  outward,  but  only  while  the  child  was  awake.  About 
the  2i)th  there  Avas  constant  contraction  of  the  flexors  of  both  extremities,  with 
opisthotonos,  and  constant  rolling  of  the  head,  loss  of  appetite,  progressive  emacia- 
tion, coated  tongue,  and  highly-inflamed  gums.  Consent  was  finally  obtained  to 
relieve  the  inflamed  gum,  and  free  incisions  were  made,  and  the  following  night  the 
child  slept  comfortably  for  three  hours  without  opiates.  In  three  days  the  gums 
were  freely  cut  again,  and  the  teeth  soon  made  their  appearance.  All  symptoms  of 
disease  had  now  ceased,  the  child  became  playful,  and  on  the  30th  the  patient  was 
discharged." 

More  recently  a  child  of  about  eighteen  months,  seen  by  me  in  consulta- 
tion, had  tonic  contraction  of  the  flexors  of  the  left  thigh  and  leg,  continuing 
nearly  a  month,  so  that  the  thigh  was  flexed  on  the  body  and  the  leg  on  the 
thigh.  The  infant  was  cutting  five  teeth  at  the  time,  and  the  gums  were 
considerably  swollen  over  them.  The  normal  state  of  the  affected  limb 
returned  after  these  teeth  had  penetrated  the  gum. 

The  opinion  has  been  prevalent  in  the  profession  that  painful  and  dif- 
ficult dentition  is  one  of  the  chief  causes  of  infantile  paralysis,  but  it  is  now 
admitted  that  it  is  only  a  subordinate  or  remote  cause,  if  indeed  it  is  proper 
to  consider  it  a  cause  at  all.     (See  art.  Paralysis.) 

The  older  writers  sometimes  expressed  the  opinion  that  acute  meningitis 
occasionally  results  from  teething.  The  facts,  however,  that  are  relied  upon 
to  prove  this  are  uncertain.  The  occurrence  of  meningitis  during  dentition 
is  probably  in  most  instances  merely  a  coincidence. 

Teething  does  not  often  disturb  the  respiratory  system.  A  cough  occurs 
in  some  infants  at  each  period  of  dental  evolution.  It  is  attended  by  little 
expectoration,  but  is  sometimes  associated  with  an  inflammatory  turgescence 
of  the  bronchial  mucous  membrane. 

Eczema  and  certain  other  cutaneous  diseases,  as  well  as  acceleration  of 
pulse  and  more  or  less  fever,  are  common  during  dentition,  but  their  depend- 
ence on  it  as  a  cause  has  not  been  demonstrated. 

Diagnosis. — The  accidents  of  dentition  which  are  located  in  the  mouth 
are  easily  diagnosticated,  except  the  odontalgia  which  writers  describe,  and 


694  LOCAL  DISEASES. 

which  is  not  necessarily  attended  by  any  perceptible  anatomical  alteration  of 
the  gums.  Those  accidents  which  pertain  to  remote  and  concealed  organs 
are  usually  detected  with  ease,  though  it  is  often  difficult  to  determine  with 
certainty  their  relation  to  dentition.  It  is  certain,  as  the  nature  of  diseases 
becomes  better  understood,  dentition  becomes  less  and  less  important  as  an 
etiological  factor. 

Treatment. — It  is  obvious  that  remedial  measures  in  cases  of  difficult 
dentition  must  be  twofold — namely,  those  directed  to  the  state  of  the  gums, 
and  those  designed  to  relieve  the  derangements  or  diseases  to  which  denti- 
tion has  given  rise.  If  there  be  diarrhoea,  this  should  be  controlled  by 
proper  remedies,  so  as  to  reduce  the  number  of  evacuations  to  two  or  three 
daily.  It  is  well  to  state  to  the  friends  of  the  child  who  believe  that 
diarrhoea  is  salutary  during  the  period  of  teething  that  this  number  is 
quite  sufficient,  and  that  more  frequent  evacuations  endanger  the  safety  of 
the  child. 

The  nervous  affections,  as  convulsions,  require  such  soothing  and  deriva- 
tive measures  as  are  recommended  in  our  remarks  on  Diseases  of  the  Nervous 
System.  The  bromide  of  potassium  I  have  found  especially  useful  and  safe 
in  cases  of  fretfulness  and  nervous  excitement  during  the  period  of  dentition 
and  perhaps  having  dentition  as  the  cause.  Demulcent  and  soothing  lotions 
are  sometimes  useful  in  cases  of  painful  dentition,  and  the  infant  may  be 
allowed  to  hold  in  its  mouth  an  India-rubber  ring,  which  seems  to  give  con- 
siderable relief. 

Mothers  often  attempt  to  '-rub  through  a  tooth,"  as  they  term  it,  by 
means  of  a  ring  or  thimble.  This  should  be  forbidden.  So  great  friction 
cannot  fail  to  have  an  injurious  effect  by  increasing  the  swelling  and  inflam- 
mation, unless  the  tooth  have  already  reached  the  mucous  membrane. 

We  come  now  to  a  subject  which  has  engaged  the  attention  of  many 
physicians  of  ample  experience,  and  in  reference  to  which  there  is  still  a  dif- 
ference of  opinion  among  the  highest  authorities  in  medicine.  I  refer  to 
scarification  of  the  gums. 

The  gum-lancet  is  much  less  frequently  employed  than  formerly.  It  is 
used  more  by  the  ignorant  practitioner,  who  is  deficient  in  the  aJDility  to 
diagnosticate  obscure  diseases,  than  by  one  of  intelligence,  who  can  discern 
more  clearly  the  true  pathological  state.  Its  use  is  more  frec|uent  in  some 
countries,  as  England,  under  the  teaching  of  great  names,  than  in  others, 
as  France,  where  the  highest  authorities,  as  Rilliet  and  Barthez,  dis- 
countenance it. 

It  is  well  to  bear  in  mind,  as  aiding  in  the  elucidation  of  this  subject,  the 
remark  made  by  Trousseau,  that  the  tooth  is  not  released  by  lancing  the  gum 
over  the  advancing  crown.  The  gum  is  not  rendered  tense  by  pressure  of 
the  tooth,  as  many  seem  to  think,  for  if  so  the  incision  would  not  remain 
linear,  and  the  edges  of  the  wound  would  not  unite,  as  they  ordinarily  do 
by  first  intention  within  a  day  or  two.  This  speedy  healing  of  the  incision 
unless  the  tooth  be  on  the  point  of  protruding  is  an  important  fact,  for  it 
shows  that  the  effect  of  the  scarification  can  last  only  one  or  two  days.  The 
early  repair  of  the  dental  follicle  is  probably  conservative,  so  far  as  the 
development  of  the  tooth  is  concerned.  It  may  help  us  to  understand  how 
active,  how  powerful,  the  process  of  absorption  is,  if  we  reflect  that  the  roots 
of  the  deciduous  teeth  are  more  or  less  absorbed  by  the  advancing  second 
set,  without  much  pain  or  suffering  from  the  pressure.  If  the  calcareous 
particles  of  the  teeth  are  so  readily  absorbed,  what  is  the  foundation  for  the 
belief  that  the  fleshy  substance  of  the  gum  is  absorbed  with  such  difficulty? 
Too  much  importance  has  evidently  been  attached  to  the  supposed  tension 
and  resistance  of  the  gum  in  the  process  of  dentition. 


DENTITION.  695 

Follicles  in  tlie  period  of  development  are  especially  liable  to  inflamma- 
tion. We  see  this  in  the  follicular  stomatitis  and  enteritis  so  common  when 
the  buccal  and  intestinal  follicles  are  in  a  state  of  most  rapid  growth.  Does 
not  this  law  in  reference  to  the  follicles  hold  true  of  those  by  which  the  teeth 
are  formed,  so  that  the  period  of  their  enlargement  and  greatest  activity, 
which  corresponds  with  the  growth  and  protrusion  of  the  teeth,  is  also  the 
period  when  they  are  most  liable  to  congestion  and  inflammation  ?  It  seems 
probable  that  the  dental  follicles  are  most  liable  to  become  inflamed,  and 
therefore  tender,  from  various  causes  apart  from  dentition  at  the  time  of  their 
greatest  functional  activity. 

If  there  be  no  symptoms  except  such  as  occur  directly  from  the  swelling 
and  congestion  of  the  gum,  the  lancet  should  seldom  be  used.  The  patho- 
logical state  of  the  gum  which  would,  without  doubt,  require  its  use  is  an 
abscess  over  the  tooth.  As  to  the  symptoms  which  are  general  or  referable 
to  other  organs,  as  fever  and  diarrhoea,  the  lancet  should  not  be  used,  because 
the  symptoms  can  be  controlled  by  other  safe  measures.  All  co-operating 
causes  should  first  be  removed,  when  in  a  large  proportion  of  cases  the 
patient  will  experience  such  relief  that  scarification  can  be  deferred. 

If  the  state  of  the  infant  be  one  of  immediate  danger,  as  in  eclampsia, 
and  it  be  not  quickly  relieved  by  the  ordinary  remedies,  scarification  may 
not  only  be  proper,  but  required  to  ensure  safety.  For  in  such  cases  all 
measures,  provided  that  they  are  safe  and  simple,  which  can  possibly  give 
relief,  should  be  employed  without  delay.  But  I  can  recall  to  mind  only  three 
accidents  of  dentition  which  would  be  likely  to  be  benefited  by  scarification — 
namely,  suppurative  inflammation  in  the  dental  follicle,  extreme  fretfulness 
continuing  day  after  day,  and  convulsions.  But  since  the  bromide  of  potas- 
sium and  hydrate  of  chloral  have  come  into  use  as  nervous  sedatives  and  as 
efficient  remedies  for  clonic  convulsions,  scarification  of  the  gums  is  much  less 
frequently  required,  for  even  severe  eclampsia  commonly  yields  to  these  medi- 
cines if  the  condition  of  the  bowels  be  attended  to..  In  some  instances  I 
have  found  that  the  elixir  anisi  (aniseed  cordial)  of  the  National  Formulary, 
containing  as  it  does  anethol  and  the  oils  of  fennel  and  bitter  almond, 
administered  in  doses  of  ten  drops  to  an  infant  of  one  year,  is  apparently 
more  quieting  in  cases  of  restlessness  than  the  bromide.  It  may  be  given 
with  the  bromide. 

Second  Dentition. — Rilliet  and  Barthez  mention  particularly  neuralgic 
pains,  rebellious  cough,  and  diarrhoea  as  eff"ects  which  they  have  observed  of 
the  second  dentition.  Rilliet  relates  the  case  of  a  girl  eleven  years  old  who 
had  a  very  obstinate  and  protracted  cough,  the  paroxysms  lasting  often  half 
an  hour  to  one  hour.  This  cough  immediately  and  permanently  disappeared 
when  the  molars  pierced  the  gums. 

Dr.  James  Jackson  ^  says :  "  I  have  seen  persons  between  twenty  and  thirty 
years  of  age  much  affected  by  a  wisdom  tooth  not  yet  protruded,  and  distinctly 
relieved  by  cutting  the  gum.  But  I  think  the  most  common  period  of  suffering 
from  the  second  dentition  is  from  the  tenth  to  the  thirteenth  year.  The  most 
characteristic  affections  are  wasting  of  fiesh  and  nervous  diseases.  The  boy  loses 
his  comeliness  and  his  complexion  is  less  clear,  while  emaciation  takes  place 
in  every  part,  though  mostly  perhaps  in  the  face.  The  nervous  symptoms  are 
various,  but  the  most  common  are  a  change  in  the  temper  and  a  loss  of  spirits. 
With  these  there  is  some  loss  of  strength.  The  patient  is  unwilling  to  engage 
in  play,  and  soon  becomes  tired  when  he  does  so.  Among  the  distinct  symp- 
toms which  are  not  uncommon  I  may  mention  pain  in  the  head  and  in  the 
eyes.  The  headache  is  not  commonly  severe,  but  it  is  such  as  inclines  the  patient 
to  keep  still.  The  eyes  are  not  only  painful,  but  are  often  affected  with  the 
morbid  sensibility  to  which  these  organs  are  subject.     I  have  known  boys  truly 

^  Letters  to  a  Young  Physician. 


696 


LOCAL  DISEASES. 


anxious  to  pursue  their  studies,  obliged  to  give  them  up  on  this  account :  and  these, 
not  having  the  disposition  to  phw,  will  of  choice  pass  the  day  with  their  mothers 
and  increase  their  troubles  for  the  want  of  air  and  exercise.  Nervous  affections 
of  a  more  severe  character  are  sometimes  manifested." 

Whether  the  symptoms  which  have  been  attributed  to  second  dentition 
have  always  been  due  to  this  cause  is  questionable.  Practically,  however,  it 
matters  little  whether  we  recognize  dentition  as  the  cause  or  assign  some- 
thing else.  Hygienic  and  medicinal  measures  to  improve  the  general  health 
will  usually  suffice  to  relieve  the  patient.  Elsewhere  I  have  related  the  case 
of  a  boy  of  nervous  temperament,  about  seven  years  old,  who  recovered 
immediately  from  a  cough  which  had  lasted  for  several  weeks  by  taking  a 
mixture  of  iron  and  nitric  acid.  Many  do  well  without  medicine,  simply  by 
hygienic  measures.  Dr.  Jackson  says :  "  The  remedies  which  I  have  found 
most  useful  are  as  follows:  First,  a  relief  from  study  or  from  regular  tasks, 
yet  using  books  so  far  as  tbey  afford  agreeable  occupation  or  amusement. 
Second,  exercise  in  the  open  air,  preferring  the  mode  most  agreeable  to  the 
patient,  and  in  more  grave  cases  the  removal  from  town  to  country." 

Rannla. 

Ranula  is  a  cyst  beneath  the  tongue,  usually  intimately  related  to  the 
salivary  ducts.  The  ducts  becoming  closed,  the  epidermic  lining  is  deposited 
in  the  interior,  and  the  secretion  accumulates  until  a  large  tumor  is  formed 
which  presses  the  tongue  upward  and  backward,  greatly  interfering  with 
the  functions  of  that  organ.  These  cysts  are  readily  recognized  on  inspec- 
tion of  the  under  surface  of  the  tongue.  The  treatment  may  at  first  be  the 
passing  of  a  setou  (Fig.  197)  to  secure  drainage  of  the  sac  and  adhesion  of 


Fig.  19 


Ranula  :  introduction  of  seton. 

its  walls.  If  this  fail,  resort  to  free  incision,  and  keep  the  wound  open; 
01-  excision  of  a  portion  of  the  walls  may  be  necessary.  If  the  disease  per- 
sists, open  the  cyst  and  cauterize  with  nitrate  of  silver,  or  even  nitric  acid. 
If  the  cyst  project  in  the  neck,  open  it  in  the  middle  line  below  the  hyoid 
bone,  and  keep  it  open  till  the  cavity  is  obliterated. 


DENTITION. 


697 


Fig.  198. 


Alveola. 

Hypertropliy  of  the  alveola  appears  as  a  congenital  affection,  and  con- 
sists of  an  expanded  and  prolonged  development  of  the  alveolar  borders  of 
the  maxillae,  immense  thickening  of  the  fibrous  tissue  of  the  gum,  and  exu- 
berant growth  of  the  papillary  surface.  AVhen  fully  developed  the  patient 
presents  an  extraordinary  appearance — a  large 
mass,  dense,  inelastic,  insensitive,  pink,  and 
smooth,  protrudes  from  the  mouth  (Fig.  198). 
Excision  should  be  performed. 

Vascular  growths,  na3vi,  and  aneurysms 
by  anastomosis  form  in  the  tissues  about  the 
necks  of  the  teeth,  especially  between  the 
incisors  or  canines  and  lateral  incisors  of  the 
upper  jaw  ;  they  have  a  purplish  color  ;  are 
smooth  and  streaked,  with  many  vessels;  are 
easily  compressed  and  become  pale  and  re- 
duced, but  are  elastic  and  resume  their  pre- 
vious aspect  on  removal  of  pressure.  The  whole  gum  is  red.  turgid,  and 
swollen,  and  the  little  tongues  of  gum  between  the  necks  of  the  teeth  are 
enlarged  and  spongy  ;  troublesome  hemorrhage  occurs  later  in  the  disease. 
These  growths  are  now  more  readily  destroyed  by  the  galvano-cautery  needles. 
If  this  treatment  fail,  excision  should  be  performed  with  a  scalpel,  the  bleed- 
ing being  controlled  by  pressure  and  ice. 

Dentigerous  cysts  are  collections  of  serum  in  the  maxillary  bones  depend- 
ent iipon  impacted  misplaced  teeth  ;  they  arise  only  when  the  tooth  or  teeth 
associated  with  them  are  imbedded  in  the  substance  of  the  jaw-bone,  and  do 
not  occur   after  the   tooth   has  pierced  the  gum  ;  they  occur  in  connection 


Front  view  of  tumor  of  alveolus, 
due  to  hypertrophy  and  dilatation 
of  tooth-fang  (Bryant). 


Fig.  199. 


Fig.  200. 


Dentigerous  tumor  of  jaw  (Bryant). 

with  the  permanent  teeth,  which  may  fail  to 
pierce  the  gum,  either  from  the  great  depth 
of  the  sac  or  growth  in  an  oblique  direction, 
or  from  arrest  of  development.  The  symp- 
toms are  expansion  of  the  jaw-bone,  weight, 
and  tension,  and  disfigurement  of  the  fea- 
tures (Fig.  199).  The  diagnosis  depends  on 
pressure,  which  reveals  fluid,  expansion  of 
bone,  and  crepitation  like  stiff  parchment, 
and  absence  of  a  tooth  or  of  teeth  which  have  never  appeared.  The  treatment 
consists  in  opening  the  cyst  freely  with  knife,  gouge,  or  trephine,  extraction 
of  the  imbedded  tooth,  and,  if  the  expansion  is  large,  removal  of  the  dilated 
bone  (Fig.  200).     The  result  is  always  satisfactory. 


Canine  tooth  as  seen  in  a  case  of  den- 
tigerous cyst.  Expanded  lower  jaw 
with  tooth  :  6,  natural  size :  a,  bone 
removed  by  tlie  trephine  (Bryant). 


698  LOCAL  DISEASES. 

Tonsil. 

Abscess  of  the  tonsil  is  a  frequent  result  of  acute  inflammation.  It 
should  be  punctured  as  soon  as  pus  is  detected,  care  being  taken  to  avoid 
wounding  the  internal  carotid  artery. 

Select  a  broad  spatula  and  a  sharp-pointed  straight  bistoury,  wrapped  to  within 
about  half  an  inch  of  its  extremity  ;  place  the  patient  in  a  chair  in  front  of  a  good 
light,  the  head  firmly  supported  by  an  assistant ;  lay  the  spatula  slightly  on  the 
tongue  until  the  abscess  is  brought  into  view ;  pass  the  knife  backward,  avoiding 
wounding  the  tongue,  and  incline  the  point,  when  it  penetrates  the  tonsil,  toward 
the  median  line  of  the  fauces,  thus  protecting  the  internal  carotid  from  all  danger  ; 
if  the  abscess  cannot  be  sufficiently  exposed,  it  may  be  necessary  to  direct  the  point 
of  the  knife  by  the  index  finger  of  the  left  hand ;  if  the  abscess  contain  a  large 
amount  of  pus'  the  patient's  head  should  be  thrown  forward  immediately  after  the 
puncture  to  avoid  the  flow  into  the  pharynx  or  larynx. 

Chronic  inflammation  of  the  tonsil  is  caused  by  repeated  acute  conges- 
tions of  the  pharyngeal  mucous  membrane,  and  consists  of  an  equable  and 
uniform  overgrowth  of  all  the  histological  elements  of  the  follicles  ;  the  size 
and  shape  of  the  entire  tonsil  undergo  an  alteration.  It  forms  a  globular 
and  often  pedunculated  tumor  which  may  project  so  far  as  to  interfere  with 
breathing  ;  or,  it  may  grow  vertically,  extending  below  into  the  pharynx  and 
upward  toward  the  posterior  nares. 

The  SYMPTOMS  depend  upon  the  peculiarties  of  the  hypertrophy.  When 
large  and  protruding  it  interferes  with  natural  sleep,  affects  the  voice,  and 
often  the  general  health  is  impaired.  There  is  "  a  vacuous,  heavy  look  from 
obstruction  to  breathing  and  consequent  imperfect  aeration  of  the  blood  ;  also 
imperfect  development,  and  often  stunting  of  the  growth ;  the  mouth  is  kept 
open,  the  breathing  is  stertorous,  and  during  sleep  snoring ;  there  is  usually 
chronic  nasal,  and  often  aural,  catarrh,  from  the  extension  of  irritation  from 
the  tonsils  to  the  neighboring  mucous  surfaces ;  the  speech  is  nasal  and  indis- 
tinct or  dead ;  the  chest  is  often  ill-developed,  pigeon-breasted,  or  has  the 
diaphragmatic  constriction."  ^ 

The  treatment  should  be  the  application  of  iodine  in  the  early  stages.  In 
advanced   cases   the   only  proper  treatment  is  removal.     Various   methods 

Fig.  201. 


have  been  employed  to  destroy  the  tonsil — compression,  massage,  electrol- 
ysis, galvano-cautery  puncture,  ignipuncture,  and  the  snare.  But  excision 
with  the  tonsillotome  has  proved  the  most  useful,  especially  when  the  tonsil 
projects.     The  danger  from  hemorrhage  is  comparatively  slight ;  the  opera- 

^  Ashby  and  Wright,  Diseases  of  Children,  p.  54. 


DENTITION.  699 

tion  is  quickly  performed  and  does  not  require  a  specially  skilled  hand.     The 
Mackenzie  instrument  is  the  more  simple  (Fig.  201). 

An  ansesthetic  should  be  given  to  the  child  to  the  extent  of  slight 
narcosis,  but  not  so  as  to  abolish  the  reflexes.  The  patient  is  placed  on  the 
back,  the  mouth-gag  is  introduced,  and  the  tonsils  removed.  The  child  is 
then  turned  on  its  face  to  facilitate  the  flow  of  blood  from  the  mouth. 
Knight  states  that  there  should  be  no  hesitation  in  adopting  this  method  in 
children  under  ten  years  of  age  and  in  older  children  of  nervous  tempera- 
ment. He  advises  to  remove  as  much  of  the  tonsil  as  possible,  for  the  stump 
does  not  shrink  and  may  prove  a  source  of  irritation,  and  the  farther  out  the 
section  is  made  the  more  nearly  we  approach  healthy  tissue. 

In  the  absence  of  a  tonsillotome  the  tonsils  may  be  partially  removed  with 
curved  hook-teeth  forceps,  and  a  straight  probe-pointed  or  curved  scissors.  If  the 
patient  is  a  child,  give  chloroform,  and  when  sufficiently  under  its  influence  to 
open  the  mouth,  seize  the  tonsil,  draw  it  out  from  between  the  pillars,  and,  having 
the  knife-blade  Avrapped  to  within  an  inch  of  the  point,  cut  away  from  below  upward 
the  proper  amount. 

Recurrent  tonsillitis  is  a  term  used  by  Leland^  of  Boston  in  describing 
that  form  of  tonsillitis  which  recurs  with  such  violent  symptoms,  often  with- 
out any  premonition.  He  says :  ''  The  onset  of  the  exacerbation  may  be 
sudden,  ushered  in  by  a  chill  more  or  less  marked,  with  high  fever,  followed 
by  more  or  less  formidable  swelling,  with  exudation,  white  or  yellow  patches, 
etc.,  to  subside  after  a  week  or  two  ;  or  it  may  go  on  to  abscess,  intratonsillar 
or  peritonsillar,  with  great  distress,  forced  starvation,  restless  days,  sleepless 
nights,  extreme  prostration  and  anxiety  (both  for  patient  and  physician), 
requiring  weeks  or  months  for  recovery.  The  mental  state  of  the  attendant 
is  not  an  enviable  one  when  he  knows  that  he  may  have  a  sudden  fatal  ter- 
mination from  extreme  faucial  swelling,  oedema  glottidis,  sufi"ocation  from 
sudden  discharge  of  pus  or  by  involvement  of  the  great  vessels — the  carotid 
and  internal  jugular — by  extension  of  inflammation." 

He  describes  two  varieties  of  tonsils  which  are  subject  to  such  recurrence  : 
First  is  the  tonsil  which  in  an  inflammatory  attack  simply  rounds  out  an 
increase  in  size — smooth,  red,  shiny,  the  parenchymatous  variety.  The  crypts 
or  lacunae  are  not  markedly  developed,  but  the  lymphoid  elements  are  increased 
in  size  and  in  number.  If  the  capsule  is  broken  and  the  finger  introduced,  a 
soft,  friable  feeling  is  communicated  to  it,  something  like  that  of  the  normal 
spleen.  After  several  inflammatory  attacks  these  tonsils  are  adherent  to  the 
pillars  of  the  fauces,  and  especially  when  this  adhesion  has  taken  place  are 
they  apt  to  be  permanently  enlarged,  and  even  to  close  the  faucial  passage, 
pushing  forward  the  uvula,  with  every  slight  cold  or  disturbance  of  the 
digestion,  or  from  some  other  ill-defined  cause,  so  that  the  voice  and 
respiration  of  the  sufi'erer  are  much  affected. 

The  other  variety  is  the  chronic  tonsil,  which  has  a  hard,  rubbery  feel, 
whose  surface  is  full  of  crypts  or  lacunas  which  run  into  its  depth  from  one- 
quarter  of  an  inch  to  one  inch  or  more,  which  crypts  usually  contain  inspis- 
sated secretion  of  a  cheesy  consistency  and  of  a  most  ofi"ensive  odor.  This  is 
the  '  lacunal '  tonsillitis  of  Wagner  or  Brown.  It  may  be  large  enough  to  just 
project  beyond  the  pillars  or  it  may  reach  even  to  the  uvula.  Because  of  the 
diseased  condition  of  the  interior  of  the  crypts  it  is  especially  liable  to  fre- 
quent infiammatory  attacks  from  even  the  slightest  cause.  It  acts  as  a  foreign 
body  in  the  fauces,  producing  a  tickling,  hacking  cough,  giving  a  malodorous 
breath,  and  doubtless  keeps  the  general  health  of  the  patient  down  from  the 
absorption  of  these  decomposing  cheesy  masses  through  the  tonsil  itself  or 

^Boston  Med.  and  Surg.  Joum.,  Oct.  12  and  19,  1893. 


700 


LOCAL  DISEASES. 


Fig.  202. 


from  their  being  swallowed.  It  is  said  that  attacks  of  indigestion  light  up 
inflammatory  conditions  in  the  tonsil.  It  is  probably  also  true  that  the  con- 
tents of  the  crypts  excite  or  keep  up  fermentative  indigestion.  This  variety 
of  tonsil  is  doubtless  the  result  of  repeated  attacks  of  the  first  vai-iety. 

The  TREATMENT  recommended  by  Leland  is  the  removal  of  the  inspissated 
secretion  of  the  crypts  on  which  the  inflammation  depends,  and  "  the  tearing 
away  of  the  partitions  between  the  crypts  so  as  to  connect  the  many  small 
contracted  mouths  into  a  few  large  wide-open  ones."  For  this  purpose  he  has 
devised  a  knife  (Fig.  202),  which  he  uses  as  follows : 

The  olive-shaped  tip  of  the  knife  is  introduced  into  a  crypt  in  the  upper  part 
of  the  tonsil,  and  then  turned  downward  and  inward  and  made  to  come  out  by 
another  in  the  lower  part.  The  substance  of  the  organ  between 
these  two  holes  is  then  cut  through.  This  can  be  repeated 
from  three  to  ten  times  at  a  sitting  until  the  surface  of  the 
tonsil  presents  the  appearance  of  being  full  of  slits.  There 
is  usually  not  much  hemorrhage,  and  this  knife  can  be  intro- 
duced oftentimes  to  its  fullest  extent  without  danger.  As 
soon  as  the  bleeding  has  ceased  the  slits  are  painted  with 
Monsel's  solution  or  with  a  mixture  of  glycerin  and  tincture 
of  iodine  in  equal  parts.  These  solutions  may  be  put  upon 
the  end  of  the  cotton-wrapped  bent  applicator  and  crowded 
down  to  the  bottom  of  the  tonsil.  This  is  done  for  antisepsis 
and  to  prevent  the  wounds  from  uniting  immediately,  as  they 
tend  to  do,  thus  rendering  the  operation  futile.  The  patient  is 
advised  to  gargle  with  hot  water  very  frequently  for  three  or 
four  days,  and  to  return  in  a  week  for  another  operation,  if 
necessary.  Dobell's  or  Seller's  solution  or  a  little  borax  may 
be  added  to  the  hot  water.  It  usually  requires  from  four  to 
eight  sittings  to  cause  a  large  tonsil  to  recede  from  the  median 
line  to  a  position  almost  out  of  sight  behind  the  pillars  of  the 
fauces.  If  the  tonsil  is  very  fibrous  and  hard,  there  will  be 
left  small  projections  upon  the  surface.  These  can  be  readily 
nipped  oS"  with  adenoidal  forceps  or  can  be  seized  by  long 
dressing  forceps  and  removed  with  a  blunt-pointed  bistoury. 
The  patient  is  then  instructed  to  return  on  the  slightest  symp- 
tom of  the  old  trouble,  that  any  crypt  which  has  escaped  treat- 
ment may  be  attended  to.  In  adults  this  method  can  be  carried 
out  with  the  greatest  facility  and  ease,  and  often  in  children  as 
young  as  ten  years  of  age.  I  have  also  been  able  to  operate 
with  satisfaction,  although  with  a  little  more  necessary  per- 
suasion, in  children  as  3'oung  as  five  or  six ;  and  recurrent 
tonsillitis  is  not  apt  to  occur  younger  than  that,  at  least  in  my 
experience.  The  first  variety  of  tonsillitis,  in  which  the  crypts 
are  not  so  much  developed  or  so  fully  diseased,  is  much 
benefited  by  this  method  if  the  capsule  is  torn  or  cut  and 
the  solution  applied  to  its  interior,  and  perhaps  even  if  only  adhesions  between  the 
tonsil  and  the  pillars  of  the  fauces  are  cut  away  by  this  method. 

Adenoid  vegetations  consist  of  nodules  of  lymphoid  tissue  which  form 
masses  of  soft  tissue  or  ridges  or  lobules  on  the  tipper  and  lateral  surfaces 
of  the  posterior  nares.  They  often  exist  in  connection  with  hypertrophy  of 
the  tonsils,  and  they  have  been  called  the  pharyngeal  tonsil.  They  may  be 
seen  with  the  laryngeal  miiTor,  and  may  be  felt  with  the  index  finger,  well 
protected  by  a  shield  of  celluloid,  passed  behind  the  soft  palate.  They  may 
be  suspected  to  exist  in  a  child  who  snores,  has  a  mucous  discharge  from  the 
nose,  and  a  thick  speech. 

According  to  Power,^  the  facial  expression  is  characteristic  in  the  later  stages  ; 
there  is  a  dull  and  heavy  look,  a  sallow  complexion,  thick  and  prominent  lips ; 

^  Power,  Surg.  Dis.  Children,  p.  281. 


CATARRHAL  PHARYNGITIS,  ETC.  701 

mouth  open;  nostrils  narrow;  alse  indented  at  junction  of  superior  and  inferior 
lateral  cartilages ;  bridge  of  nose  broad  and  often  crossed  by  a  large  vein ;  eyes 
appear  unduly  far  apart ;  often  dulness  of  hearing. 

The  TREATMENT  is  removal.  Various  instruments  have  been  devised  for 
this  purpose,  as  curettes,  forceps,  and  artificial  nails,  but  a  Volkmann's 
spoon,  passed  through  the  anterior  nares,  guided  by  a  finger  in  the  pharynx, 
effects  the  purpose.  The  child  should  be  brought  partially  under  the  anees- 
thetic  and  a  gag  employed. 

Povper  has  the  head  of  the  patient  hang  over  the  table,  so  as  to  prevent  the 
escape  of  blood  into  the  air-passages. 

The  nasal  cavity  should  be  swabbed  out  during  the  operation  with 
absorbent  cotton.  On  removing  the  gag  the  bleeding  ceases.  Recovery 
is  usually  rapid. 


CHAPTER    IV. 

CATAKEHAL  PHARYNGITIS,  PERIPHARYNGEAL   ABSCESS, 
CESOPHAGITIS. 

Catarrhal  Pharyngitis. 

Children  of  all  ages  are  liable  to  inflamniation  of  the  pharynx.  In  its 
mildest  form  it  often,  doubtless,  escapes  detection  in  the  young  infant.  In 
older  patients  it  is  revealed  by  pain  in  swallowing  solid  food  and  more  or  less 
tumefaction  below  the  ears,  apparent  to  the  sight.  It  is  said  to  be  less  fre- 
quent in  infancy  than  in  childhood.  In  the  adult  and  in  children  over  the 
age  of  four  or  five  years  inflammation  of  the  pharyngeal  surface  is  often  con- 
fined to  the  portion  of  membrane  which  covers  or  immediately  surrounds  the 
tonsils.  It  occurs  in  connection  with  infiammation  of  these  glands.  But  in 
infancy  and  early  childhood  this  limitation  is  comparatively  rare.  Catarrhal 
inflammation  of  the  fauces  at  this  age  is  ordinarily  general,  the  tonsils  par- 
ticipating in  the  morbid  state. 

Pharyngitis  is  primary  or  secondary.  The  secondary  form  occurs  in  mea- 
sles, scarlet  fever,  bronchitis,  croup,  pneumonia,  and  occasionally  in  other 
affections.  As  these  diseases  are  common,  physicians  are  oftener  called  to 
treat  patients  who  have  the  secondary  form  than  the  primary.  Rilliet  and 
Barthez  met  83  secondary  to  16  primary  cases. 

Anatomical  Characters. — The  pathological  anatomy  of  pharyngitis  is 
ascertained  by  depressing  the  tongue  and  inspecting  the  fauces.  The  faucial 
surface  is  seen  to  be  redder  than  in  health,  with  more  or  less  swelling  accord- 
ing to  the  intensity  of  the  inflammation.  In  the  primary  inflammation  the 
color  is  commonly  bright  red.  almost  like  that  of  arterial  blood.  If,  on  the 
other  hand,  the  inflammation  occur  in  connection  with  a  constitutional  malady, 
the  hue  is  often  darker.  In  grave  cases  of  scarlet  fever  or  measles  it  is  some- 
times even  livid,  indicating  a  vitiated  state  of  the  blood — a  condition  of  real 
danger.  The  tonsils  are  tumefied  so  as  to  project,  though  not  to  the  extent 
which  we  observe  in  the  adult.  They  are  less  firm  than  in  the  normal 
state.  The  follicles  of  the  throat  are  enlarged  and  active,  pouring  out  a 
muco-purulent  secretion.  This  is  sometimes  seen  in  a  layer  over  the  tonsil 
or  the  posterior  portion  of  the   fauces.     In  a  case  of  primary  pharyngitis 


702  LOCAL  DISEASES. 

examined  after  death  by  Rilliet  and  Barthez  the  tonsils  were  softened,  infil- 
trated with  pus,  and  slightly  enlarged.  A  layer  of  bloody  mucus  lay  on  the 
pharyngeal  surface,  which  was  dark  red  and  thickened.  The  submaxillary 
glands  were  also  swollen  and  somewhat  softened. 

If  the  inflammation  be  intense,  the  deep-seated  portions  of  the  tonsils 
become  involved,  and  even  sometimes  the  adjacent  connective  tissue.  In  such 
cases  by  applying  the  fingers  in  the  hollows  below  the  ears  the  tonsils  can  be 
felt. 

Causes. — The  usual  cause  of  primary  pharyngitis  is  exposure  to  cold. 
It  also  occasionally  occurs  from  the  use  of  drinks  too  hot  or  containing  some 
irritating  substance.  I  have  met  it  in  the  most  intense  form  caused  by  swal- 
lowing boiling  water,  and  in  one  case  from  acetic  acid  taken  through  mis- 
take. When  it  occurs  in  the  eruptive  fevers  it  is  usually  part  of  a  more 
extensive  phlegmasia,  in  which  the  buccal  and  perhaps  laryngeal  and  nasal 
surfaces  participate. 

Symptoms. — Fever,  witli  thirst  and  loss  of  appetite,  is  common,  and  is 
usually  proportionate  in  intensity  to  the  extent  and  severity  of  the  inflamma- 
tion. At  first  there  is  dryness  of  the  faucial  surface,  and  this  is  succeeded 
by  a  more  or  less  abundant  viscid  secretion.  Swallowing  is  painful,  except 
in  mild  cases.  The  muscles  of  the  anterior  half-arches,  which  by  their  con- 
traction close  the  opening  from  the  pharyngeal  to  the  buccal  cavity,  and  those 
of  the  posterior  arches,  which  close  the  opening  to  the  nasal  cavity,  both 
which  sets  lie  a  little  under  the  mucous  membrane,  are  often  so  infijtrated 
with  serum  that  their  contractile  power  is  diminished,  and  if  the  same  happen 
with  the  constrictor  muscles,  which  carry  downward  the  food,  swallowing 
becomes  difficult,  and  in  the  attempt  more  or  less  of  the  ingesta  is  liable  to 
return  into  the  mouth  or  enter  the  nostril.  During  health  the  air  passes 
through  the  nostrils  in  the  pronunciation  of  two  letters  only — namely,  n  and 
m — but  in  severe  pharyngitis,  in  consequence  of  the  swelling  and  the  impair- 
ment of  the  action  of  the  muscles  concerned  in  speech,  the  air  passes  through 
the  nostrils  with  the  utterance  of  many  words,  producing  the  nasal  tone  of 
voice.  Sometimes  the  inflammation  traverses  the  Eustachian  tube  to  the 
middle  ear,  causing  earache,  which  may  be  relieved  by  the  escape  of  pus  down 
the  tube  or  by  perforation  of  the  drum  into  the  external  ear. 

The  breath  is  foul,  but  not  fetid  ;  the  respiration  normal  or  but  slightly 
accelerated  ;  there  is  commonly  no  cough,  but  it  is  sometimes  present,  due  to 
the  extension  of  the  inflammation  to  the  upper  part  of  the  larynx  or  to  the 
collection  of  mucus  around  the  aperture  of  the  glottis.  In  most  cases  of 
pharyngitis  a  light  fur  covers  the  tongue,  and  stomatitis  of  a  mild  grade 
is  present,  as  shown  by  redness  of  the  buccal  surface  and  increased  mucous 
secretion. 

Chronic  pharyngitis,  which  is  so  common  in  adults,  and  which  is  produced 
in  some  by  gastric  derangements,  and  in  others  by  excessive  smoking  or  the 
prolonged  use  of  intoxicating  drinks,  and  in  others  still  by  the  sypbilitie  or 
mercurial  cachexia,  is  comparatively  rare  in  children. 

Prognosis. — In  mild  cases  of  pharyngitis  convalescence  commences 
within  a  week.  If  the  inflammation  be  dependent  on  a  constitutional  malady, 
it  may  continue  considerably  longer,  especially  if  the  glands  of  the  neck  and 
the  connective  tissue  be  much  involved.  The  prognosis  in  secondary  pharyn- 
gitis is  less  favorable  than  in  that  of  the  primary  form.  In  fatal  cases  there 
is  usually  a  vitiated  state  of  the  blood,  either  from  the  coexisting  constitu- 
tional disease  or  from  previous  cachexia. 

Pharyngitis  may,  however,  become  dangerous  from  complications  to  which 
it  gives  rise.  The  proximity  of  the  inflammation  to  the  brain  or  its  eff'ect 
upon  the  cerebro-spinal  axis  through  the  medium   of  the  nerves  sometimes 


CATARRHAL  PHARYNGITIS,  ETC.  703 

gives  rise  to  clonic  convulsions.  In  a  recent  case  of  primary  pharyngitis  in 
my  practice  repeated  and  violent  convulsions  occurred  in  an  infant  about  one 
year  old  from  this  cause.  They  commenced  at  the  inception  of  the  inflamma- 
tion, and  constituted  the  only  real  danger.  Pharyngitis  may  interfere  mate- 
rially with  nutrition  in  consequence  of  the  dysphagia,  but  in  most  cases  of 
primary  pharyngitis  this  symptom  does  not  continue  sufficiently  long  to 
endanger  the  life  of  the  patient.  In  grave  constitutional  affections,  as  scarlet 
fever,  the  difficulty  of  swallowing  and  the  consequent  innutrition  augment 
the  danger.  As  regards,  therefore,  the  prognosis  in  catarrhal  pharyngitis, 
whether  primary  or  secondary,  it  may  be  stated  as  a  rule  that  it  is  not,  per  se, 
a  fatal  disease,  but  is  only  so  from  complications  or  from  aggravating  the 
primary  malady  with  which  it  is  associated. 

Diagnosis. — This  is  not  difficult,  provided  that  attention  be  directed  to 
the  throat ;  but  the  physician  often  fails  to  discover  it  at  his  first  visit  from 
neglecting  to  examine  this  part.  In  many  cases  the  local  symptoms  are  not 
well-marked,  and  in  the  absence  of  these  the  febrile  reaction  may  at  first  be 
referred  to  some  other  cause  than  the  true  one.  Inspection  not  only  reveals 
the  presence  of  inflammation,  but  enables  us  to  determine  the  form  with  the 
aid  of  the  microscope.  This  instrument,  now  in  common  use,  enables  us  to 
differentiate  simple  catarrhal  inflammation  from  diphtheritic,  pseudo-diph- 
theritic, and  other  forms  of  pharyngitis. 

Treatment. — Mild  cases  of  simple  pharyngitis  require  little  treatment. 
With  moderate  counter-irritation  around  the  neck,  as  by  one  of  the  following 
prescriptions,  and  by  appropriate  remedies  the  patient  recovers  : 


R.  Olei  caryophylli,  .^ij  ; 

Olei  camphorati,  §iv. — Misce. 


For  external  use, 

R.  Olei  terebintliinse,  ,^ss  ; 

Olei  camphorati,  §iij. — Misce. 

For  external  use. 

Sometimes  warm-water  applications,  or,  if  the  temperature  exceeds  103° 
F.,  applications  containing  ice.  give  most  relief. 

In  severe  forms  of  the  disease  occurring  independently  of  any  other 
malady  more  active  measures  are  sometimes  required.  Carl  Seller's  tablet, 
which,  according  to  the  published  formula,  contains  several  sodium  combina- 
tions with  aromatics  and  antiseptics,  will  be  found  very  useful  for  this  and 
other  forms  of  pharyngitis,  sprayed  frequently  over  the  fauces  according  to 
the  following  formula : 

R.  Creasoti  (Morson's  beechwood),      gtt.  ij  ; 
Seiler*  s  tablet  for  the  fauces,  No.  j  ; 

Aquffi  destillat.,  §iij. — Misce. 

Spray  fauces,  and  if  necessary  nares,  every  hour. 

If  there  be  stupor  or  restlessness,  with  unusual  heat  of  head,  and  start- 
ing or  twitching  of  the  limbs  which  threatens  convulsions,  two  to  five  grains 
of  the  bromide  of  potassium  given  every  two  or  three  hours  produce  a  calm- 
ative effect. 

Diaphoretic  and  sometimes  cardiac  sedatives  are  also  indicated,  such  as 
liquor  ammonias  acetatis,  spiritus  aetheris  nitrosi,  ipecacuanha,  and  aconite. 
Medicines  of  this  kind  may  be  variously  combined  according  to  the  age  and 
condition  of  the  patient  and  the  severity  of  the  disease. 

As  the  symptoms  abate  the  intervals  between  the  doses  may  be  in- 
creased. 


704  LOCAL  DISEASES. 

In  cases  attended  by  mucli  tenderness  and  dysphagia  great  relief  is  often 
obtained  by  hot  poultices  frequently  applied  over  the  neck. 

The  treatment  of  secondary  pharyngitis  will  be  described  in  connection 
with  the  treatment  of  the  diseases  which  it  complicates.  Suffice  it  here  to 
say  that  this  form  of  inflammation  must  not  be  treated  by  those  depressing 
remedies  which  may  be  useful  in  cases  of  idiopathic  pharyngitis. 

Peripharyngeal  Abscess. 

An  abscess  occasionally  forms  between  the  pharynx  and  vertebral  column 
(retropharyngeal)  or  upon  the  side  of  the  pharynx  in  the  submucous  connec- 
tive tissue.  This  constitutes  a  disease  which  may  be  fatal,  but  which  can 
ordinarily  be  promptly  relieved  by  the  surgeon. 

Yet  if  we  look  over  the  records  of  peripharyngeal  abscess  we  shall  see 
that  in  a  large  jDroportion  of  fatal  cases  the  disease  was  supposed  to  be  some- 
thing else,  and  so  treated  until  its  nature  was  revealed  by  post-mortem  exam- 
ination. 

This  abscess  may  occur  at  any  age,  but  is  most  common  in  infancy  and 
childhood.  It  is  more  frequent  in  the  first  two  years  of  life  than  at  any 
other  period.  Of  the  cases  collated  by  Allen  in  which  the  age  is  stated.  20 
were  under  ten  years  and  21  over  this  age.  The  abscess  occurs  in  some 
patients  from  caries  of  the  vertebral  column,  and  in  others  from  inflamma- 
tion developed  in  the  connective  or  small  lymphatic  glands  lying  immediately 
outside  the  pharynx,  or  from  a  catarrhal  pharyngitis.  The  patient  is  usually 
scrofulous  or  in  a  reduced  state  of  system. 

Writers  describe  two  kinds  of  peripharyngeal  abscess,  the  primary  and 
secondary.  This  distinction  is  based  on  the  fact  whether  or  not  the  inflam- 
mation which  leads  to  the  abscess  be  dependent  on  an  antecedent  pathological 
state.  In  the  primary  form  the  cause  is  usually  some  irritating  substance 
which  has  been  swallowed,  and  which,  lodging  in  the  pharynx,  produces 
phlegmonous  pharyngitis. 

The  CAUSE  is  mentioned  in  20  cases  of  the  primary  form,  collated  by 
Allen,  as  follows:  exposure  to  cold,  10  cases;  lodgement  of  bone  in  pharynx, 
8  cases ;  blow  with  a  fencing-foil,  1  case.  In  the  last  case  the  button  of  a 
fencing-foil  passed  through  the  right  nostril  into  the  pharynx. 

The  secondary  form  occasionally  occurs  after  measles  and  scarlet  fever. 
The  inflammation  of  the  pharynx  common  in  tho.se  diseases  extends  to  the 
subjacent  connective  tissue,  and,  aided  by  the  dyscrasia  of  the  patient, 
becomes  suppurative.  The  most  common  cause  of  the  second  form  is, 
however,  caries  occurring  in  the  cervical  vertebrae,  and  it  is  similar,  both 
as  regards  cause  and  nature,  to  lumbar  abscess.  It  would  follow  the  same 
chronic  course  were  it  not  for  its  proximity  to  the  air-passages,  which  renders 
the  symptoms  urgent  and  dangerous.  In  a  few  recorded  cases  the  abscess 
was  a  sequel  of  erysipelas. 

In  19  cases  of  secondary  abscess  in  Allen's  collection  the  cause  is  assigned  as 
follows :  erysipelas  of  face,  2 ;  inflammation  following  a  fall  upon  the  inferior 
maxilla,  1  ;  after  cerebritis,  1 ;  syphilis,  4  ;  caries  of  the  cervical  vertebrae,  6  ; 
scrofula,  5. 

The  opinion  is  expressed  by  Mr.  Fleming  ^  that  the  suppuration  of  peri- 
pharyngeal abscesses  begins  in  a  large  proportion  of  cases  in  the  small 
lymphatic  glands  which  lie  in  the  connective  tissue  external  to  the  pharynx. 
The  late  Prof.  George  T.  Elliott  ^  has  recorded  the  case  of  an  infant  of  seven 
months  in  whom  abscess  immediately  followed  and  was  apparently  due  to 
parotiditis. 

1  Dublin  Journ.  of  Med.  ScL,  vol.  xviii.  z  Obst.  Clinic,  X.  Y. 


CATARRHAL  PHARYNGITIS,  ETC.  705 

In  rare  instances,  the  abscess,  or  the  local  disease  which  leads  to  it,  appears 
to  exist  from  birth.  Thus  Dr.  E.  0.  Hocken  relates '  the  history  of  an  infant 
which  died  at  the  age  of  nine  weeks.  It  had  always,  when  taking  the  breast, 
thrown  back  its  head  as  if  nearly  suffocated.  The  walls  of  the  abscess  w.ere 
thick  and  firm,  described  by  the  writer  as  cartilaginous.  Occasionally  there 
is  no  apparent  cause  of  the  abscess  except  the  strumous  or  cachectic  state. 

Anatomical  Characters. — The  seat  of  the  abscess  is  not  the  same  in 
all  cases.  The  swelling  can  ordinarily  be  seen  on  examining  the  fauces,  but 
occasionally  it  is  so  low  as  to  be  really  perioesophageal,  and  therefore  invisible. 
The  size  of  the  abscess  varies :  sometimes  it  is  large,  pressing  inward  the 
wall  of  the  pharynx  even  against  the  velum  palati,  and  into  the  posterior 
nares  if  the  abscess  have  a  high  location,  or  if  lower  against  the  larynx,  so 
as  to  embarrass  respiration.  Sometimes  the  abscess  is  so  large  or  has  such 
lateral  extension  that  there  is  external  swelling  along  the  side  of  the  neck. 
In  a  few  cases  on  record  the  pus,  instead  of  being  discharged  into  the  pharynx, 
made  its  way  down  the  neck  between  the  muscles  and  the  connective  tissue 
to  the  pleural  cavity,  which  it  entered,  producing  fatal  pleuritis. 

The  walls  of  the  abscess  have  been  found  in  a  different  state  in  different 
cases.  Sometimes  the  sac  at  the  projecting  point  is  so  thin  that  it  seems  as 
if  there  might  have  been  a  spontaneous  cure  could  life  have  been  preserved 
a  few  hours  longer.  In  other  cases  the  sac  is  so  thick  and  firm  that  its  rup- 
ture for  many  days  would  be  impossible, 

Symptoms. — The  precursory  symptoms  differ  in  different  cases  according 
to  the  nature  of  the  cause,  whether  it  be  phlegmonous  pharyngitis  or  simply 
adenitis  or  vertebral  caries.  If  the  abscess  proceed  from  caries,  it  is  preceded 
by  deep-seated  pain,  greatly  increased  by  movements  of  the  head,  and  prob- 
ably preceded  also  by  induration  along  the  sides  of  the  vertebras. 

The  patient  with  this  disease  is  restless,  his  mouth  hot  and  dry,  tongue 
furred,  deglutition  more  or  less  difficult.  Sometimes  after  suppuration  has 
occurred  thei-e  are  alternations  of  rigors  and  fever.  The  symptoms  indicate 
approximately  the  seat  of  the  inflammation,  but  on  examination  we  do  not 
find  that  degree  of  redness  of  the  mucous  surface  which  we  had  been  led  to 
expect.  The  tissues  which  are  chiefly  involved  in  the  inflammation,  being 
submucous,  are  hidden  from  view.  We  observe  redness  of  the  pharynx,  but 
it  is  disproportionate  to  the  intensity  of  the  symptoms.  Some  patients  fre- 
quently experience  a  chilly  sensation  through  the  entire  period  of  the  abscess, 
though  greater  at  one  time  than  at  another,  and  occasionally  convulsions 
occur,  especially  in  young  infants.  In  ordinary  cases  embarrassment  of  res- 
piration begins  early,  and  is  the  cause  of  the  chief  danger.  It  becomes  more 
and  more  marked  as  the  abscess  increases.  It  is  noticed  both  during  inspi- 
ration and  expiration.  The  dysphagia  also  increases,  sometimes  to  such  a. 
degree  that  drinks  are  taken  with  difficulty  and  solid  foods  refused.  The 
respiratory  symptoms  bear  considerable  resemblance  to  those  in  protracted 
laryngitis,  for  which  this  disease  has  been  mistaken.  While  the  respiration 
becomes  impeded  or  whistling,  the  voice  is  also  feeble  or  indistinct  from  the 
pressure  of  the  tumor. 

But  the  symptoms  described  above  are  not  all  present  in  every  case. 
They  vary  according  to  the  size  and  location  of  the  abscess,  whether  it  be 
high  or  low,  posterior  or  lateral.  I  have  met  the  disease  in  a  child  old  enough 
to  make  known  the  subjective  symptoms,  in  whom  there  was  little  or  no  dys- 
phagia;  and  others  report  similar  cases.  When  the  tumor  has  attained  such 
a  size  that  it  produces  well-marked  symptoms  and  jeopardizes  the  life  of  the 
patient,  it  or  a  part  of  it  can  ordinarily  be  seen  on  depressing  the  tongue, 
but  usually  its  location  and  condition  can  be  better  ascertained  by  exploration 
'  Prov.  Med.  and  Surg.  J  own.,  1842. 
45 


706  LOCAL  DISEASES. 

with  the  finger.  The  dyspnoea  increases  as  the  abscess  enlarges,  and  after  a 
time,  unless  it  burst  spontaneously  or  be  opened  by  the  surgeon,  imperfect 
oxygenation  of  the  blood  results.  In  some  patients  paroxysms  of  dyspnoea 
occur,  so  as  to  threaten  immediate  suffocation  ;  coughing  or  attempts  to  swal- 
low induce  these  paroxysms,  and  the  patient  is  forced  to  remain  in  an  erect 
or  semi-erect  posture ;  the  tongue  is  protruded,  the  head  thrown  back,  the 
pulse  is  frequent  and  rapid,  the  limbs  become  livid  and  cool,  and  finally  death 
results  from  dyspnoea.  Occasionally,  when  death  seems  inevitable,  the  abscess 
breaks  during  the  struggles  of  the  child  and  the  patient  is  restored  to  health. 
In  rare  cases  the  result  is  different.  The  trachea  and  bronchial  tubes  are 
deluged  by  the  purulent  discharge  and  immediate  suffocation  occurs. 

The  following  was  an  example :  In  May,  1871,  a  boy  two  years  and  five  months 
old,  who  had  the  symptoms  of  an  abscess  for  three  months,  was  brought  to  the  class 
at  Bellevue.  The  head  was  carried  on  one  side,  its  rotation  caused  pain,  and  a 
laryngeal  rale  accompanied  respiration.  The  upper  part  of  the  tumor  could  be 
detected  by  the  finger,  but  on  account  of  its  low  location  it  was  impossible  to  open 
it  with  a  bistoury.  The  temperature  was  103°,  pulse  156.  The  case  remained 
under  observation,  but  in  a  few  days  the  dyspnoea  suddenly  became  so  urgent  that 
death  Avas  imminent,  when  the  attending  physician  of  the  class.  Dr.  Swezey,  broke 
the  abscess  with  his  finger  and  pus  was  ejected  on  the  floor ;  death,  however, 
occurred  almost  immediately. 

A  correct  appreciation  of  the  symptoms  and  nature  of  peripharyngeal  abscess 
will  be  best  obtained  by  relating  a  case.  I  select  the  following  from  the  Trans,  of 
the  Lond.  Pathol.  Soc,  Oct.  20,  1846:  A  female  infant  died  at  the  age  of  seven 
months,  having  had  difficult  breathing  three  weeks  and  extreme  dyspnoea  during 
the  last  days  of  life.  The  dyspnoea  was  constant,  and  was  aggravated  by  mental 
excitement,  by  movements  of  the  body,  and  by  exposure  to  cold.  During  the  par- 
oxysms a  peculiar  croupy  sound  accompanied  inspiration.  There  was  no  dysphagia 
through  the  entire  sickness,  and  death  occurred  from  apnoea.  The  sac  of  the  abscess 
was  of  the  size  of  a  pigeon's  egg,  and  was  situated  between  the  upper  cervical  ver- 
tebrae and  the  back  of  the  pharynx.  The  abscess  was  flattened  in  front,  so  as  not 
to  cause  any  decided  prominence  of  the  wall  of  the  pharynx.  From  the  sac  a  sec- 
ond small  cyst  extended  forward,  forming  a  nipple-like  swelling  in  the  pharynx 
which  completely  closed  the  orifice  of  the  glottis.  Its  aperture  of  communication 
with  the  body  of  the  abscess  admitted  the  point  of  the  little  finger,  and  the  whole 
swelling  was  freely  movable  and  perfectly  translucent  at  its  extremities  and  sides. 
The  abscess  might  have  been  easily  punctured,  with  probably  the  preservation  of 
life. 

The  DURATION  of  this  malady  is  very  different,  according  to  the  inflam- 
mation, the  rapidity  with  which  the  abscess  enlarges,  and  the  direction  which 
it  points.  A  lateral  or  downward  extension  is  not  so  immediately  dangerous 
to  life  as  the  anterior. 

The  time  when  the  abscess  begins  to  form  cannot  be  precisely  ascertained, 
and  most  writers  in  determining  its  duration  compute  from  the  first  appear- 
ance of  symptoms  which  are  referable  to  the  pharynx. 

Dr.  J.  Byrne  ^  relates  a  fatal  case  in  which  the  disease  had  apparently  continued 
only  about  one  week.  The  patient  was  an  infant  one  year  old,  and  its  death  was 
from  apnoea.  The  abscess  was  large,  extending  from  the  base  of  the  skull  to  the 
thorax  and  pressing  both  on  the  larynx  and  trachea.  M.  Besserer^  gives  the  his- 
tory of  an  infant  four  months  old  who  died  in  the  same  way  after  thirteen  days. 
An  infant  nine  months  old,  whose  case  was  published  by  Dr.  W.  C.  Worthington,* 
lived  nine  days.  The  abscess  occurred  from  exposure  to  cold ;  the  patient  was 
treated  for  croup  and  died  from  suffocation.  The  anterior  wall  of  the  abscess  was 
very  thin.  In  two  cases  treated  by  me  the  symptoms  indicated  a  continuance  of 
the  disease  from  two  to  four  weeks,  and  in  a  third  case  four  months.  A  fourth  case 
is  interesting  on  account  of  the  short  duration  of  the  severe  symptoms.     The  fol- 

^Amer.  Journ.  of  Med.  Sci,  1838.  ^  Arch.  gen.  de  Med.,  1840. 

^  Prov.  Med.  and  Surg.  Journ.,  1842. 


CATARRHAL  PHARYNGITIS,  ETC.  707 

lowing  is  the  record  of  it ;  M.  E ,  aged  seven  months,  female,  nursing,  inmate 

of  the  New  York  Foundling  Asylum,  was  observed  to  have  difficult  breathing  for 
the  first  time  on  March  28,  1875.  Since  about  March  8th  some  swelling  had  been 
noticed  along  the  side  of  the  neck,  but  it  gave  rise  to  no  marked  symptoms,  and  she 
had  not  seemed  ill  till  the  obstruction  in  the  respiration  commenced.  At  my  visit 
on  the  evening  of  the  28th  the  infant  was  pointed  out  to  me  as  in  a  dying  condition. 
She  was  lying  in  a  state  of  stupor,  pallid  and  gasping  for  breath,  with  a  tempera- 
ture of  103°,  and  very  feeble  pulse,  numbering  about  200  per  minute.  On  carrying 
the  finger  into  the  throat  an  abscess  could  be  readily  detected  situated  in  the  walls 
of  the  pharynx,  on  the  left  side  posteriorly.  This  was  easily  opened  by  a  curved 
bistoury,  around  which  adhesive  plaster  was  wound  to  within  half  an  inch  of  the 
point.  The  breathing  immediately  began  to  improve.  On  the  following  day  the 
infant  Avas  playing  in  the  mother's  lap,  with  a  pulse  of  140,  but  a  normal  tempera- 
ture. With  the  use  of  cod-liver  oil  and  the  syrup  of  the  iodide  of  iron  its  health 
was  soon  fully  restored.  In  the  fifth  case  the  abscess  was  ruptured  by  the  finger, 
and  in  a  sixth  it  was  opened  by  the  lancet.     All  these  patients  recovered. 

When  the  abscess  grows  slowly  and  presses  lightly  on  the  air-passages  the  case 
may  continue  for  months.  Such  a  one  was  observed  by  the  late  Professor  Willard 
Parker  (Allin).  This  infant  was  one  year  old  ;  it  suffered  from  pharyngeal  symp- 
toms nine  months,  was  treated  for  tonsillitis,  and  death  occurred  as  usual  from 
apnoea.  The  abscess  was  two  inches  long,  and  there  was  no  disease  of  the  vertebras. 
The  same  surgeon  saved  the  life  of  another  patient  four  years  old,  in  whom  the 
disease  was  protracted,  by  puncturing  the  abscess ;  the  late  Professor  Post  also 
treated  successfully  a  case  which  had  continued  three  months  (Allin). 

Diagnosis. — The  diagnosis  of  retropharyngeal  abscess  is  ordinarily  easy, 
provided  that  the  physician  examine  carefully  and  bear  in  mind  the  occasional 
occurrence  of  such  an  abscess.  In  a  large  proportion,  however,  of  the 
recorded  fatal  cases  the  true  nature  of  the  disease  was  not  recognized  during 
life.  Especially  is  the  diagnosis  difficult  when  the  cerebro-spinal  system  is 
early  implicated  and  symptoms  arise  which  divert  attention  from  the  throat 
to  the  brain. 

The  maladies  for  which  peripharyngeal  abscess  is  most  frequently  mis- 
taken are  laryngitis  and  simple  but  severe  pharyngitis,  From  laryngitis,  for 
which  it  has  been  most  frequently  mistaken,  it  may  be  distinguished  by  the 
dysphagia  and  by  the  character  of  the  initial  symptoms.  In  laryngitis  there 
is  usually  the  peculiar  cough  from  the  first  or  very  early,  while  in  abscess 
there  is  an  initial  period  of  several  days,  or  even  weeks,  before  respiration  is 
materially  affected.  This  is  the  period  of  inflammation  which  precedes  sup- 
puration. 

In  abscess,  pressure  of  the  larynx  backward  is  badly  tolerated,  greatly 
increasing  the  dyspnoea,  while  in  pharyngitis  and  croup  this  effect  is  not  so 
marked.  In  abscess  the  horizontal  position  aggravates  the  dyspnoea,  but  not 
in  pharyngitis  and  croup.  The  character  of  the  voice  also  aids  in  diagnosti- 
cating an  abscess  from  laryngitis,  since  in  the  former  it  is  usually  nasal,  and 
in  the  latter  hoarse  and  whispering.  But  the  decisive  test  is  afforded  by 
inspection  and  digital  exploration.  The  tumor  is  seen — or,  if  situated  too 
low  to  be  seen  is  felt — upon  the  walls  of  the  pharynx. 

If  the  symptoms  of  abscess  are  masked  by  those  arising  from  the  cerebro- 
spinal system,  as  by  convulsions,  the  priority  of  the  pharyngeal  symptoms 
aids  in  determining  the  true  disease. 

In  a  case  of  suspected  abscess  the  physician  should  not  only  carefully 
inspect  the  fauces,  but  should  also  employ  digital  examination.  The  finger 
will  often  detect  fluctuation  before  the  abscess  is  apparent  to  the  eye. 

Prognosis. — With  proper  treatment  the  result  is  usually  favorable,  but 
if  the  disease  be  not  recognized,  many  die.  In  Dr.  Allin"s  cases,  of  those 
under  the  age  of  twelve  years,  9  died,  while  10  recovered  by  the  opening  of 
tlie  abscess  by  the  lancet,  trocar,  or  finger,  and  1  by  its  spontaneous  rupture. 


708  LOCAL  DISEASES. 

If  the  abscess  be  due  to  disease  of  the  spinal  column,  death  may  occur 
immediately  after  the  sac  is  opened,  the  caries  of  the  intervertebral  cartilages 
producing,  according  to  Dr.  Allin,  dislocation  of  the  vertebrae.  Death  may 
also  occur,  though  rarely,  from  pleuritis,  in  consequence  of  the  bursting  of 
the  abscess  into  the  pleural  cavity.  Even  in  caries,  if  the  sac  be  properly 
opened,  and  if  need  be  reopened,  and  the  head  supported  by  suitable  appara- 
tus, recovery  is  possible,  as  in  a  case  treated  by  Prof.  Post. 

Treatment. — The  proper  treatment  of  peripharyngeal  abscess  is  simple, 
consisting  in  breaking  or  puncturing  the  sac  by  the  finger,  the  lancet,  bis- 
toury, or  pharyngotome.  Each  method  has  been  successfully  employed.  In 
the  majority  of  cases  the  proper  way  to  open  the  abscess  is  by  the  ordinary 
curved  scalpel  or  bistoury,  which  should  be  covered  by  a  strip  of  adhesive 
plaster  to  within  half  an  inch  of  the  point.  If  the  abscess  be  postpharyngeal, 
it  should  be  opened  in  the  median  line.  A  single  incision  suffices  to  evacuate 
the  pus.  If  the  abscess  point  or  be  elastic,  there  is  little  danger  of  wound- 
ing any  important  vessel  or  producing  dangerous  hemorrhage  if  the  operation 
be  properly  performed,  It  may  be  necessary  to  open  the  abscess  more  than 
once,  as  in  a  case  reported  by  Dr.  Post  and  another  which  I  saw  with  Dr. 
Livingston  of  this  city.  In  certain  cases,  when  the  knife  cannot  be  readily 
employed,  the  abscess  may  be  opened  by  pressure  with  the  finger-nail  or  the 
edge  of  a  teaspoon.  At  the  moment  of  puncture  the  child's  head  should  be 
thrown  forward,  so  as  to  give  free  escape  to  the  pus  externally. 

When,  as  in  caries  of  the  cervical  vertebrge,  the  abscess  is  deep-seated  and 
causes  external  prominence,  it  may  be  more  successfully  and  safely  opened  by 
an  external  incision  in  the  following  manner  (Chiene)  : 

Commence  the  incision  one  inch  below  the  mastoid  process,  and  immediately 
behind  the  posterior  border  of  the  sterno-mastoid  muscle,  and  extend  it  about 
one  inch  in  length,  down  to  and  dividing  the  deep  fascia ;  with  a  blunt  direc- 
tor the  dissection  is  continued  and  the  abscess  opened,  one  finger  pressing  on  the 
wall  of  the  pharynx  through  the  mouth.  The  pus  may  be  evacuated  by  pressure 
on  the  pharynx.  The  cavity  should  be  thoroughly  cleansed  by  the  douche,  using 
the  bichloride  solution  (1  :  5000).  The  cavity  should  not  be  scraped,  but  the  drain- 
age-tube should  be  inserted  so  as  to  reach  the  most  dependent  place.  Recovery  is 
usually  entirely  satisfactory. 

Patients  with  this  disease  ordinarily  require  constitutional  treatment, 
especially  the  use  of  tonics,  ferruginous  and  vegetable.  The  citrate  of  iron 
and  quinine,  the  citrate  of  iron  and  ammonium,  and  in  strumous  cases  the 
syrup  of  the  iodide  of  iron  with  cod-liver  oil,  are  eligible  preparations.  Nutri- 
tious diet  and  often  alcoholic  stimulants  are  required. 

Swallowing  Foreign  Substances. 

The  child  is  very  liable  to  swallow  such  articles  as  buttons  and  pennies 
which  have  been  given  it.  Parents  are  often  greatly  alarmed,  but  usually 
these  small  round  bodies  are  harmless.  It  is  well  to  advise  giving  a  large 
supply  of  soft  food,  as  bread  and  potatoes,  and  after  a  few  days  add  a  dose 
of  castor  oil. 

If  the  foreign  body  is  thin  and  pointed,  as  a  pin,  needle,  fish-bone,  bristle, 
it  most  frequently  sticks  between  one  or  other  of  the  pillars  of  the  fauces 
and  the  tonsil,  or  in  the  mucous  folds  connecting  the  base  of  the  tongue 
with  the  epiglottis  ;  if  more  bulky,  it  is  arrested  at  or  about  the  junction  of 
the  pharynx  and  the  oesophagus.  The  symptoms  of  a  small  pointed  body  in 
any  of  these  positions  are — local  pain,  with  a  pricking,  increased  on  pressure, 
behind  the  angle  of  the  jaw  ;  sometimes  there  is  difficulty  or  pain  in  swal- 
lowing, with  a  disposition  to  vomit ;  when   it  is  at  the  upper  orifice  of  the 


CATARRHAL   PHARYNGITIS,   ETC. 


709 


larynx,  there  may  be  cougli  and  dyspnoea  ;  if  the  body  is  large,  it  usually 
causes  death.  In  every  case,  instead  of  wiping  the  parts  roughly  with  a 
sponge,  make  the  most  careful  attempts  to  discover  and  remove  the  body ; 
if  it  is  small  and  not  detected  by  the  sight  or  finger,  use  a  laryngeal  mirror, 
requiring  the  patient  to  inspire  deeply  while  the  tonge  is  depressed ;  when 
found,  seize  it  with  properly  curved  forceps  (Fig.  203).  Or,  employ  the 
bristle  probang  (Fig.  204),  which  must  be  introduced,  closed,  below  the  for- 
eign body,  then  spread  out  and  slowly  withdrawn.  If  the  obstructing  body 
is  food,  dislodge  it  with  the  finger,  or  by  inverting  the  trunk,  as  of  a  child, 
and  giving  to  the  back  in  that  region  a  smart  blow,  or  by  forcing  it  down- 
ward with  a  probang  (Fig.  205).     If  asphyxia  is  threatened,  perform  trach- 


FiG.  203. 


Fig.  204. 


Fig.  205. 


Pharyngeal  forceps. 


Bristle  probang. 


n 


fi 


Probangs. 


eotomy  or  laryngotomy.  If  the  body  is  irregular  and  too  firmly  impacted 
to  be  removed  without  dangerous  violence,  open  the  pharynx,  even  though 
severe  symptoms  are  present.  Pharyngotomy  and  oesophagotomy  have  the 
same  details. 

If  the  body  passes  beyond  the  pharynx,  it  is  most  liable  to  lodge  oppo- 


FiG.  206. 


Probang  forceps. 


Irregular  curved 
forceps. 


site  the  cricoid  cartilage,  or  just  above  the  diaphragm,  where  the  tube  is 
most  constricted ;  if  small  in  bulk,  but  pointed,  as  a  needle,  it  may  stick  in 
the  mucous  membrane  a  long  time,  or  loosen  easily  by  ulceration,  or  pene- 


710  LOCAL  DISEASES. 

trate  the  walls ;  if  large,  hard,  and  irregular,  deglutition  is  generally  difficult 
and  serious  results  are  early  threatened.     The  diagnosis  depends  upon  the 

Fig.  208. 


Right-angled  forceps. 


history.  External  palpation  rarely  gives  any  assistance  in  ascertaining  the 
presence  of  a  foreign  body  lodged  in  the  cesophagus ;  the  tube  lies  so  deep 
behind  the  trachea  and  below  all  of  the  muscles  of  the  neck  that  the  hardest 
and  most  irregular  substances  lodged  in  it  can  very  rarely  be  appreciated  by 
external  examination. 

Attempt  prompt  removal ;  if  the  substance  be  digestible,  endeavor  to  force 
it  onward  into  the  stomach  by  the  probang ;  if  indigestible,  attempt  to  with- 
draw it  by  means  of  forceps  having  a  suitable  curve  (Figs.  206,  207,  208). 
Introduce  them,  well  oiled,  with  the  blades  closed,  using  them  as  a  probe, 
until  the  object  is  reached,  when  they  should  be  opened  and  an  attempt  be 
made  to  seize  the  foreign  body  ;  if  successful,  the  most  careful  manipulation 
is  necessary  in  withdrawing  it  to  avoid  lacerating  the  mucous  membrane ; 
if  the  body  is  small,  use  a  probang  to  which  a  dry  sponge  is  fastened,  or  a 
sound  to  which  a  skein  of  silk  is  attached,  so  as  to  form  a  snare  with  a  great 
number  of  loops,  or  the  bristle  probang  (Fig.  204).  These  instruments  should 
be  passed  beyond  the  obstruction  and  gently  rotated  during  its  withdrawal. 
Coins  and  such  bodies  may  often  be  extracted  with  a  flat  blunt  hook  con- 
nected by  a  thin  strip  of  steel  to  the  end  of  a  long  whalebone  probang  (Fig. 

209).     Vomiting  induced  by  titillating  the 
Fig.  209.  fauces  or  injecting  apomorphia  into  the  arm 

will  sometimes  dislodge  a  small  body,  but 
if  the  obstruction  is  firm,  excessive  vomit- 
ing may  fix  it  more  firmly  or  rupture  the 
cesophagus.  If  respiration  is  dangerously 
embarrassed,  tracheotomy  must  be  per- 
formed, and  if  the  obstruction  is  below 
the  point  of  operation,  a  tube  must  be 
Hooks  for  extracting  coins.  carried    down    the    trachea     sufficiently    to 

admit  the  air  to  the  lungs.  When,  how- 
ever, a  solid  substance,  though  only  of  moderate  size  and  irregular  shape, 
has  become  fixed  at  the  commencement  of  the  oesophagus  or  low  down  in 
the  pharynx,  and  has  resisted  a  fair  trial  for  its  extraction  or  displacement, 
its  removal  should  at  once  be  effected  by  incision  into  that  tube,  though  no 
urgent  symptoms  are  present. 

CEsophagotomy  for  the  removal  of  a  foreign  body  is  not  difficult,  especially 
when  the  body  can  be  located  by  external  pressure : 

Place  the  patient,  fully  anaesthetized,  on  the  back,  the  head  and  shoulders 
slightly  elevated  and  face  turned  to  the  opposite  side.  If  tlie  foreign  body  pro- 
ject, make  the  operation  at  that  point ;  if  not,  operate  on  the  left  side,  to  which 
the  oesophagus  inclines.  Make  an  incision  in  the  course  of  the  depression  between 
the  sterno-mastoid  and  the  trachea,  extending  from  about  opposite  the  upper  bor- 
der of  the  thyroid  cartilage  nearly  to  the  sterno-clavicular  articulation,  through  the 
integument  (Fig.  210);  divide  the  platysma  myoides  muscles  and  the  cervical 
fascia;    separate  the  edges  of  the  wound  and  draw  the   omo-hyoid  muscle  out- 


CATARRHAL  PHARYNGITIS,  ETC. 


711 


Fig.  210. 


ffisophagotomy. 


ward  or  cut  it ;  divide  the  outermost  fibres  of  the  sterno-hyoid  and  thyroid  to  a 
sufficient  extent,  3 ;  the  carotid  sheath,  2,  is  now  fully  exposed,  and  should  be 
drawn  outward  with  the  sterno-mastoid  and  retained  :  separate 
the  thyroid  body  as  far  as  it  may  be  necessary  with  the  handle 
of  the  knife  and  draw  it  inward ;  now  draw  the  larynx  some- 
what forward,  turn  it  slightly  upon  its  long  axis,  and  pass  the 
finger  behind  it  to  discover  the  position  of  the  foreign  body. 
If  it  is  not  found,  pass  a  pair  of  long  curved  forceps  well  down 
into  the  pharjmx  through  the  mouth,  open  them  so  as  to  press 
the  walls  of  the  tube  well  toward  the  wound  as  a  guide,  care- 
fully avoiding  the  recurrent  laryngeal  nerve ;  open  the  tube, 
1,  suflaciently  to  admit  the  finger,  and  extend  the  cut  upward 
into  the  pharynx,  4,  or  downward  along  the  oesophagus,  as  may 
be  necessary  to  reach  the  object  sought;  seai'ch  for  the  foreign 
body  with  the  finger,  and  when  found  extract  it  by  means  of 
suitable  forceps.  The  wound  should  not  be  closed  with  su- 
tures. For  the  first  few  days  the  patient  should  be  fed  by 
the  rectum,  but  later  through  a  tube  passed  by  the  mouth  below  the  wound. 

Stricture  of  the  oesophagus  in  children  is  generally  due  to  cicatrices 
caused  by  attempts  to  swallow  hot  or  corrosive  fluids.  It  occurs  chiefly  on 
a  level  with  the  cricoid  cartilage  or  the  bifurcation  of  the  trachea.  It  may 
be  linear,  annular,  or  tubular,  or  the  cicatrix  may  embrace  only  part  of  the 
circumference  of  the  tube  and  thus  form  a  rigid  valve-like  projection.  The 
leading  symptom  of  organic  stricture  is  gradually  increasing  difficulty  of 
deglutition,  with  its  concomitant  distress  and  pain.  If  the  patient  is  thin 
and  the  stricture  high,  it  may  sometimes  be  felt  externally.  To  determine 
its  presence  and  peculiarities,  place  the  patient  in  a  sitting  posture,  with  the 
head  thrown  back,  and  pass  an  olive-pointed  oesophageal  bougie  along  the 
posterior  wall  of  the  pharynx  down  the  tube  to  the  seat  of  obstruction  : 
the  extent  and  condition  of  the  stricture  can  thus  be  made  out.  The 
diagnosis  in  the  early  period  depends  upon  the  history. 

The  treatment  of  the  cicatricial  form  is  by  dilatation,  oesophagotomy,  or 
oesophagostomy.  Dilators  are  made  of  diff"erent  graduated  sizes,  of  hard 
rubber,  cylindrical,  tapering  at  both  ends  alike,  and  securely  fastened  to  a 
whalebone  stem  (Fig.  211)  ;   they 

may  be  held  in  the  stricture  for  a  Fig.  211. 

short  time  at  each  introduction, 
giving  the  benefit  of  pressure ; 
the  tolerance  of  these  bougies  by 
the  oesophagus  gradually  increases, 
though  their  pressure  against  the 
larynx  may  interfere  with  respira- 
tion and  prevent  their  long  retention 
within  the  stricture. 

Place  the  patient  in  a  chair  with 
the  head  thrown  back.  Now  depress 
the  tongue  with  the  finger  or  a  spatula, 
and,  holding  the  bougie  as  a  pen,  pass 
it  along  the  posterior  wall  of  the  pharynx  down  to  the  obstruction,  and  gently 
insinuate  the  conical  extremity  into  the  contracted  passage.  Apply  the  gag  to  keep 
the  mouth  open.  The  force  used  should  be  slight,  lest  the  wall  of  the  tube  be  per- 
forated, as  has  been  done.  The  object  is  to  open  the  stricture  laterally  and  not 
push  it  downward :  repeat  the  operation  every  second  or  third  day,  gradually 
increasing  the  size  of  the  bougie  as  the  stricture  is  enlarged.  If  the  stricture  is 
unyielding  and  deglutition  impossible,  gastrostomy  must  be  performed. 

Sands  says  :  "  Gradual  dilatation  is  usually  the  safest  and  best  mode  of  treat- 
ment whenever  it  is  practicable ;  it  should  always  be  resorted  to  as  a  preventive 
measure  in  the  incipient  stage  of  the  disease  before  cicatrization  has  occurred ;  as 


CEsophageal  dilators. 


712  LOCAL  DISEASES. 

a  rule,  treatment  should  be  commenced  within  a  week  or  ten  days  of  the  injury  and 
continued  indefinitely.' " 

(Esophagostomy  is  the  establishment  of  a  fistulous  opening  in  the  neck 
for  the  relief  of  stricture  of  the  oesophagus.  It  should  never  be  performed 
unless  there  is  reason  to  believe  that  it  will  be  possible  to  introduce  a  tube 
into  the  gullet  below  the  seat  of  stricture.  The  advantages  are  that  it  is 
attended  with  little  shock  and  facilitates  the  subsequent  dilatation  of  the 
stricture  ;  the  disadvantages  are — the  doubt  whether  the  opening  will  be 
below  the  stricture,  the  adhesion  of  diseased  parts  to  surrounding  structures, 
and  the  difficulty  of  operating  in  the  vicinity  of  large  vessels,  nerves,  and  the 
thyroid  gland. 

The  operation  is  as  follows  :  Place  the  patient  on  his  back  with  his  shoulders 
somewhat  raised  and  his  head  turned  toward  the  right  side  :  an  anjesthetic  having 
been  given,  .standing  behind  the  patient's  head,  make  an  incision  through  the  skin 
on  the  left  side  from  just  above  the  sterno-clavicular  articulation  to  about  the  level 
of  the  hyoid  bone  :  cut  the  platysma.  and  if  a  vein  of  any  size,  such  as  the  external 
or  anterior  jugular,  is  met  with,  divide  it  between  two  ligatures  and  turn  aside  ;  slit 
the  superficial  fascia  on  a  grooved  director  along  the  line  of  the  original  incision, 
and  lay  bare  the  anterior  edge  of  the  sterno-mastoid :  the  patient's  head  should 
then  be  slightly  raised,  so  as  to  relax  the  tissues  of  the  neck,  and  an  assistant 
should  draw  aside  the  sterno-mastoid  with  a  retractor ;  the  omo-hyoid  (which  can 
be  recognized  by  its  direction  inward  and  upward)  is  now  brought  into  view, 
and  should  be  divided  as  near  to  its  hyoid  insertion  as  possible :  the  carotid  sheath 
is  next  to  be  held  aside,  together  with  the  sterno-mastoid,  whilst  the  trachea  is 
drawn  inward  by  a  second  assistant;  the  connective  tissue  being  torn  through  with 
the  handle  of  the  knife,  the  left  lobe  of  the  thyroid  body  should  be  raised  and 
pushed  toward  the  middle  line,  when  the  trachea  will  be  fully  exposed,  together 
with  the  cesophagus  behind  it. 

When  the  tube  has  been  opened,  a  silk  ligature  should  be  passed  through  each 
edge  of  the  oesophageal  wound,  and  again  through  the  corresponding  lip  of  the 
cutaneous  incision,  and  the  gullet  should  be  gently  drawn  toward  the  surface  and 
loosely  attached  to  the  outer  wound.  A  curved  tube  measuring  about  three  inches 
in  length  below  and  one  above  the  bend,  with  a  suitable  shield  at  its  upper  extremity, 
should  be  introduced  into  the  cesophagus  through  the  wound  and  fixed  in  position 
by  means  of  tapes  round  the  neck.  Sutures  may  be  used  to  bring  the  edges  of  the 
skin-wound  together  above  and  below  the  feeding-tube  should  this  appear  desirable. 

CEsophagitis. 

Disease  of  the  oesophagus  in  infancy  and  childhood  is  comparatively  rare, 
inflammation  being  the  most  frequent  affection  of  this  portion  of  the  diges- 
tive tube  in  these  periods,  and,  indeed,  the  only  one  which  claims  attention. 
It  is  most  common  in  infants  under  the  age  of  three  or  four  months  who  are 
deprived  of  the  breast-milk  and  are  given  a  diet  which  is  with  difficulty 
dige.sted.  and  perhaps  taken  too  hot  or  too  cold.  It  is  therefore  most  com- 
mon in  foundling  hospitals.  I  have  frequently  observed  it  in  the  Infants' 
Hospital  and  the  Nursery  and  Child's  Hospital  of  this  city,  chiefly  at  the 
autopsies  of  bottle-fed  infants  under  the  age  of  sis  months  whose  symptoms 
had  indicated  disease  or  derangement  of  the  digestive  function.  Many  of 
them  had  diarrhoea  and  died  in  a  state  of  emaciation.  CEsophagitis  in  these 
cases  was  associated  with  simple  or  gangrenous  stomatitis,  thrush,  or  with 
gastritis  or  entero-colitis.  Sometimes  all  these  inflammations  coexisted.  In 
a  few  cases  the  confervoid  growth  of  thrush  had  extended  from  the  mouth 
to  the  cesophagus.  It  occurred  in  small  hemispherical  masses  scarcely  as 
large  as  a  pin's  head.  Swallowing  corrosive  or  strongly  irritating  substances, 
as  the  acids  or  alkalies,  is  an  occasional  cause  of  oesophagitis,  the  irritant  at 
the  same  time  producing  stomatitis  and  gastritis. 


CATARRHAL  PHARYNGITIS,  ETC.  713 

Anatomical  Characters. — The  inflamed  surface  sometimes  presents  a 
uniformly  injected  appearance.  Usually,  however,  there  is  greater  intensity 
of  the  inflammation  in  streaks  or  patches  than  over  the  surface  generally. 
I  have  frequently  observed  at  autopsies  a  greater  degree  of  inflammation  in 
the  lower  than  in  the  upper  half  of  the  oesophagus,  even  when  the  infant 
had  stomatitis  at  the  time  of  death. 

CEsophagitis  occurring  from  faulty  regimen  or  antihygienic  conditions  is 
not  accompanied  by  as  much  thickening  of  the  walls  of  the  tube  as  often 
occurs  in  some  other  portions  of  the  digestive  canal ;  as,  for  example,  in  the 
colon.  Diphtheritic  inflammation  of  the  oesophagus  is  accompanied  by  so 
great  infiltration  of  the  mucous  membrane  and  underlying  connective  tissue 
that  I  have  seen  the  oesophageal  walls  three  or  four  times  the  normal 
thickness. 

Occasionally  ulcerations  of  the  oesophageal  mucous  membrane  are  observed 
in  the  lower  part  of  the  tube,  and  Billard  describes  the  ulcerative  form  of 
oesophagitis.  At  the  first  autopsies  at  which  I  observed  these  ulcers  I  sup- 
posed that  they  were  pathological  and  indicated  a  severe  grade  of  inflamma- 
tion ;  but  a  more  extended  observation  has  convinced  me  that  they  are 
usually  post-mortem,  and  are  not  at  all  dependent  on  inflammation  of  the 
oesophagus.  The  solvent  power  of  the  gastric  juice  not  only  causes  tilcera- 
tion  in  the  stomach,  but,  entering  the  oesophagus,  may  and  not  infrequently 
does  produce  a  solvent  action  on  the  mucous  tissue  there  in  the  cadaver.  At 
the  meeting  of  the  London  Pathological  Society,  March  4,  1852,  Dr.  Grraily. 
Hewitt  presented  a  specimen  in  which  the  gastric  juice  had  not  only  eaten 
entirely  through  the  coats  of  the  oesophagus  an  inch  above  the  stomach,  but 
had  even  attacked  the  left  lung.  Over  the  age  of  six  months  inflammation 
of  the  oesophagus  is  rare. 

The  SYMPTOMS  of  oesophagitis  in  yovxng  and  emaciated  infants,  in  whom 
it  ordinarily  occurs,  are  not  well  pronounced.  Pain  in  deglutition  or  tender- 
ness on  pressure  over  the  oesophagus,  if  present  in  these  infants,  is  ordinarily 
not  appreciable,  nor  have  they  seemed  to  me  to  vomit  oftener  than  other 
infants  of  this  class  who  suff"ered  from  indigestion  and  gastro-enteritis  with- 
out oesophagitis.  It  is  therefore  difiicult  to  diagnosticate  oesophagitis  in  them. 
It  is,  according  to  my  observation,  oftener  present  than  absent  in  spoon-fed 
infants  of  three  months  or  under  who  have  persistent  stomatitis  and  entero- 
colitis. 

Treatment. — In  the  oesophagitis  of  foundlings  and  ill-nourished  infants, 
which  arises,  as  has  been  stated,  from  faulty  regimen,  no  treatment  is  required 
apart  from  that  designed  to  relieve  the  stomatitis  or  entero-colitis  with  which 
it  occurs.  Attention  must  be  directed  mainly  to  the  diet  and  hygienic  man- 
agement. The  remedial  measures  proper  for  such  patients  are  more  fully 
detailed  in  our  remarks  on  entero-colitis.  Qilsophagitis  produced  by  swallow- 
ing corrosive  or  highly  irritating  substances  requires  the  same  treatment  as 
in  the  adult — to  wit,  poultices,  demulcent  drinks,  etc. 


714  LOCAL  DISEASES. 


CHAPTER    V. 

INDIGESTION,   CONGESTION  OF    STOMACH,   GASTRITIS,   FOLLICULAE 
GASTRITIS,   DIPHTHERITIC  GASTRITIS. 

Indigestion. 

Indigestion  is  more  common  during  infancy  than  in  any  other  period  of 
life.  While  the  digestive  organs  in  the  adult  readily  assimilate  a  great 
variety  of  food,  it  is  necessary  for  the  well-being  of  the  infant  that  its  diet 
be  simple  and  carefully  prepared.  Departure  from  this  rule  leads  to  indiges- 
tion and  ulterior  diseases. 

After  the  age  of  two  years  a  mixed  diet  is  readily  assimilated,  the  digestive 
function  is  less  frequently  disordered,  and  indigestion  presents  few  peculiarities 
to  distinguish  it  from  that  of  the  adult. 

Indigestion  in  some  children  is  habitual ;  in  others  the  digestive  process  is 
ordinarily  well  performed,  but  from  some  temporary  derangement  of  system 
or  error  of  diet  an  acute  attack  of  indigestion  occurs.  Hence,  two  forms  of 
this  ailment  may  be  described  ;  first,  acute,  referring  to  temporary  attacks ; 
secondly,  chronic,  referring  to  the  habitual  state.  The  subject  of  the  diges- 
tion in  infancy  and  childhood  is  treated  of  in  other  chapters  of  this  book,  to 
which  the  reader  is  referred. 

In  the  majority  of  cases  of  indigestion  the  fault  does  not  exist  in  the 
child.  It  is  fed  too  often  or  irregularly  or  upon  a  diet  that  is  unwholesome 
or  indigestible.  It  is  well  known  that  the  milk  of  the  mother  or  the  wet- 
nurse  is  liable  to  changes  which  render  it  for  the  time  unsuitable  for  the 
infant.  Her  food  may  be  of  such  a  quality,  or  her  mind  so  excited,  or  some 
function  of  her  system  so  disordered,  as  to  effect  a  temporary  change  in  the 
constitution  of  her  milk.  The  occurrence  of  the  catamenia  or  of  gestation 
in  mothers  who  are  suckling  not  infrequently  produces  this  unfavorable 
result. 

The  most  common  cause  of  indigestion  in  the  infant  is  artificial  feeding. 
This,  in  the  cities,  is  productive  of  a  great  amount  of  gastric  and  intestinal 
derangement  and  disease.  The  younger  the  infant  the  less  frequently  does  it 
thrive  if  brought  up  by  hand. 

Whatever  care  may  be  bestowed  in  the  preparation  of  its  food,  whether 
cow's  or  goat's  milk  or  farinaceous  substances  be  used,  there  is  seldom  that 
healthy  nutrition  which  is  observed  in  infants  who  receive  the  breast-milk. 
The  "  swill-milk  "  in  common  use  among  the  poor  families  of  this  city  is 
totally  unfit  for  the  feeding  of  infants,  and  is  apt  to  cause  flatulence,  acidity, 
and  indigestion.  Acute  indigestion  occurs  in  children  of  any  age  from  food 
unsuitable  in  quality  or  quantity,  which  produces  gastralgia  and  other  symp- 
toms to  be  detailed  hereafter.  Those  who  suffer  habitually  from  malassimila- 
tion  are  especially  liable  to  such  acute  attacks. 

In  the  period  of  childhood,  chronic  indigestion  is  much  less  frequent  than 
in  infancy,  but  children  are  perhaps  more  subject  than  infants  to  the  acute 
form.  This  is  induced  by  ingesta  taken  in  too  large  quantity  or  of  a  kind 
which  is  with  difficulty  digested.  Cherries,  currants,  raisins,  and  the  paren- 
chyma of  oranges  and  lemons,  dried  fruits,  and  confectionery,  which  are  so 
often  heedlessly  given  to  children,  are  common  causes  of  acute  attacks  of 
indigestion.  These  substances,  being  but  partially  digested  or  not  at  all,  and 
sometimes  accumulating  for  days  in  the  stomach  or  intestines,  may  lead  to  a 
very  serious  and  dangerous  condition. 


INDIGESTION,   ETC.  715 

Symptoms. — Vomiting  is  a  symptom  that  should  always  arrest  attention 
and  its  cause  be  ascertained.  If  the  child  cease  to  grow  and  lose  its  vivacity, 
the  vomiting  has  pathological  significance.  Frequent  vomiting,  without  other 
marked  symptoms  referable  to  the  digestive  apparatus,  and  with  evident  loss 
of  flesh  and  strength,  is  in  most  cases  a  symptom  of  gastric  indigestion  or 
of  incipient  meningitis.  The  presence  of  mucus  in  the  ejected  matter, 
eructation  of  gas,  and  the  apparent  absence  of  headache  and  of  other  menin- 
geal symptoms  apart  from  the  vomiting,  aid  in  establishing  the  diagnosis  of 
gastric  indigestion. 

The  nursing  infant,  if  the  milk  continually  disagree  with  it,  is  fretful. 
It  has  a  discontented  aspect ;  it  seldom  smiles,  and  is  not  amused  by  playthings 
or  is  only  amused  for  a  short  time.  Its  features  are  pallid  and  bear  the  appear- 
ance of  faulty  nutrition.  Its  body  and  limbs  are  more  or  less  wasted  or  are 
soft  and  flabby.  Vomiting  is  frequently  present,  and  sometimes  a  large  mass 
or  masses  of  casein  are  ejected  which  have  evidently  lain  a  considerable  time 
in  the  stomach.  The  bowels  may  be  constipated  or  loose  and  the  evacuations 
are  unhealthy.  This  state  of  the  infant,  continuing,  prevents  the  necessary 
rest  of  the  mother,  and  may  afi"ect  unfavorably  her  health,  so  as  to  reduce  the 
quantity  of  her  milk  or  render  it  still  more  unwholesome. 

In  habitual  indigestion  of  young  children  fermentation  of  the  food  occurs 
to  a  great  extent,  instead  of  normal  digestion,  and  the  fermentation  results 
in  the  production  of  acids.  Whatever  irritates  the  gastro-intestinal  surface 
causes  an  increased  secretion  of  mucus,  and  it  is  believed  that  the  mucus, 
since  it  is  alkaline,  prevents  to  a  great  extent  the  digestive  action  of  the 
pepsin,  which  requires  an  acid  medium,  so  that  lactic,  butyric,  and  the  fatty 
acids  result.  This  acid  fermentation,  beginning  in  the  stomach,  extends  to 
the  intestines  as  the  food  is  carried  downward.  Hence  the  acid  breath, 
sour-smelling  ejecta,  fetid  stools,  flatulence,  and  colicky  pains,  indicating 
both  gastric  and  intestinal  dyspepsia,  so  common  in  young,  improperly-fed 
infants. 

Habitual  indigestion  is,  as  might  be  expected,  more  common  and  severe 
in  artificially  fed  infants  than  in  those  at  the  breast,  and  it  is  more  likely  to 
result  in  gastro-intestinal  catarrh.  In  rural  localities,  where  children  are 
much  of  the  time  in  the  open  air,  have  good  constitutions,  active  digestion, 
and  fresh  food,  dyspepsia  is  comparatively  rare,  but  in  large  cities,  in  which 
the  conditions  of  life  are  so  diff"erent,  its  occurrence  is  common.  Gross  care- 
lessness in  the  feeding,  and  ignorance  on  the  part  of  mothers  of  the  dietetic 
requirements  of  young  children  contribute  greatly  to  its  frequency. 

Attacks  of  acute  indigestion  not  infi'equently  occur  from  careless  and 
improper  feeding  in  children  who  are  habitually  dyspeptic,  as  well  as  in  those 
whose  digestive  function  is  usually  well  performed.  In  these  acute  attacks 
young  children,  especially  infants,  often  suff"er  much  from  colicky  pains, 
gastralgia,  or  enteralgia.  Their  countenances  indicate  suff"ering ;  they  utter 
sharp  cries  ;  their  thighs  are  flexed  over  the  abdomen  and  moved  from  side  to 
side.  Warm  spirituous  lotions,  friction  or  gentle  pressure  upon  the  abdomen, 
give  some  relief,  especially  if  they  be  attended  by  the  expulsion  of  flatus. 
Vomiting  or  an  evacuation  of  the  bowels  commonly  removes  the  ofi"ending 
substance,  and  the  pain  subsides. 

Attacks  of  acute  indigestion  come  on  suddenly,  and  occasionally  are  so 
severe  that  they  produce  dangerous  symptoms,  as  eclampsia.  Apart  from 
pain  or  a  sensation  of  weight  or  fulness  in  the  abdomen,  symptoms  of  a  reflex 
character  frequently  occur,  such  as  headache,  drowsiness  or  languor,  sudden 
twitching  of  the  limbs  premonitory  of  convulsions,  and  even  severe  or  repeated 
convulsions.  One  of  the  most  severe  attacks  of  eclampsia  which  I  have  seen 
occurred  in  a  boy  of  eight  or  ten  years,  induced  by  swallowing  the  pulp  of 


716  LOCAL  DISEASES. 

oranges  which  he  had  been  in  the  habit  of  eating,  and  which  had  accumulated 
in  the  stomach  and  intestines.  The  expulsion  of  the  offending  substance 
gave  immediate  relief.  In  some  children  with  acute  indigestion  the  pulse  is 
notably  accelerated,  the  face  flushed,  the  surface  hot,  and  the  temperature 
elevated  two  or  three  degrees  above  normal. 

As  the  child  advances  in  years  and  becomes  stronger  its  digestive  func- 
tion is  more  active,  a  greater  variety  of  food  can  be  assimilated,  and  indi- 
gestion, whether  temporary  or  habitual,  is  less  frequent  than  in  the  first  years 
of  life. 

Prognosis. — Indigestion  in  the  adult,  when  not  due  to  organic  disease, 
involves  little  danger  to  life,  but  in  infancy  its  consequences  are  often  serious. 
Habitual  indigestion  in  the  infant,  whether  due  to  the  bad  quality  of  the 
breast-milk  or  to  artificial  feeding,  is  liable  to  cause  inflammation  of  the  buc- 
cal, oesophageal,  gastric,  or  intestinal  mucous  membrane,  and  in  some  patients 
of  two  or  more  of  these  divisions  of  the  intestinal  tract.  Thus,  especially 
in  the  warm  months,  the  fermenting  products  of  indigestion  often  cause 
dangerous  catarrhal  inflammation,  accompanied  by  vomiting  and  frequent 
stools. 

Many  cases  of  atrophy  in  infants,  characterized  by  arrested  growth  and 
gradual  loss  of  flesh  and  strength,  till  perhaps  the  features  have  a  sunken 
and  senile  appearance  from  the  waste  and  the  skin  lies  in  wrinkles,  originate 
in  habitual  indigestion.  Henoch  points  out  the  frequency  of  gastro-malacia 
in  infants  who  have  suffered  from  severe  dyspepsia  accompanied  by  the  abun- 
dant production  of  acids.  The  softening  of  the  stomach  is  believed  to  be 
largely,  if  not  entirely,  cadaveric,  the  result  of  post-mortem  digestion  from 
the  presence  of  pepsin  and  the  acids  of  fermentation.  The  gastric  mucous 
membrane  can  be  readily  scraped  away  by  the  nail,  and  it  presents  a  gelatini- 
form  appearance.  Sometimes  even  the  stomach  is  perforated  and  the  adjacent 
organs  are  acted  on  by  the  corrosive  liquids. 

If  the  dyspepsia  have  not  continued  so  long  as  to  cause  inflammatory 
complications,  prompt  recovery  is  probable  by  the  use  of  suitable  food  and 
corrective  medicines.  If  such  complications  be  present,  recovery  can  only 
be  gradual. 

Diagnosis. — Habitual  indigestion  does  not  usually  continue  long  without 
the  occurrence  of  more  or  less  gastro-intestinal  catarrh.  The  poor  nutrition 
and  appetite,  the  unhealthy,  flatulent  stools  containing  mucus,  the  vomiting 
and  occasional  colicky  pains,  are  symptoms  which  plainly  indicate  a  dyspeptic 
origin.  Attacks  of  acute  indigestion  are  also  easily  diagnosticated,  in  most 
instances  by  the  sudden  occurrence  of  the  symptoms,  such  as  vomiting,  pain 
in  the  abdomen  or  a  sensation  of  fulness,  eructation  of  gas,  etc.,  and  the 
speedy  subsidence  of  symptoms  when  the  cause  is  removed.  But  sometimes, 
especially  in  children  over  the  age  of  two  or  three  years,  the  symptoms  may 
so  closely  resemble  those  of  other  acute  diseases  that  a  careful  examination 
is  required  in  order  to  make  a  clear  and  correct  discrimination.  Thus  I  have 
related  above  the  history  of  a  case  in  which  the  high  temperature  and  expira- 
tory moan  closely  resembled  those  of  pneumonia,  but  the  symptoms  quickly 
abated  on  the  expulsion  of  a  considerable  quantity  of  orange-pulp.  An 
attack  of  acute  indigestion,  attended  by  vomiting,  rapid  pulse,  elevated 
temperature,  with  perhaps  some  erythema,  may  be  mistaken  for  the  com- 
mencement of  one  of  the  febrile  diseases  to  which  children  are  so  liable. 
If  on  examination  of  the  fauces  no  redness  of  the  throat  be  observed,  scarlet 
fever  and  diphtheria  can  be  excluded.  By  a  free  evacuation  of  the  bowels 
the  symptoms  abate  and  the  attack  ends,  so  that  if  there  were  any  doubt  in 
the  diagnosis  it  is  soon  dispelled. 

When  eclampsia  results  from  an  attack  of  acute  indigestion,  the  physi- 


INDIGESTION,  ETC.  717 

cian  is  often  compelled  to  act  promptly  without  a  clear  diagnosis,  but  the 
result  of  treatment  soon  renders  the  nature  of  the  attack  apparent. 

Treatment. — The  first  indication  in  treatment  is  obviously  the  removal 
of  the  cause.  In  acute  indigestion,  when  there  is  reason  to  believe  that  there 
is  some  offending  substance  in  the  stomach  or  intestines,  if  the  symptoms 
occur  soon  after  the  substance  is  taken  an  emetic  may  be  administered,  and 
ipecacuanha,  in  syrup  or  powder,  is  a  safe  and  usually  efficient  remedy.  If 
several  hours  have  elapsed  a  purgative  should  be  given,  as  castor  oil,  either 
alone  or  in  combination  with  syrup  of  rhubarb,  or  an  enema  of  glycerin  and 
water  may  be  employed. 

If  the  symptoms  be  urgent,  especially  if  convulsions  be  threatened,  we 
should  not  wait  for  the  slow  action  of  a  purgative,  but  should  resort  at  once 
to  an  enema  to  open  the  bowels.  Sometimes  the  pain  in  acute  indigestion 
is  such  as  to  require  immediate  treatment.  I  have  found  in  such  cases  five 
to  ten  drops,  according  to  the  age,  of  the  spiritus  anisi,  a  very  useful  remedy. 
The  following  mixture  will  be  found  useful  in  such  cases : 

R.  Bismuth  subnitrat,  ;5ij  ; 

Wyeth'  s  elixir  of  digestive  ferments,  5j  ; 

Aquse  anisi,  ^iij. — Misce. 

Shake  bottle.     Give  one  teaspoonful  every  two  to  three  hours  if  in  pain  from 
indigestion. 

If  in  the  acute  indigestion  of  infants  diarrhoea  occur,  the  camphorated 
tincture  of  opium,  in  combination  with  bismuth  and  pepsin,  may  be  given. 
Infants,  whose  diet  consists  largely  of  cow's  or  goat's  milk,  digest  with  most 
difficulty  the  casein,  which  often  passes  the  bowels  in  an  imperfectly  digested 
state,  or  it  collects  in  a  large  and  firm  mass  in  the  stomach,  causing  gas- 
tralgia  and  rendering  the  child  fretful  till  it  is  vomited.  I  have  elsewhere 
recommended,  as  important  to  prevent  these  attacks  of  acute  dyspepsia,  the 
use  of  the  upper  third  of  the  milk,  which  contains  less  than  the  average 
casein.  The  addition  of  a  little  farinaceous  food,  as  barley-water,  to  the 
nursing-bottle  will  sometimes  produce  the  same  effect  by  mechanically  sepa- 
rating the  particles  of  casein.  Peptonized  milk,  as  recommended  in  our  re- 
marks elsewhere,  will  also  be  found  useful  in  certain  cases,  and  also  the  em- 
ployment of  a  good  preparation  of  pepsin  at  each  feeding. 

In  chronic  indigestion  the  means  of  relief  are  different.  They  are  two- 
fold :  first,  as  regards  change  of  diet ;  secondly,  measures  to  improve  the 
digestive  function.  Spoon-fed  infants,  suffering  from  habitual  indigestion, 
require  the  utmost  care  as  regards  the  character  of  their  food,  its  preparation, 
and  the  times  of  feeding.  Often  it  is  best,  if  practicable,  to  procure  a  wet- 
nurse,  and  sometimes  removal  to  a  more  salubrious  locality  is  followed  at 
once  by  improvement  in  the  digestive  function.  If  the  infant  be  already 
wet-nursed,  the  milk  should  be  examined  microscopically  and  otherwise,  and 
inquiry  should  be  instituted  in  reference  to  the  health  and  diet  of  the  wet- 
nurse.  Sometimes  a  change  of  wet-nurse  is  advisable.  (For  facts  and  con- 
siderations bearing  on  this  point  the  reader  is  referred  to  the  chapters  relating 
to  regimen.) 

Children  with  chronic  indigestion  are  occasionally  much  benefited  by  the 
moderate  and  judicious  use  of  alcoholic  stimulants.  These  should  be  given 
sparingly  with  their  food,  and  should  be  discontinued  as  soon  as  the  digestive 
function  is  fully  restored.  M.  Donne  and  some  other  French  writers  recom- 
mended the  habitual  use  of  wine  for  infants  even  in  a  state  of  health,  but 
there  are  reasons,  moral  as  well  as  physical,  why  alcoholic  stimulants  should 
only  be  used  as  medicines  and  not  in  a  state  of  health. 

If  the  case  be  one  of  simple  or  uncomplicated  indigestion,  one  of  the 


718  LOCAL  DISEASES. 

pepsin  preparations  of  the  shops,  and  tonics  may  be  employed.  In  many 
instances,  however,  especially  in  infancy,  gastro-intestinal  inflammation  has 
supervened,  and  in  such  cases  those  remedies  should  be  employed  which 
exert  a  favorable — or  at  least  not  an  unfavorable — effect  on  the  inflamed  sur- 
face over  which  they  pass. 

In  habitual  indigestion  remedies  are  obviously  required  which  increase 
the  quantity  of  the  digestive  ferments.  The  following  will  be  found  a  use- 
ful prescription  in  cases  of  indigestion  in  which  gastro-intestinal  catarrh  has 
supervened  : 

R.  Acidi  hydrochlorici  dilut.,  gtt.  svj-xxxij  ; 

Pepsini  puri,  in  lamellis,  3J  ; 

Bismuth,  subnitrat.,  gij  ; 

Syr.  simplic,  5^  ! 

Aquae  destillat.,  giij. — Misce. 

Shake  bottle,  and  give  one  teaspoonful  before  each  feeding. 

The  lactopeptin  of  the  shops  is  also  useful,  and  when  diarrhoea  accom- 
panies the  indigestion  the  following  may  be  prescribed : 

R.  Bismuth,  subnitrat.,  giij  ; 

Lactopeptin,  gij ; 

Pepsini  puri,  in  lamellis,  §j. 

Give  as  much  as  goes  on  a  five-cent -piece  to  a  child  of  ten  months  before  each 
feeding. 

If  the  stools  continue  frothy  and  offensive  on  account  of  the  fermenta- 
tion the  following  will  be  found  beneficial : 

R.  Salol  or  resorcin,  gr.  iv  ; 

Syr.  simplic,  §ss ; 

Aqua?  destillat.,  ^iss. — IVIisce. 

Dose  :  One  teaspoonful  every  two  hom's  to  a  child  of  one  year. 

In  children  over  the  age  of  three  or  four  years  the  vegetable  tonics 
are  often  useful,  as  quinine  in  half-grain  or  one-grain  doses.  Iron  may 
also  be  given,  especially  the  milder  preparations,  as  the  citrate,  in  anaemic 
cases. 

Among  the  useful  vegetable  stomachics  and  tonics  may  also  be  men- 
tioned the  compound  tincture  of  cinchona,  the  compound  tincture  of  gen- 
tian, the  infusion  of  columbo,  the  fluid  extract  of  columbo,  and  the  fluid 
extract  of  cinchona. 

If  chronic  indigestion  be  complicated  with  gastro-intestinal  inflammation, 
subacute  or  chronic,  for  this  is  the  form  which  is  usually  present,  there  are 
still  certain  tonics  which  may  be  advantageously  administered.  Columbo 
and  the  compound  tincture  of  cinchona  are  often  useful  in  these  cases,  and 
of  the  chalybeates  wine  of  iron  or  the  citrate  of  iron  and  ammonium  or  the 
liquor  ferri  nitratis  may  be  safely  administered.  In  most  cases,  however, 
change  in  the  diet  properly  made  will  be  found  more  useful  than  tonic  and 
corrective  medicines. 

Infants  affected  with  diarrhoea  from  indigestion  often  improve  under  the 
use  of  powders  consisting  of  equal  parts  of  subnitrate  of  bismuth  and  lacto- 
peptin. An  infant  of  three  months  can  take  three  grains  of  each  every  three 
hours  or  before  each  feeding,  or  it  may  take  three  or  four  grains  of  the  sub- 
nitrate  of  bismuth  with  half  a  grain  of  pure  pepsin  in  scales. 

Dyspepsia  often  rapidly  disappears  by  hygienic  measures  without  the  use 


INDIGESTION,  ETC.  719 

of  medicines,  as  by  removal  from  the  city  to  the  country,  out-door  exercise. 
In  infants  also  marked  improvement  is  often  observed  on  the  approach  of  the 
cool  and  bracing  weather  of  autumn  and  winter. 

Cong-estion  of  the  Stomach. 

Passive  congestion  of  the  stomach  is  described  among  the  diseases  of  this 
organ  by  Billard,  but  it  is  a  pathological  state  of  little  importance  in  itself. 
It  occurs  in  new-born  infants  asphyxiated  at  birth  and  with  difficulty  resusci- 
tated. In  these  cases  there  is  generally  intense  capillary  congestion  through- 
out the  system.  The  mucous  membrane  of  the  stomach  is  injected,  but  not 
more  than  that  of  the  mouth  or  intestines.  If  circulation  and  respiration 
be  fully  established,  the  injection  of  the  capillaries  subsides.  No  treatment 
is  required,  except  measures  to  promote  the  circulatory  and  respiratory  func- 
tions. In  cyanosis  and  atelectasis  there  is  often  general  congestion  of  the 
capillaries  of  the  systemic  circulatory  system  on  account  of  the  obstruction 
to  the  flow  of  blood  through  the  heart  in  the  one  disease  and  through  the 
lungs  in  the  other.  There  is  in  these  cases  passive  congestion  of  the  stomach, 
but  not  more  than  of  other  organs. 

Gastritis. 

Inflammation  of  the  stomach,  except  when  produced  by  the  direct  con- 
tact of  some  irritant,  is  rare  in  infancy  and  childhood  independently  of  dis- 
ease in  some  other  portion  of  the  intestinal  tract.  Cases  have,  however,  been 
reported  in  which  it  was  not  known  that  any  irritating  ingesta  had  been  taken, 
and  in  which  a  careful  examination  revealed  a  healthy  or  nearly  healthy  state 
of  other  portions  of  the  digestive  tube.  The  subjects  were  for  the  most  part 
young  infants.     The  following  is  an  example  related  by  Billard : 

An  infant,  four  days  old.  remarkable  for  the  color  of  its  face  and  firm- 
ness of  flesh,  refused  the  breast  and  vomited  yellow,  acid  matter.  On  the 
following  day  the  vomiting  had  increased,  the  legs  were  oedematous,  face 
pallid  and  pinched,  respiration  difficult,  skin  cold,  pulse  slow  and  irregular, 
and  pressure  on  the  epigastric  region  produced  cries  indicative  of  pain. 
Third  day  :  general  sinking ;  face  thin  and  expressive  of  great  pain ;  stools 
natural.  Fourth  and  fifth  days  :  condition  the  same.  Death  occurred  on  the 
sixth  day,  and  the  autopsy  was  made  on  the  day  following.  With  the 
exception  of  slight  pneumonia  no  disease  was  discovered  in  any  part  of  the 
system  besides  the  stomach.  The  mucous  membrane  of  this  organ  was 
intensely  vascular  near  the  cardiac  orifice  and  along  the  lesser  curvature. 
This  part  was  also  tumefied,  and  could  be  easily  raised  with  the  finger-nail. 
The  remainder  of  the  gastric  surface  was  hypersemic,  but  to  a  less  extent. 

This  case  is  interesting  as  showing  what  may  happen,  though  rarely.  A 
nursing  infant  is  seized  with  gastritis  without  apparently  having  taken  any 
irritating  ingesta  and  without  other  diseases  of  the  digestive  apparatus.  It 
is  probable,  however,  that  in  cases  like  the  above  the  cause,  if  ascertained, 
would  be  found  in  the  ingesta ;  perhaps  drinks  too  hot,  perhaps  elements 
of  colostrum  or  pathological  elements  in  the  milk,  which  might  produce 
gastritis  in  young  infants,  in  whom  the  mucous  membrane  is  delicate  and 
sensitive. 

Gastritis  is  not  uncommon  in  infancy  in  connection  with  inflammation  of 
the  intestines.  The  latter  inflammation  is  sometimes  apparently  subordinate 
to  the  former,  and  if  such  patients  die  the  fatal  result  is  due  mainly  to  the 
gastric  disease.  The  reverse  is,  however,  the  rule.  The  gastritis  is  ordinarily 
subordinate  to  the  intestinal  catarrh. 


720  LOCAL  DISEASES. 

Cause. — Gastritis,  as  I  have  observed  it  in  infants,  lias  been  in  most  cases 
due  in  great  part  to  the  continued  use  of  improper  food — of  food  not  suitable 
to  the  age  of  the  child,  and  which  was  therefore  with  difficulty  digested. 
31ilk,  acid  or  otherwise  unwholesome,  farinaceous  substances,  stale  or  of  an 
inferior  quality  and  not  properly  prepared,  drinks  too  hot  or  too  cold,  may  be 
specified  among  the  causes.  Therefore  this  disease  is  most  common  in  bottle- 
fed  infants,  and  is  comparatively  rare  in  those  who  receive  abundant  and 
wholesome  breast-milk.  Antihygienic  agencies,  apart  from  the  diet,  no  doubt 
exert  some  influence  in  the  production  of  gastritis,  as  they  do  of  stomatitis. 
Uncleanliness  and  residence  in  damp  and  dark  apartments  or  in  an  atmosphere 
loaded  with  noxious  gases  produce  a  condition  of  system  which  strongly  pre- 
disposes to  these  inflammations,  if  indeed,  they  may  not  be  enumerated 
among  the  direct  causes. 

Rilliet  and  Barthez  have  called  attention  to  the  fact  that  certain  medicinal 
substances  given  to  children  occasionally  cause  gastritis.  They  have  observed 
this  efiect  from  the  use  of  tartar  emetic,  kermes  mineral,  and  croton  oil. 
Gastritis  occurring  in  this  way  may  or  may  not  be  associated  with  inflamma- 
tion in  contiguous  portions  of  the  digestive  tube.  Elsewhere  I  have  related 
a  case  in  which  gastro-enteritis  occurred  in  a  child  nine  years  old  after  having 
taken  a  considerable  quantity  of  kerosene  oil  for  spasmodic  croup. 

Inflammation  of  the  stomach  is  thought  by  some  to  accompany  measles 
and  scarlet  fever  dui'ing  the  eruptive  period,  but  this  opinion  is  probably 
incorrect.  If  it  occur,  it  corresponds  with  the  stomatitis  and  dermatitis  of 
these  diseases,  and  disappears  as  they  subside.  It  is  mild  and  accompanied 
by  few  symptoms.  I  have,  as  stated  in  the  remarks  on  Scarlet  Fever,  exam- 
ined in  certain  instances  the  stomachs  of  those  who  have  died  during  the 
eruptive  periods  of  these  diseases,  and  found  them  free  from  any  apj^reciable 
inflammatory  lesion. 

Age. — From  the  records  of  about  seventy  cases  of  inflammatory  disease 
of  the  digestive  mucous  membrane  which  I  have  preserved  it  appears  that 
gastritis  is  not  common  over  the  age  of  six  months.  On  the  other  hand,  it 
is  common  in  infants  under  the  age  of  three  months  who  are  deprived  of 
breast-milk.  I  have  met  it  chiefly  in  foundlings  fed  with  the  bottle,  and  hav- 
ing at  the  same  time  entero-colitis,  and  often  also  stomatitis  and  oesophagitis. 
In  these  cases  there  is  sometimes  continuous  or  almost  continuous  injection 
and  thickening  of  the  mucous  membrane  from  the  lip  to  near  the  pyloric 
orifice  of  the  stomach,  and  even  beyond  this  orifice  in  the  intestines. 
The  following  is  an  example  of  gastritis  as  it  frequently  occurs  in  found- 
ling institutions : 

Case. — R.  W ,  female,  two  weeks  old,  was  admitted  into  the  New  York 

Infant  Asylum,  August  24,  1865,  ansemic  and  somewhat  emaciated.  She  was  in 
part  wet-nursed  and  in  part  bottle-fed.  The  emaciation  increased,  and  nearly  the 
entire  buccal  cavity  became  covered  with  the  confervoid  growth  of  sprue.  On 
September  4th  diarrhcea  commenced.  Borax  was  used  for  the  mouth  and  alkalies 
and  astringents  to  check  the  diarrhoea,  but  without  material  improvement. 

The  following  was  the  record  for  September  7th  :  "  Cries  almost  constantly^ 
with  feeble  or  whining  voice :  still  has  thrush ;  nurses  and  does  not  vomit ; 
stools  five  or  six  daily,  and  green  ;  pulse  130,  feeble."  Death  occurred  Septem- 
ber 8th. 

Autopsy,  September  9th. — Mouth  and  fauces  not  examined  ;  mucous  membrane 
of  oesophagus  vascular  in  its  whole  extent,  with  slight  thickenins;,  but  without 
ulceration  ;  mucous  membrane  of  stomach  hypergemic,  like  that  of  the  oesophagus, 
and  somewhat  thickened,  except  in  its  pyloric  extremity,  where  the  appearance  was 
natural  or  nearly  so  ;  the  color  in  the  central  part  of  the  inflamed  ga.stric  membrane 
was  deep  red  ;  no  thrush  was  noticed  except  on  the  buccal  surface  during  life ; 
along  the  great  curvature  of  the  stomach  were  white  flakes  resembling  those  of 
thrush,  but  which  were  found  by  the  microscope  to  consist  mainly  of  oil-globules 


INDIGESTION,  ETC.  721 

and  epithelial  cells,  -without  the  crj-ptogamic  formation  :  mucous  membrane  of  small 
intestines  healthy  in  its  -whole  extent,  except  slightly  increased  vascularity  in  a 
few  places  in  the  ileum  :  mucous  membrane  of  colon  much  injected  throughout, 
except  near  the  ileo-csecal  valve,  vrhere  the  vascularity  was  slight :  in  the  trans- 
verse and  descending  colon  the  redness  was  pretty  uniform,  and  the  membrane 
was  thickened,  but  not  ulcerated ;  solitary  glands  and  Peyer"s  patches  moderately 
elevated. 

The  observations  of  Valleix  show  how  frequently  gastritis  is  associated 
with  severe  attacks  of  thrush.  In  23  of  his  cases  of  the  latter  disease  in 
which  the  condition  of  the  stomach,  was  noted  after  death,  this  organ  pre- 
sented inflammatory  lesions  in  17,  and  in  3  others  appearances  which,  may 
or  may  not  have  been  due  to  inflammation. 

Symptoms. — A  difficulty  exists  in  isolating  and  defining  the  symptoms  of 
gastritis,  from  the  fact  that  it  commonly  coexists  with  other  inflammations 
of  the  digestive  tube.  Though  we  may  never  be  able  to  diagnosticate  this 
catarrh  as  certainly  as  we  can  croup  or  pneumonia,  still  there  are  symptoms 
which  arise  directly  from  the  gastritis,  and  with  care  we  may  be  able  to  dis- 
tinguish them  from  those  symptoms  which  are  due  to  other  pathological 
states. 

If  gastritis  be  acute,  pain  is  present.  In  the  above  case  from  Billard, 
as  well  as  in  a  case  observed  by  myself  and  related  under  the  head  of  Gelat- 
inous Softening,  there  were  frequent  cries,  and  the  countenance  indicated 
much  sufi"ering  until  the  stage  of  collapse.  If  there  be  less  intensity  of 
inflammation  and  the  disease  be  more  protracted,  as  is  ordinarily  the  case,  the 
pain  is  not  so  severe,  and  it  may  be  so  slight  as  not  to  attract  attention. 
Sometimes  there  is  tenderness,  so  that  pressure  upon  the  epigastric  region  is 
badly  tolerated.  Vomiting  is  regarded  as  one  of  the  most  constant  symp- 
toms. The  infant  after  nursing  seems  in  distress  till  the  milk  is  vomited,  but 
it  nurses  with  avidity  in  consecjuence  of  the  thirst  if  it  be  not  too  exhausted 
or  feeble.  The  dejections  may  be  C[uite  regular  throughout  the  disease,  as  in 
the  case  from  Billard.  There  is  ordinarily,  however,  diarrhoea  from  the 
presence  of  entero-colitis.  The  pulse  is  sometimes  accelerated  and  sometimes 
nearly  natural.  The  emaciation  in  gastritis  is  rapid,  since  not  only  the  nutri- 
ment is  in  great  measure  vomited,  but  the  digestive  function,  so  far  as  the 
stomach  is  concerned,  is  seriously  impaired.  The  features  become  wrinkled 
and  senile,  the  eyes  hollow,  the  limbs  attenuated,  and  the  cranial  bones 
uneven.     Death  occurs  from  exhaustion. 

Anatomical  Characters. — Simple  gastritis  may  afi"ect  the  entire  mucous 
surface  of  the  stomach  or  be  limited  to  a  certain  part.  The  part  which  is  most 
likely  to  escape  is  that  toward  the  pyloric  orifice.  This  portion  of  the  organ 
is  sometimes  found  in  nearly  or  quite  the  normal  state,  while  the  cardiac  half 
or  two-thirds  is  inflamed.  The  vascularity  of  the  diseased  surface  is  not  uni- 
form. In  one  place  there  is  simple  arborescence  ;  in  another  intense  continu- 
ous redness ;  and  between  these  two  extremes  are  difi"erent  grades  of  vascu- 
larity. The  mucous  membrane  is  somewhat  thickened,  softened,  and  the 
secretion  of  mucus  increased.  Extravasation  of  blood  is  not  infrequent 
under  the  mucous  membrane,  usually  in  points,  and  the  mucus  may  be  mixed 
with  more  or  less  blood.  Small  shreds  or  portions  of  coagulated  milk  are 
often  found  with  the  mucus  attached  to  the  gastric  surface.  I  have  observed, 
though  rarely,  small  superficial  ulcers  at  the  point  where  the  inflammation 
had  been  most  intense. 

Dr.  A.  Jacobi  says :  ••  Indeed,  the  boundary-line  between  a  simple  dys- 
pepsia and  a  gastric  catarrh  is  perhaps  never  made  out  clearly.  The  epithelium 
of  the  mucous  membrane  does  not  belong  to  it  exclusively,  but  spreads  in  the 
contiguity  of  the  tissues  into  the  muciparous  and  the  peptic  glands.  Thus 
46 


722  LOCAL  DISEASES. 

the  inflammatory  condition  of  the  surface  becomes  at  once  a  parenchymatous 
afi'ection,  though  it  be  possible  that  an  uncomplicated  catarrh  and  an  uncom- 
plicated inflammation   may  have   an   occasional  existence Unless   a 

gastric  catarrh  or  a  dyspepsia  ....  be  relieved  at  once,  the  merely  func- 
tional or  superficial  disorder  becomes  organic  and  deep-seated.  These  changes 
may  refer  either  to  the  tissue  or  the  secretion.  Inflammatory  thickening, 
erosions,  ulcerations,  or  (Moncorvo)  dilatation  of  the  stomach  will  be  observed 
in  a  great  many  instances.     The  secretions  become  abnormal ;  the  normal 

hydrochloric  acid  of  the  gastric  juice  is  almost  invariably  diminished 

Lactic  acid,  however,  is  produced  in  much  larger  quantities  than  the  first 
stage  of  digestion  requires,  and  with  it  acetic,  butyric,  and  the  rest  of  the 
fatty  acids." 

Diagnosis. — In  protracted  cases,  when  entero-colitis  is  present,  it  is  dif- 
ficult to  make  a  positive  diagnosis.  Our  opinion  must  then  be  little  more 
than  a  plausible  conjecture.  In  the  acute  attacks  we  can  diagnosticate  the 
gastritis  with  more  certainty.  If  a  young  infant  affected  with  sprue  be 
seized  with  pain,  and  vomits  often  ;  if  emaciation  be  rapid  and  there  be  no 
diarrhoea,  or  diarrhoea  not  sufficient  to  account  for  the  prostration  ;  if  the 
buccal  mucous  membrane,  dotted  with  the  points  of  thrush,  presents  a  dry 
appearance  and  the  deep-red  color  of  severe  stomatitis, — there  can  be  little 
doubt  of  the  presence  of  gastritis.  The  diagnosis  is  rendered  more  certain 
by  signs  of  tenderness  when  pressure  is  made  upon  the  epigastric  region. 

Prognosis. — Like  other  inflammations,  gastritis  is  probably  sometimes 
so  mild  that  it  does  not  materially  increase  the  suiFering  or  danger  of  the 
child.  This  mild  form  of  the  disease  under  favorable  circumstances  soon 
subsides.  In  other  cases,  by  the  continuance  or  increase  of  the  cause,  the 
inflammatory  process  becomes  more  severe  and  extensive,  resulting  even  in 
disintegration  of  the  mucous  membrane.  Those  cases  are  especially  severe 
and  likely  to  end  fatally  which  are  protracted  and  accompanied  by  severe 
thrush,  with  a  desiccated  appearance  of  the  buccal  surface  or  with  entero- 
colitis. Pain,  vomiting,  and  rapid  emaciation  in  such  children  indicate  the 
speedy  approach  of  death.  Improvement  in  the  stomatitis  or  entero-colitis 
is  a  favorable  indication,  but  these  inflammations  may  improve  without  cor- 
responding improvement  in  the  gastritis. 

Treatment. — All  food  or  drinks  except  those  of  a  bland  and  unirritating 
nature  should  be  forbidden.  If  practicable,  the  young  infant  should  have  the 
mother's  milk  or  that  of  a  wet-nurse.  If  this  be  impossible,  the  reader  is 
referred  to  the  chapter  on  Infantile  Alimentation  for  advice  in  relation  to  the 
feeding.  Death  occurs  from  exhaustion,  and  it  is  therefore  important  that 
the  vital  powers  be  not  reduced.  To  relieve  the  thirst,  and  at  the  same  time 
sustain  the  child,  I  have  found  half  a  teacupful  of  carbonic-acid  water,  Vichy 
water,  or  plain  water,  mixed  with  one  teaspoonful  of  the  liquid  peptonoids  of 
the  Arlington  Chemical  Works  or  of  Fairchild's  panopepton,  agreeable  and 
useful  to  the  patient. 

Follicular  Gastritis;  Diphtheritic  Gastritis. 

The  pathological  character  of  follicular  gastritis  is  similar  to  that  of  fol- 
licular stomatitis.  It  is  an  inflammation  afiPecting  the  gastric  follicles  and 
ending  in  their  ulceration.  It  is  not  a  frequent  disease  ;  it  occurs  in  young 
infants.  Billard  observed  fifteen  cases.  The  symptoms  in  these  patients 
were  similar  to  those  in  simple  gastritis  of  a  severe  form.  The  emaciation 
and  prostration  were  rapid,  and  death  occurred  early.  We  can  only  diagnos- 
ticate the  gastritis  without  determining  its  follicular  character.  How  many 
recover  it  is  impossible  to  ascertain,  but  the  disease  is  likely  to  be  fatal  on 


OASTRO-INTESTINAL  BACTERIA.  723 

account  of  the  intensity  of  the  inflammation,  not  only  of  the  follicles,  but 
of  the  intervening  mucous  membrane.     The  treatment  is  that  of  gastritis. 

Diphtheritic  gastritis  is  infrequent.  It  occasionally  occurs  during  epi- 
demics of  diphtheria.  Allusion  is  elsewhere  made  to  a  case  treated  in  the 
Nursery  and  Child's  Hospital  of  this  city  in  December,  1859.  The  patient, 
eighteen  months  old,  had  had  previously  protracted  entero-colitis,  and  died 
exhausted  after  a  brief  attack  of  diphtheria.  There  were  lesions  referable 
to  the  entero-colitis,  and  the  body  was  much  emaciated.  The  diphtheritic 
exudation  was  found  covering  the  fauces,  epiglottis,  glottis  to  the  rinia  glot- 
tidis,  the  entire  oesophagus,  and  almost  the  entire  stomach.  The  mucous 
surface  underneath  was  injected;  that  of  the  oesophagus  and  stomach  espe- 
cially was  very  vascular,  softened,  and  thickened,  and  the  submucous  connec- 
tive tissue  was  infiltrated. 

The  pseudo-membrane  taken  from  the  epiglottis  and  examined  under  the 
microscope  presented  an  amorphous  appearance ;  no  cells  were  noticed  in  it, 
and  fibrillation  was  not  distinct ;  that  from  the  stomach  was  found  to  consist 
almost  entirely  of  cells.  The  digestive  process,  so  far  as  the  stomach  was 
concerned,  had  evidently  been  almost  if  not  entirely  suspended,  and  hence  in 
part  the  sudden  prostration.  Diphtheritic  gastritis  probably  does  not  occur 
without  general  infection  of  the  system  with  the  diphtheritic  virus.  The 
proper  treatment  is  the  use  of  one  of  the  solvents  of  pseudo-membranes 
which  do  not  irritate  the  mucous  membrane,  while  the  constitutional  treat- 
ment proper  for  diphtheria  is  employed. 

Dilatation  of  Stomach. 

The  stomach  may  undergo  abnormal  dilatation,  according  to  Dr.  A. 
Jacobi,  from  overfeeding  with  bulky,  especially  amylaceous,  food ;  from 
diminished  contractility  in  its  muscular  coat  consequent  on  debility  ;  from 
imperfect  digestion  and  flatulence  ;  from  catarrhal  gastritis  and  peritoneal 
adhesions.  In  its  treatment  he  recommends  medicines  (as  bismuth)  which 
diminish  fermentation,  the  avoidance  of  fats  and  starches  and  of  large  quan- 
tities of  fluid  ingesta.  Milk  may  be  given  in  small  quantities  and  often. 
Raw  beef,  beef  peptones,  and  peptonized  milk  are  useful,  as  is  also  an 
abdominal  binder.  Faradic  and  galvanic  currents  have  been  used  with  some 
advantage,  and  the  tincture  of  nux  vomica  or  strychnia,  gr.  yi-g  to  ^5--^,  three 
times  daily,  will  increase  the  contractility  of  the  muscular  coat  of  the 
stomach.^ 


CHAPTER   VI. 

GASTEO-INTESTINAL  BACTEEIA. 

Recent  investigations  have  demonstrated  that  these  organisms  sustain  an 
important  causal  relation  to  the  indigestion,  malassimilation,  and  diarrhoeal 
diseases  of  infancy.  They  are  minute  unicellular  bodies,  and  are  classified 
as  follows :  first,  the  micrococci,  or  globular  bacteria ;  secondly,  the  bacilli, 
or  rod-shaped  bacteria  ;  and  thirdly,  the  spirilla,  or  spiral  bacteria. 

The  pathogenic  character  of  these  bodies  has  been  to  a  considerable  ex- 
tent elucidated  by  the  microscopic  examinations  and  experiments  of  several 
European  scientists,  prominent  among  whom  is  Escherich,  and  by  the  inves- 
tigations of  Booker  and  Vaughn  in  America. 

^  Arch,  of  Pediatrics,  Aug.,  1889. 


724  LOCAL  DISEASES. 

Bacteria  are  not  present  in  the  stomach  and  intestines  in  the  foetus,  nor 
in  the  meconium  at  birth.  They  are  conveyed  to  the  digestive  tract  of  the 
newly-born  through  the  air  and  saliva  and  the  liquid  ingesta,  and  it  is 
believed  that  they  sometimes  obtain  entrance  through  the  anus,  for  they 
have  been  found  in  the  meconium  three  to  seven  hours  after  birth  (Esch- 
erich).  AVhen  the  meconium  is  expelled  the  bacteria  which  it  contains 
disappear,  and  other  species  subsequently  take  their  place  in  the  milk-feces. 
The  feces  of  healthy  nurslings  contain  a  larger  number  of  bacteria,  of  which 
the  bacterium  lactis  aerogenes  and  bacterium  coli  commune  are  uniformly 
present. 

According  to  Booker,  in  the  healthy  suckling  the  stomach  contains  few 
bacteria,  chiefly  bacilli ;  the  duodenum  also  contains  but  few ;  but  they 
increase  in  number  on  tracing  the  intestine  downward.  On  reaching  the 
lower  end  of  the  upper  third  of  the  small  intestine,  we  find  a  considerable 
number  of  bacteria,  including  diplococci,  bacteria  lactis  aerogenes,  and  colon 
bacteria.  The  bacteria  lactis  aerogenes  undergo  no  farther  increase  in  the 
lower  part  of  the  small  intestines  and  in  the  colon,  but  the  colon  bacteria 
(bacterium  coli  commune)  undergo  a  great  increase  in  number  in  the  lower 
part  of  the  ileum  and  in  the  colon.  They  exist  in  large  numbers  in  the 
entire  length  of  the  colon,  and  of  larger  size  than  in  the  small  intestine. 
The  bacterium  lactis  aerogenes  occurs  in  the  form  of  "  short,  thick  rods,  with 
rounded  ends."  Injected  into  the  blood  of  guinea-pigs  and  rabbits,  it  causes 
death,  preceded  by  the  phenomena  of  intestinal  catarrh.  The  bacterium 
coli  commune  is  believed  to  be  always  present  in  feces,  whatever  the  diet. 
It  is  also  rod-shaped,  and  it  varies  in  size  and  length,  the  largest  and  longest 
specimens  attaining  the  length  of  five  micro-millimetres.  According  to 
Booker,  both  these  microbes  promote  fermentation  in  the  intestines.  Many 
other  forms  of  bacteria  have  been  discovered  in  the  milk-feces  of  infants,  in 
addition  to  the  two  which  we  have  described.  Escherich  discovered  twelve 
varieties,  micrococci  and  bacilli. 

To  the  physician  the  gastro-intestinal  bacteria  are  mainly  interesting  on 
account  of  the  supposed  causal  relation  which  they  sustain  to  certain  abnor- 
mal conditions  of  the  digestive  tract,  especially  to  the  diarrhoea!  affections. 
It  is  important  in  investigating  this  subject  to  ascertain  what  bacteria  are 
present  in  normal  feces,  and  whether  they  exert  pathogenic  action  under  cer- 
tain circumstances.  This  has  been,  in  a  measure,  ascertained,  as  we  have 
seen,  but  another  interesting  and  important  inquiry  relates  to  new  forms  of 
bacteria  that  appear  in  the  feces  in  diseased  conditions  of  the  stomach  and 
intestines,  and  the  causal  relation  which  they  bear  to  these  conditions.  New 
forms  of  bacteria  may  appear  in  the  feces  in  gastro-intestinal  disease  without 
sustaining  a  causal  relation  to  it  or  influencing  it.  Again,  although  not 
causing  the  disease,  they  may  influence  its  course  and  duration,  or  they  may 
cause  gastro-intestinal  disease  by  lodging  in  the  food,  especially  in  milk,  and 
producing  by  their  agency  poisonous  chemical  substances  in  it  before  it  is 
employed  in  the  nursery.  The  well-known  poisoning  by  the  tyrotoxicon  in 
the  hotels  at  Long  Branch,  this  poison  being  produced  in  milk  probably  by 
mierobic  action  six  or  eight  hours  after  the  milking,  was  an  instance  of  this 
kind.  Again,  a  species  of  bacteria  not  occurring  in  the  stools  in  health,  but 
appearing  in  disease,  as  in  indigestion,  inanition,  or  diarrhoea,  may  be  the  chief 
factor  in  causing  this  morbid  state. 

According  to  Booker,  none  of  the  gastro-intestinal  secretions  have  an  inju- 
rious effect  on  bacteria,  except  the  gastric  juice,  but  certain  bacteria  are 
antagonistic  to  others,  so  that  their  presence  prevents  the  full  development 
of  the  latter.  Bacteria,  which  in  the  normal  state  of  the  gastro-intestinal 
tract  do  not  find  a  soil  suitable  for  their  development  in  the  stomach  or 


GASTRO-INTESTINAL  BACTERIA.  725 

intestines,  obtain  the  conditions  favorable  for  their  growth  and  propagation 
in  diseased  states,  as  when  indigestion  or  catarrh  is  present. 

The  pathogenic  action  of  bacteria  in  the  digestive  tract  can  be  most  suc- 
cessfully investigated  by  experimenting  with  them  when  they  have  been  iso- 
lated from  other  substances  by  repeated  cultivations.  Hayem  and  Lesage 
have  isolated  a  bacillus  which  they  have  discovered  in  green  stools  of  infants, 
and  which  they  believe  produce  by  its  disturbing  action  the  green  color  and 
abnormal  state  of  the  stools.  The  green  color  in  the  feces  of  infantile  diar- 
rhoea they  believe  to  be  sometimes  due  to  an  excess  of  the  bile-pigment,  but 
in  other  instances  is  produced  by  the  action  of  a  bacillus,  which  occurs 
especially  in  the  upper  two-thirds  of  the  small  intestine,  where  it  attains 
the  length  of  two  {o  three  micro-millimetres.  Injected  into  the  blood  of 
sucking  animals,  this  bacillus  appeared  in  the  duodenum  ten  or  twelve  hours 
subsequently,  and,  increasing  in  number,  caused  green  discoloration  of  the 
intestinal  contents.  The  same  result  was  produced  when  this  microbe  was 
administered  in  the  ingesta.  In  its  dry  state  it  floats  in  the  air,  so  that  when 
an  infant  having  green  stools  produced  by  its  action  enters  a  ward,  others  are 
liable  to  be  attacked  with  the  green  diarrhaea  if  its  soiled  diapers  are  allowed 
to  dry  in  the  room. 

Baginsky  has  investigated  the  stools  in  the  acid  diarrhoea  of  infants,  and 
has  isolated  two  forms  of  bacteria  which  liquefy  gelatin.  One  of  these  pro- 
duces green  coloring  matter,  and  is  probably  the  same  as  that  described 
above ;  the  other  was  constantly  present  in  the  acid  diarrhoeal  feces,  was 
poisonous  to  animals,  and  it  is  probably  impotent  in  the  pathogenic  role. 
Baginsky  believes  from  his  observations  that  the  bacterium  lactis  aerogenes 
present  in  the  normal  stools  of  the  suckling  is  under  favorable  circumstances 
antagonistic  to  the  development  of  pathogenic  organisms. 

Dr.  Booker  has  isolated  forty  bacteria  from  the  stools  of  30  infants, 
all  seriously  sick  with  diarrhoeal  diseases,  11  having  cholera  infantum,  1-i 
catarrhal  enteritis,  and  5  dysentery.  The  largest  number  of  these  organisms 
occurred  in  cases  of  cholera  infantum,  and  the  next  largest  number  in  cases 
of  catarrhal  entero-colitis.  According  to  Booker,  the  bacteria  of  the  normal 
milk-feces  still  appear  in  the  diarrhoeal  stools.  The  bacterium  coli  commune 
was  found  by  him  in  all  the  diarrhoeal  cases,  but  its  number  appeared  to 
diminish  according  to  the  severity  of  the  attack.  On  the  other  hand,  the 
bacterium  lactis  aerogenes  occurred  in  larger  number  in  the  diarrhoeal  stools 
than  in  healthy  milk-feces.  Booker  discovered  bacteria  of  the  proteus  group 
in  7  of  the  11  cases  of  cholera  infantum  ;  which  is  a  matter  of  significance, 
inasmuch  as  Escherich  did  not  find  any  bacterium  of  this  group  in  normal 
milk-feces. 

In  a  very  interesting  and  instructive  paper  read  before  the  American 
Pediatric  Society  in  June,  1890,  Dr.  Victor  C.  Vaughan  detailed  his  experi- 
ments, which  showed  that  "  three  micro-organisms,  differing  sufficiently  to 
be  recognized  as  different  species,  produce  poisons,  all  of  which  cause  vomit- 
ing and  purging,  and,  when  used  in  sufficient  quantity,  death"  in  cats  and 
dogs  experimented  on.  Dr.  Vaughan  concludes  his  paper  with  the  following 
aphorisms  :  "  1.  There  are  many  germs,  any  one  of  which,  when  introduced 
into  the  intestine  of  the  infant  under  certain  favorable  circumstances,  may 
produce  diarrhoea.  2.  Many  of  these  germs  are  probably  truly  saprophytic. 
3.  The  only  digestive  secretion  which  is  known  to  have  any  decided  germici- 
dal effect  is  the  gastric  juice.  Therefore,  if  this  secretion  be  impaired,  there 
is  at  least  the  possibility  that  the  living  germ  will  pass  on  to  the  intestine, 
will  there  multiply,  and  will,  if  it  be  capable  of  so  doing,  elaborate  a  chemical 
poison,  which  may  be  absorbed.  4.  Any  germ  which  is  capable  of  growing 
and  producing  an  absorbable  poison  in  the  intestine  is  a  pathogenic  germ. 


726  LOCAL  DISEASES. 

5.  The  proper  classification  of  germs  in  regard  to  their  relation  to  disease 
cannot  be  made  from  their  morphology  alone,  but  must  depend  largely  upon 
the  products  of  their  growth." 


CHAPTER    VII. 

SIMPLE  DIAREHCEA. 

DiARRH(EA  is  frequent  during  the  whole  period  of  infancy.  French  writers 
describe  several  varieties,  according  to  the  character  of  the  evacuations,  as 
acescent,  mucous,  and  serous.  M.  Rostan  even  describes  fourteen  distinct 
kinds.  But  the  tendency  of  medical  science  in  modern  times  is  to  simplify 
the  nomenclature  of  diseases — to  describe  under  a  single  name  those  affections 
which  are  essentially  the  same,  though  differing  somewhat  in  their  features. 
Now,  all  the  forms  of  diarrhoea  in  the  infant  may  be  so  grouped  as  to  reduce 
the  number  to  not  more  than  three  or  four.  In  this  way  repetition  and 
prolixity  are  avoided,  as  well  as  an  unnecessary  refinement. 

The  most  common  form  of  diarrhoea  is  that  enunciated  in  our  heading. 
But  often  a  diarrhoea  which  is  non-inflammatory  at  first  becomes  a  catarrh. 
Thus  the  simple  diarrhoea  of  infancy  may  become  an  entero-eolitis  from  the 
continued  use  of  improper  diet. 

Causes.  —  These  are  various.  Conditions  or  agencies  which  have  no 
appreciable  effect  in  the  adult  often  increase  the  number  of  evacuations  in 
young  children.  Food  which  imperfectly  digests,  and  some  of  which  perhaps 
ferments,  stimulates  the  intestinal  follicles  to  excessive  secretion,  and  increases 
the  peristaltic  movements  by  its  irritating  action,  thus  causing  diarrhoea.  Too 
frequent  and  abundant  feeding  is  another  cause,  especially  in  young  infants, 
some  of  whom  may  vomit  the  surplus  food  and  remain  well,  but  others  do 
not.  Food  which  cannot  be  assimilated  becomes  an  irritant  in  consequence 
of  fermentative  change,  and  produces  frequent  and  unhealthy  evacuations. 
In  the  light  of  our  present  knowledge  we  assign  to  the  agency  of  intestinal 
bacteria  an  important  causal  relation  to  those  forms  of  diarrhoea  which  are 
attended  by  fermenting,  imperfectly-digested,  and  unhealthy  stools.  By  the 
investigations  of  Booker  and  others  it  is  now  known  that  many  forms  of 
bacteria  exist  in  the  stools,  and  when  abundant  excite  the  vermicular  and 
peristaltic  movements  so  as  to  excite  more  abundant  evacuations. 

The  mother's  milk  or  the  milk  of  the  wet-nurse  may  disagree,  either 
from  some  temporary  derangement  of  her  system  or  continued  ill-health,  or 
from  causes  which  are  not  understood.  Diarrhoea  in  the  nursling  is  the 
result. 

Fright  or  strong  mental  impressions  will  also  in  some  children  increase 
the  number  of  evacuations.  This  cause  being  transient,  the  diarrhoea  soon 
subsides. 

Another  cause  is  exposure  to  cold.  Children  who  are  insufficiently  clothed 
in  the  winter  season,  who  are  taken  from  a  heated  room  into  a  cool  one  with- 
out sufficient  protection,  or  who  lie  uncovered  at  night  are  very  subject  to 
diarrhoeal  attacks  from  the  impression  of  cold  on  the  system. 

^  The  cause  of  simple  diarrhoea  may  exist  in  the  child  itself.  In  some 
children  the  evolution  of  the  teeth  is  attended  by  a  relaxed  state  of  the 
bowels,  which  ceases  when  the  gum  is  pierced,  but  whether  it  is  a  cause 
of  the  diarrhoea  we  are  not  prepared  to  state.     Worms  in  the  intestines  may 


SIMPLE  DIARRHOEA.  727 

also  operate  as  a  cause.  Diarrhcea  is  occasionally  salutary  within  certain 
limits,  and  of  course  it  is  not  strictly  correct  to  call  it  a  disease  when  it 
is  a  means  of  relief.  If  occurring  from  excessive  or  irritating  ingesta,  it  is 
obviously  conservative. 

Symptoms. — Diarrhoea  may  come  on  suddenly ;  at  other  times  there  are 
precursory  symptoms  continviing  for  some  days.  Whether  or  not  there  be 
antecedent  symptoms  depends  chiefly  on  the  cause.  If  this  be  exposure  to 
cold  or  the  use  of  improper  aliment,  it  commonly  occurs  immediately. 

Among  the  prodromic  symptoms  sometimes  present  are  restlessness,  dis- 
turbed sleep,  transient  abdominal  pains,  nausea  or  vomiting,  and  other  symp- 
toms of  indigestion.  The  stools  in  simple  diarrhoea  diff"er  much  in  color  and 
consistence  in  different  cases,  and  perhaps  at  different  periods  in  the  same 
case.  In  infants  they  are  often  green.  This  color,  which  is  a  source  of 
anxiety  to  the  inexperienced,  and  especially  to  the  parents,  is  often  produced 
by  trivial  causes.  Slight  indigestion  will  produce  it,  and  so  will  excess  of 
food,  even  when  bland  and  unirritating.  We  have  already  stated  that  a  cer- 
tain microbe  has  the  power  to  produce  the  green  color.  The  stools  in  infantile 
diarrhoea  often  contain  particles  of  coagulated  casein,  but  in  children  advanced 
beyond  the  period  of  first  dentition  they  do  not  differ  materially  in  appearance 
from  the  evacuations  of  the  adult.  They  are  usually  passed  easily,  but  if 
they  be  acid  or  in  any  way  irritating  there  may  be  more  or  less  tenesmus, 
especially  in  infants.  Sometimes  before  the  evacuations  there  is  a  sensation 
of  fulness  in  the  abdomen.  In  that  form  of  diarrhoea  which  has  been  desig- 
nated acescent  not  only  are  the  stools  acid,  but  matters  vomited  have  an  acid 
odor  and  give  an  acid  reaction. 

During  the  quiet  hours  of  sleep,  when  no  foods  and  drinks  are  taken,  the 
diarrhoea  diminishes.  If  the  complaint  be  slight,  there  is  little  thirst ;  but 
if  the  stools  be  frequent  and  thin,  especially  if  they  approach  the  watery 
character,  the  patient  is  thirsty.  The  appetite  varies,  the  tongue  is  moist 
and  covered  with  a  light  fur,  and  there  is  often  more  or  less  meteorism, 
but  no  abdominal  tenderness. 

The  features  in  this  disease  are  pallid.  In  a  few  days,  if  the  evacuations 
continue,  there  is  evident  loss  of  weight  and  flesh.  The  rotunditj^  of  the 
limbs  is  gradually  lost  and  the  tissues  become  soft  and  flabby.  But  in  most 
cases  when  the  malady  has  reached  this  stage  its  original  character  is  lost, 
and  it  has  become  inflammatory. 

Certain  epiphenomena,  as  Barrier  terms  them,  occur  at  times  in  non- 
inflammatory as  well  as  in  inflammatory  diarrhoea ;  as,  for  example,  a  sym- 
pathetic cough  or,  which  is  more  serious,  cerebral  complications.  Convul- 
sions or  stupor,  indicating  the  supervention  of  spurious  hydrocephalus,  may 
occur  in  either  form  of  diarrhoea.  This  disease  is  described  elsewhere.  More 
or  less  fever  may  occur  in  simple  diarrhoea,  but  it  is  not  constant  and  the 
pulse  may  or  may  not  be  accelerated. 

Anatomical  Characters. — It  is  obvious  from  the  nature  of  simple 
diarrhoea  that  it  is  attended  by  little  or  no  perceptible  anatomical  change. 
In  cases  supposed  to  be  simple  or  non-inflammatory,  which  have  ended  fatally 
either  from  the  diarrhoea  or  an  intercurrent  disease,  the  most  marked  lesions 
observed  have  been  more  or  less  tumefaction  of  the  intestinal  glands,  with 
perhaps  diminished  firmness  and  resistance  of  the  mucous  membrane.  Cases 
like  the  following,  which  have  usually  been  regarded  as  non-inflammatory, 
are  not  infrequent,  but  it  seems  probable  that  in  at  least  a  certain  proportion 
of  such  cases  the  intestinal  follicular  apparatus  has  passed  beyond  the 
physiological  state  of  an  exaggerated  functional  activity,  and  that  the  dis- 
ease should  be  designated  a  catarrh  or  inflammation.  Inasmuch  as  non- 
inflammatory diarrhoea,  if  protracted,  is  very  liable  to  become  inflammatory. 


728  LOCAL  DISEASES. 

it  is  often  difficult  to  determine  whether  the  malady   has  undergone  this 
change,  even  with  the  aid  of  post-mortem  inspection. 

On  the  7th  of  July,  1865,  a  foundling  one  month  old  died  at  the  Infant 
Asylum.  It  was  much  emaciated,  with  eyes  sunken  and  features  pinched, 
at  the  time  of  its  death.  It  was  wet-nursed  to  the  close  of  its  life,  but  the 
nurse's  .milk  was  insufficient.  It  did  not  vomit,  did  not  have  any  marked 
acceleration  of  pulse  (128  per  minute),  and  its  evacuations  were  about  four 
daily,  and  thin.  The  stomach  and  intestines  were  pale  throughout.  The 
solitary  glands,  particularly  those  in  the  colon,  and  the  patches  of  Peyer 
were  tumefied  so  as  to  be  visible  and  somewhat  raised  above  the  surround- 
ing surface.  But  no  lesions  being  observed  which  are  characteristic  of 
inflammation,  the  disease  was  regarded  as  non-inflammatory. 

Niemeyer,  with  others,  describes  even  the  mildest  forms  of  diarrhoea  under 
the  term  catarrhal  inflammation,  and  he  appears  to  consider  the  transient 
efi"ects  of  a  purgative  as  an  incipient  catarrh.  But  it  seems  to  me  prefer- 
able, in  the  present  state  of  pathological  knowledge,  to  regard  all  those  diar- 
rhoeas which  immediately  abate  with  the  removal  of  the  cause,  and  which  are 
attended  by  no  marked  anatomical  change,  as  non-inflammatory  or  simple. 
They  are  characterized  by  increased  secretion  of  the  intestinal  follicles  and 
increased  peristalsis. 

Prognosis. — In  a  large  proportion  of  cases  simple  diarrhoea  is  not  dan- 
gerous. With  the  adoption  of  suitable  measures  to  remove  the  cause  and 
the  use  of  medicines  to  control  the  discharges  the  patient  recovers.  The 
remark  already  made  may  be  repeated  here,  that  occasionally  diarrhoea  is 
salutary  within  certain  limits,  as  when  there  is  a  foreign  substance  in  the 
intestines  either  irritating  mechanically  or  by  its  chemical  properties,  and 
which  the  diarrhoea  serves  to  remove. 

The  danger  arises  from  complications,  as  spurious  hydrocephalus,  or  from 
the  emaciation  and  exhaustion,  or  from  its  eventuating  in  inflammation. 

If  the  rotundity  of  the  figure  and  firmness  of  the  tissues  be  preserved, 
showing  that  alimentation  is  still  sufficient,  and  no  complication  arise,  the  diar- 
rhoea is  not  as  a  rule  dangerous.  In  infants  that  over-nurse  and  do  not  vomit 
the  surplus  milk,  the  evacuations  are  sometimes  green  and  frequent,  and  yet 
fulness  of  figure  is  preserved  and  the  development  of  the  body  proceeds  as 
usual.  On  the  other  hand,  diarrhoea  attended  by  emaciation  or  softness  or 
flabbiness  of  the  flesh  involves  danger  and  requires  immediate  treatment. 

Treatment. — It  is  necessary,  in  order  to  treat  diarrhoea  in  infancy  and 
childhood  successfully,  to  ascertain  the  cause,  and,  as  far  as  possible,  to 
remove  it.  It  is  not  till  the  cause  ceases  to  operate  that  we  can  expect  a 
satisfactory  result  from  medication.  The  disease  may  be  temporarily  relieved 
by  medicine,  but  it  usually  returns  at  once  when  treatment  is  omitted,  unless 
the  patient  be  removed  from  the  influence  of  the  agencies  which  produce  it. 
These  remarks  are  especially  applicable  to  the  diarrhoea  of  infants.  With 
them  very  generally,  when  aff'ected  with  this  complaint,  there  is  some  fault 
as  regards  the  quantity  or  quality  of  food.  Attention  to  this  matter  will 
show  the  need  of  a  change  of  wet-nurse,  or,  if  the  infant  be  spoon-fed,  a 
change  in  the  character  of  its  food  or  in  the  mode  of  preparation,  or  even  in 
the  quantity  given.  Sometimes  by  change  in  the  diet  and  the  adoption  of 
hygienic  measures  the  complaint  ceases,  so  as  to  require  no  medication. 
Sometimes  the  temporary  abstinence  from  milk-food,  and  the  employment 
of  barley  gruel  in  its  place  or  the  use  of  barley  gruel  and  peptonized  milk, 
or,  better,  barley  gruel  mixed  with  the  white  of  an  egg,  added  to  a  little  cold 
water  and  beaten  in  a  saucer  five  minutes,  suffice  to  cure  the  diarrhoea.  If 
medicines  be  needed  and  the  symptoms  are  not  urgent,  it  is  occasionally 
advantageous  to  commence  treatment  by  the  use  of  one  of  the  milder  purga- 


SI3IPLE  DIARBHCEA.  729 

tives  in  a  small  dose.  In  the  infant,  in  whom  the  dejections  are  so  generally 
acid,  an  alkaline  laxative  or  a  laxative  conjoined  with  an  alkali  often  has  a 
good  effect  as  preliminary  treatment.  Half  a  teaspoonful  to  one  teaspoonful 
of  castor  oil  or  a  proportionate  dose  of  calcined  magnesia  removes  any  acid 
or  irritating  substance  from  the  intestines,  and  is  followed  by  a  diminution  in 
the  number  of  stools.  The  improvement,  however,  without  subsequent  treat- 
ment is  usually  only  for  a  day  or  two.  A  purgative  dose  of  castor  oil  is 
often  given  as  a  domestic  remedy  in  infantile  diarrhoea,  the  beneficial  effect 
from  it  having  popularized  its  use  for  this  purpose.  Trousseau  usually  gave 
E-ochelle  salts,  but  this  medicine  is  too  severe  and  dangerous  for  the  treat- 
ment of  infantile  diarrhoea,  especially  in  warm  months. 

If  there  have  been  previous  constipation  and  the  diarrhoea  have  just  com- 
menced, a  purgative  is  obviously  indicated.  West  says :  "  Provided  there 
1)6  neither  much  pain  nor  much  tenesmus,  and  the  evacuations,  though 
watery,  are  fecal  and  contain  little  mucus  and  no  blood,  very  small  doses  of 
the  sulphate  of  magnesia  and  tincture  of  rhubarb  have  seemed  to  me  more 
useful  than  any  other  remedy : 

R.  Magnesiffi  .sulphatis,  5j  ; 

Tinct.  rhei,  ,^j  ; 

Syr.  zingiberis,  5j  ; 

Aquae  canii,  .^ix. — Misce. 

Dose,  3j  three  times  daily  for  a  child  one  year  old. 

I  seldom  fail  to  observe  from  it  a  speedy  diminution  in  the  frequency  of 
the  action  of  the  bowels  and  a  return  of  the  natural  character  of  the 
evacuations." 

Since  many  cases  of  simple  diarrhoea  are  due  to  the  use  of  food  which 
does  not  readily  digest,  but  undergoes  in  part  fermentation,  the  food  should 
be  carefully  selected  and  prepared  according  to  the  directions  given  in  the 
chapters  relating  to  artificial  feeding.  In  cases  of  fermentation,  due  often 
to  microbic  agency,  the  digestion  is  very  imperfect,  and  the  diarrhoea  which 
results  is  often  best  treated,  so  far  as  medicines  are  concerned,  by  the  use  of 
pepsin  and  bismuth  subnitrate,  as  ten  or  fifteen  grains  of  pepsinum  sac- 
charatse  and  bismuth  subniti-ate  given  at  each  feeding. 

In  the  simple  diarrhoea  of  infants  the  compound  powder  of  chalk  and 
opium  is  sometimes  a  good  remedy,  combining  as  it  does  an  astringent  with 
the  opiate  and  alkali.  It  may  be  given  in  doses  of  three  grains  to  a  child 
one  year  old  every  three  hours  midway  between  the  feedings.  The  follow- 
ing is  a  convenient  formula  for  administering  substantially  the  same  medi- 
cines in  the  liquid  form  : 

R.  Tinct.  opii  deodorat.,  gtt.  xvj  ; 

Bismvith.  subnitrat.,  3y  5 

"VVyeth's  elix.  of  digestive  ferments 

or  Fairchild's  essence  of  pepsin,    Jss; 
Aquae,  ^iss. — Misce. 

Shake  well,  and  give  one  teaspoonful  every  three  hours  between  the  feedings. 

If  the  patient  be  not  relieved  by  the  opiate,  digestive  ferment,  and  bis- 
muth, and  by  proper  regimen,  in  all  probability  inflammation  of  the  intes- 
tinal mucous  membrane  is  present.  In  patients  over  the  age  of  two  or  three 
years  simple  diarrhoea  approaches  in  character  that  of  the  adult,  and  the 
treatment  appropriate  for  the  adult  is  proper  in  these  cases,  allowance  being 
made  for  the  difference  in  age.  In  infants,  in  whom  this  disease,  if  pro- 
tracted, very  soon  becomes  an  undoubted  entero-colitis,  attended  if  it  be  pro- 


730  LOCAL  DISEASES. 

tracted  by  emaciation  and  weak  heart,  stimulating  digestive  agents  are  often 
required  at  an  early  period  on  account  of  the  prostration  and  feeble  power 
of  endurance. 


CHAPTER    VIII. 

INTESTINAL  CATAKKH  OF  INFANCY   (ENTEEO-COLITIS). 

It  is  customary  with  writers  to  treat  of  inflammation  of  the  small  and 
large  intestines  in  infancy  as  a  single  disease,  for  the  following  reasons: 
First,  the  symptoms  of  colitis  at  this  period  of  life  do  not  ordinarily  differ, 
in  any  marked  degree,  from  those  of  enteritis.  The  tormina,  tenesmus,  and 
abdominal  tenderness  which  characterize  colitis  in  childhood  and  adult  life 
are  ordinarily  lacking  or  are  not  appreciable  by  the  observer,  and  the  muco- 
sanguineous  evacuations  are  oftener  absent  than  present.  On  account  of  this 
absence  of  symptoms  Bouchut  says :  "  Dysentery  is  a  very  rare  disease 
among  young  children.  Its  existence  might  even  be  denied  if  it  had  not 
heen  observed  at  the  period  of  some  severe  epidemics  of  dysentery."  If 
Bouchut  refers  by  the  term  "  dysentery  "  to  the  ordinary  phenomena  of  that 
disease,  his  remark  is  correct ;  but  as  regards  the  lesions  it  is  erroneous,  for 
colitis  is  a  common  infantile  malady.  Billard,  after  analyzing  eighty  cases 
of  intestinal  inflammation  in  infants,  says :  "  From  this  calculation  it  is 
evidently  very  difiicult  to  make  a  correct  diagnosis  of  inflammation  of  the 
intestinal  tube  in  suckling  infants,  yet  it  would  seem  as  if  the  proper  signs 
of  enteritis  or  ileitis  were  the  rapid  tympanitis  of  the  abdomen,  the  diar- 
rhoea, accompanied  with  vomiting  ;  while  in  colitis,  diarrhoea  alone,  without 
tympanitis,  is  the  most  frequent."  And  again  :  "  In  consequence  of  the 
impossibility  we  have  found  to  exist  of  tracing  with  exactitude  the  series  of 
symptoms  proper  to  inflammation  of  the  different  portions  of  the  digestive 
tube,  we  shall  content  ourselves  with  presenting  an  analytical  sketch  of  the 
causes,  symptoms,  and  ordinary  course  of  inflammation  of  the  mucous  mem- 
brane of  the  intestines  in  general." 

The  frequent  absence  of  any  pathognomonic  symptom  or  sign  by  which 
to  determine  the  exact  seat  of  intestinal  inflammation  in  the  infant  is  admitted 
by  recent  observers  as  well  as  Billard. 

The  second  reason  why  intestinal  inflammation  in  the  infant  is  described 
as  a  single  disease  is,  that  enteritis  and  colitis  in  the  majority  of  cases  coexist. 
This  will  be  seen  when  we  come  to  speak  of  the  anatomical  characters. 

In  rural  districts  infantile  diarrhoea  is  not  so  prevalent  and  fatal  as  in 
cities.  In  the  farming  sections  it  does  not  materially  increase  the  death-rate, 
and  it  is  therefore  not  so  important  a  malady  as  in  cities.  In  cities  it  largely 
increases  the  aggregate  of  deaths.  Especially  fatal  is  that  form  of  it  which 
is  known  as  the  summer  epidemic,  as  is  seen  by  the  mortuary  records  of 
any  large  city.  Thus,  in  New  York  City  during  1882  the  deaths  from  diar- 
rhoea reported  to  the  Health  Board,  tabulated  in  months,  were  as  follows : 

Jan.  Feb.  Mar.  Apr.  May.  June.  July.  Aug.  Sept.  Oct.  Nov.  Dec. 
Under  five  years  .  .  34  32  50  50  72  231  1533  817  362  195  68  35 
Over  five  years.    .    .14      15      14      20      15        19        131      149       84        55      31      24 

It  is  seen  that  in  1882  in  New  York  City  the  deaths  from  diarrhoea  under 
the  age  of  five  years  were  greatly  in  excess  of  the  number  during  the  whole 
period  of  life  subsequently  to  that  age. 


43 

46 

34 

52 

40 

58 

47 

45 

61 

89 

144 

157 

1205 

1387 

1007 

1012 

587 

608 

255 

185 

105 

57 

56 

50 

INTESTINAL   CATARRH  OF  INFANCY.  731 

The  following  statistics  show  how  great  a  destruction  of  life  this  malady 
causes  even  under  the  surveillance  of  an  energetic  Health  Board  ;  and  before 
this  Board  was  established  it  was  much  greater,  as  I  had  abundant  opportuni- 
ties to  observe.  The  last  annual  report  of  the  New  York  Board  of  Health 
was  made  in  1875,  since  which  time  weekly  bulletins  have  been  issued.  The 
deaths  from  diarrhoea  at  all  ages  in  the  last  three  years  in  which  annual 
reports  were  issued  were  as  follows : 

1873.  1874.  1875. 

January -    -  94 

February 84 

March 93 

April 114 

May 95 

June 220 

July 1514 

August 967 

September ^   .  424 

October 213 

November  . 87 

December 53 

In  its  annual  report  for  1870  the  Board  states  :  "  The  mortality  from  the 
diarrhoeal  aifections  amounted  to  2789,  or  33  per  cent,  of  the  total  number 
of  deaths ;  and  of  these  deaths,  95  per  cent,  occurred  in  children  less  than 
five  years  old,  92  per  cent,  in  children  less  than  two  years  old,  and  67  per 
cent,  in  those  less  than  a  year  old."  Every  year  the  reports  of  the  Health 
Board  furnish  similar  statistics,  but  enough  have  been  given  to  show  how 
great  a  sacrifice   of  life  infantile  diarrhoea  produces  annually  in  that  city. 

What  we  observe  in  New  York  in  reference  to  this  disease  is  true  also,  to 
a  greater  or  less  extent,  in  other  cities  of  this  country  and  Europe,  so  far  as 
we  have  reports.  Not  in  every  city  is  there  the  same  proportionate  mortality 
from  this  cause  as  in  New  York,  but  the  frequency  of  infantile  diarrhoea  and 
the  mortality  which  attends  it  render  it  an  important  disease  in,  I  believe, 
most  cities  of  both  continents.  In  country  towns,  whether  in  villages  or 
farm-houses,  this  disease  is  comparatively  unimportant,  inasmuch  as  few  cases 
occur  in  them,  and  the  few  that  do  occur  are  of  mild  type,  and  consequently 
much  less  fatal  than  in  cities. 

The  comparative  immunity  of  rural  districts  has  an  important  relation,  as 
we  will  see,  to  the  hygienic  management  of  these  cases. 

Etiology. — The  intestinal  catarrh  of  infants  is  occasionally  produced  by 
taking  cold.  Infants  insufficiently  protected  by  clothing  and  exposed  to 
sudden  changes  of  temperature  or  to  currents  of  air  in  the  apartments 
where  they  reside,  or  heedlessly  exposed  out-doors  by  careless  nurses,  some- 
times become  affected  with  diarrhoea,  even  of  a  fatal  character.  They  con- 
tract an  intestinal  inflammation  from  taking  cold,  just  as  other  infants  may 
contract  coryza  or  bronchitis  from  the  same  cause. 

But  the  most  common  causes  of  infantile  diarrhoea  are,  first,  the  use  of 
food  which  is  unsuitable  for  infantile  digestion,  and  which  therefore  acts  as 
an  irritant ;  and,  secondly,  residence  in  a  foul  atmosphere,  to  which  we  will 
soon  call  attention,  and  which  largely  increases  the  percentage  of  deaths  in 
our  cities  during  the  hot  months.  Diarrhoea  due  to  taking  cold  occurs  in  all 
localities  and  climates,  but  it  is  obviously  most  common  in  time  of  change- 
able weather.  That  due  to  the  use  of  unsuitable  food  and  foul  air  occurs 
for  the  most  part  in  cities,  and  much  more  frequently  in  the  summer  season 
than  in  the  cool  months,  as  the  above  statistics  show.  Infantile  intestinal 
catarrh,  however  produced,  presents  nearly  the  same  anatomical  characters, 


732  LOCAL  DISEASES. 

so  that,  whatever  its  etiology,  it  is  proper  to  describe  it  as  one  disease ;  but 
that  form  of  it  which  requires  most  elucidation,  and  the  causes  of  which  we 
will  consider  in  the  following  pages,  is  that  produced  by  impure  air  and 
improper  diet. 

The  prevalence  and  severity  of  infantile  diarrhoea  in  cities  correspond 
closely  with  the  degree  of  atmospheric  heat,  as  may  be  inferred  from  the 
foreaoing  statistics.  In  New  York  this  disease  begins  in  the  month  of  3Iay 
— earlier  in  some  years  than  in  others — in  a  few  scattered  cases,  commonly 
of  a  mild  type.  Cases  become  more  and  more  numerous  and  severe  as  the 
weather  srows  warmer,  until  July  and  August,  when  the  diarrhoea  attains  its 
maximum  prevalence  and  severity.  In  these  two  months  it  is  by  far  the  most 
frequent  and  fatal  of  all  the  diseases  in  the  cities.  In  the  middle  of  Sep- 
tember new  patients  begin  to  be  less  common,  and  in  the  latter  part  of  this 
month  and  subsequently  new  cases  do  not  occur,  unless  under  unusual  cir- 
cumstances which  favor  the  development  of  this  malady.  In  New  York  a  con- 
siderable number  of  deaths  of  infants  occur  from  diarrhoea  in  October.  October 
is  not  a  hot  month  in  our  latitude — its  average  temperature  is  lower  than  that 
of  May — and  yet  the  mortality  from  this  disease  is  considerably  larger  in  the 
former  than  in  the  latter  month.  This  fact,  which  seems  to  show  that  the 
prevalence  of  the  summer  diarrhoea  does  not  correspond  with  the  degree  of 
atmospheric  heat,  is  readily  explained.  The  mortality  in  October,  and  indeed 
in  the  latter  part  of  September,  is  not  that  of  new  cases,  but  is  mainly  of 
infants,  as  I  have  observed  every  year,  who  contract  the  disease  in  July  or 
August  or  earlier,  and  linger  in  a  state  of  emaciation  and  increasing  weak- 
ness till  they  finally  succumb,  some  even  in  cool  weather. 

The  fact  is  therefore  undisputed,  and  is  universally  admitted,  that  the 
summer  season,  stated  in  a  general  way,  is  the  cause  of  this  annually  recur- 
ring diarrhoeal  epidemic.  That  atmospheric  heat  does  not  in  itself  cause 
the  diarrhoea  is  evident  from  the  fact  that  in  rural  districts  there  is  the  same 
intensity  of  heat  as  in  cities,  and  yet  the  summer  complaint  does  not  occur. 
The  cause  must  be  looked  for  in  the  state  of  the  atmosphere  engendered  by 
heat  where  unsanitary  conditions  exist,  as  in  large  cities.  Moreover,  obser- 
vations show  that  the  noxious  effluvia  with  which  the  air  becomes  polluted 
under  such  circumstances  constitute  or  contain  the  morbific  agent.  Thus,  in 
one  of  the  institutions  of  this  city  a  few  years  since,  on  May  10th,  which 
happened  to  be  an  unusually  warm  day  for  this  month,  an  oiFensive  odor  was 
noticed  in  the  wards,  which  was  traced  to  a  large  manure  heap  that  was  being 
upturned  in  an  adjacent  garden.  On  this  day  four  young  children  were 
severely  attacked  by  diarrhoea,  and  one  died.  Many  other  examples  might 
be  cited  showing  how  the  foul  air  of  the  city  during  the  hot  months,  when 
animal  and  vegetable  decomposition  is  most  active,  causes  diarrhoea.  Several 
years  since,  while  serving  as  sanitary  inspector  for  the  Citizens'  Association  in 
one  of  the  city  districts,  my  attention  was  particularly  called  to  one  of  the 
streets,  in  which  a  house-to-house  visitation  disclosed  the  fact  that  nearly 
every  infant  between  two  avenues  had  diarrhoea,  and  usually  in  a  severe  form, 
not  a  few  dying.  The  street  was  compactly  built  with  wooden  tenement- 
houses  on  each  side,  and  contained  a  dense  population,  mainly  foreigners,  poor, 
ignorant,  and  filthy  in  their  habits.  It  had  no  sewer,  and  the  refuse  of  the 
kitchens  and  bed-chambers  was  thrown  into  the  street,  where  it  accumulated 
in  heaps.  "Water  trickled  down  over  the  sidewalks  from  the  houses  into  the 
gutters  or  was  thrown  out  as  slops,  so  that  it  kept  up  a  constant  moisture  of 
the  refuse  matter  which  covered  the  street,  and  promoted  the  decay  of  the 
animal  and  vegetable  substances  which  it  contained.  The  air  in  the  domiciles 
and  street  under  such  conditions  of  impurity  was  necessarily  foul  in  the 
extreme,  and  stifling  during  the  hot  days  and  nights  of  July  and  August ; 


INTESTINAL  CATARRH  OF  INFANCY.  733 

and  it  was  evidently  the  important  factor  in  producing  the  numerous  and 
severe  diarrhoeal  cases  which  were  in  these  domiciles. 

In  another  locality,  occupied  by  tripe-dealers  and  a  low  class  of  butchers 
who  carried  on  fat-  and  bone-boiling  at  night,  the  air  was  so  foul  after  dark 
that  the  peculiar  impurity  which  tainted  it  could  be  distinctly  noticed  in  the 
mouth  for  a  considerable  time  after  a  night  visit.  In  the  street  where  these 
nuisances  existed  and  in  adjacent  streets  the  summer  diarrhoea  was  very 
prevalent  and  destructive  to  human  life.  Murchison  states  that  20  out  of  25 
boys  were  affected  with  purging  and  vomiting  from  inhaling  the  effluvia  from 
the  contents  of  an  old  drain  near  their  school-room.  Physicians  are  familiar 
with  a  similar  fact  showing  this  purgative  effect  of  impure  air — that  the 
atmosphere  of  a  dissecting-room  often  causes  diarrhoea  in  those  otherwise 
healthy. 

The  impurities  in  the  air  of  a  large  city  are  very  numerous.  Among  those 
of  a  gaseous  nature  are  sulphurous  acid,  sulphuric  acid,  sulphuretted  hydro- 
gen ;  various  gases  of  the  carbon  group,  as  carbonic  acid,  carburetted  hydrogen, 
and  carbonic  oxide ;  gases  of  the  nitrogen  group,  as  the  acetate,  sulphide, 
and  carbonate  of  ammonium,  nitrous  and  nitric  acids;  and  at  times  com- 
pounds of  phosphorus  and  chlorine  (Parkes).  A  theory  deserving  consider- 
ation is  that  certain  gaseous  impurities  found  in  the  air  form  purgative  com- 
binations. J).  F.  Lincoln,  in  his  interesting  paper  on  the  atmosphere,  in  the 
Cydopsedia  of  3Iedicine,  writes  in  regard  to  sulphuretted  hydrogen :  '•  When 
in  the  air,  freely  exposed  to  the  contact  of  oxygen,  it  becomes  sulphuric  acid. 
Sulphide  of  ammonium  in  the  same  circumstances  becomes  a  sulphate,  which, 
encountering  common  salt  (chloride  of  sodium),  produces  sulphate  of  sodium 
and  chloride  of  ammonium.  The  sulphates  form  a  characteristic  ingredient 
of  the  air  in  manufacturing  districts."  The  sulphates,  we  know,  are  for  the 
most  part  purgatives,  but  whether  they  or  other  chemical  agents  exist  in  the 
respired  air  in  sufficient  quantity  to  disturb  the  action  of  the  intestines, 
even  where  atmospheric  impurities  are  most  abundant,  is  problematical  and 
uncertain. 

Again,  the  solid  impurities  in  the  air  of  a  large  city  are  very  numerous, 
as  any  one  may  observe  by  viewing  in  a  darkened  room  a  sunbeam  which  is 
made  visible  by  the  numerous  particles  floating  in  it.  These  particles  consist 
largely  of  organic  matter,  which  sometimes  has  been  carried  a  long  distance 
by  the  wind.  The  remarkable  statement  has  been  made  that  in  the  air  of 
Berlin  organic  forms  have  been  found  of  African  production.  Ehrenberg 
discovered  fragments  of  insects  of  various  kinds — rhizopods,  tardigrades, 
polygastrics,  etc. — which,  existing  in  considerable  quantity  and  inhaled  in 
hot  weather  when  decomposition  and  fermentation  are  most  active,  may  be 
deleterious  to  the  system.  Monads,  bacteria,  vibriones,  amorphous  dust  con- 
taining spores  which  retain  their  vitality  for  months,  are  among  the  substances 
found  in  the  air  of  cities.  The  well-known  hazy  appeai'ance,  when  viewed  from 
a  distance,  of  the  atmosphere  resting  over  a  large  city  like  New  York  is  due 
to  the  gaseous  and  solid  impurities  with  which  the  air  is  so  abundantly  sup- 
plied— impurities  which  assume  importance  in  pathological  studies,  since 
minute  organisms  are  now  believed  to  cause  so  many  diseases  the  etiology  of 
which  has  heretofore  been  obscure.  There  can  be  no  reasonable  doubt,  from 
recent  investigations,  that  the  deleterious  agents  which  cause  the  form  of 
diarrhoea  which  we  are  considering  are  to  a  great  extent  bacteria,  which  find  a 
soil  most  favorable  for  their  propagation  where  the  air  as  well  as  ingesta  con- 
tains impurities.  In  foul  air,  as  in  the  summer  season  in  the  crowded  parts 
of  the  city,  and  especially  where  decomposing  animal  and  vegetable  matter 
exists,  the  number  of  micro-organisms  is  vastly  greater,  as  diflferent  observers 
have  remarked,  than  in  salubrious  localities.     Foul  air  and  unwholesome  food 


734  LOCAL  DISEASES. 

— food  that  has  begun  to  undergo  decomposition  or  that  digests  with  diiBeulty, 
so  that  part  of  it  ferments — aiford  the  conditions  which  are  eminently  favor- 
able for  the  development  of  pathogenic  as  well  as  non-pathogenic  germs.  We 
have  seen  that  Booker  and  Vaughn  have  found  bacteria  in  diarrhceal  stools 
which  when  isolated  by  cultivation  either  kill  the  animals  experimented  on 
or  cause  intestinal  catarrh  in  them,  or  the  toxins  produced  by  the  bacteria 
have  this  effect.  The  evidence,  therefore,  is  strong  that  bacteria  are  the 
chief  causal  agents  of  those  forms  of  diarrhoea  which  originate  from  foul 
air  and  unwholesome  and  indigestible  food. 

In  those  portions  of  our  cities  which  are  occupied  by  the  poor  more  than 
anywhere  else  those  conditions  prevail  which  render  the  atmosphere  foul  and 
unwholesome.  One  accustomed  to  the  pure  air  of  the  country  would  scarcely 
believe  how  stifling  and  poisonous  the  atmosphere  becomes  during  the  hot 
summer  days  and  close  summer  nights  in  and  around  the  domiciles  in  the 
poor  quarters  of  the  city.  Among  the  causes  of  this  foul  air  may  be  men- 
tioned too  dense  a  population,  the  occupancy  of  small  rooms  by  large  families, 
rigid  economy,  and  ceaseless  endeavor  to  make  ends  meet,  so  that  in  the 
absorbing  interest  sanitary  requirements  are  sadly  neglected.  Adults  of  such 
families,  and  children  of  both  sexes  as  soon  as  they  are  old  enough,  engage 
in  laborious  and  often  filthy  occupations.  Many  of  them  seldom  bathe,  and 
they  often  wear  for  days  the  same  under-garments,  foul  with  perspiration  and 
dirt.  The  intemperate,  vicious,  and  indolent,  who  always  abound  in  the  quar- 
ters of  the  city  poor,  are  notoriously  filthy  in  their  habits  and  add  to  the  insa- 
lubrity by  their  presence.  Children  old  enough  to  be  in  the  streets  and  adults 
away  at  their  occupations  escape  to  a  great  extent  the  evil  eff'ects  of  impure 
air,  but  the  infantile  population  always  suffers  severely. 

Every  physician  who  has  witnessed  the  summer  diarrhoea  of  infants  is 
aware  of  the  fact  that  the  mode  of  feeding  has  much  to  do  with  its  occur- 
rence. A  large  proportion  of  those  who  each  summer  fall  victims  to  it 
would  doubtless  escape  if  the  feeding  were  exactly  proper.  In  New  York 
City  facts  like  the  following  are  of  common  occurrence  in  the  practice  of  all 
physicians :  Infants  under  the  age  of  eight  months,  if  bottle-fed,  nearly 
always  contract  diarrhoea,  and  usually  of  an  obstinate  character,  during  the 
summer  months.  The  younger  the  infant,  the  less  able  is  it  to  digest  any 
other  food  than  breast-milk,  and  the  more  liable  is  it  therefore  to  suffer  from 
diarrhcea  if  bottle-fed.  In  the  institutions  nearly  every  bottle-fed  infant 
under  the  age  of  four  or  even  six  months  suffers  in  the  hot  months  from  symp- 
toms of  indigestion  and  intestinal  catarrh,  while  the  wet-nursed  of  the  same 
ages  remain  well.  Sudden  weaning,  the  sudden  substitution  of  cow's  milk 
or  an  artificially  prepared  food  in  place  of  breast-milk  in  hot  weather,  almost 
always  produces  diarrhoea,  often  of  a  severe  and  fatal  nature.  Feeding  an 
infant  in  the  hot  months  with  indigestible  and  improper  food,  as  fruits  with 
seeds  or  the  ordinary  table  food  prepared  in  such  a  way  that  it  overtaxes  the 
digestive  function  of  the  infant,  causes  diarrhoea,  and  sometimes  that  severe 
form  of  it  which  will  be  described  under  the  term  cholera  infantum.  Many 
obstinate  cases  of  the  summer  complaint  begin  to  improve  under  change  of 
diet,  as  by  the  substitution  of  one  kind  of  milk  for  another  or  the  return  of 
the  infant  to  the  breast  after  it  has  been  temporarily  withdrawn  from  it.  It 
is  a  common  remark  in  the  families  of  the  city  poor  that  the  second  summer 
is  the  period  of  greatest  danger  to  infants.  This  increased  liability  of  infants 
to  contract  diarrhoea  in  the  second  summer  is  due  to  tbe  fact  that  most  infants 
in  their  second  year  are  table-fed,  while  in  the  first  year  they  are  wet-nursed. 
Such  facts,  with  which  all  physicians  are  familiar,  show  how  important  the 
diet  is  as  a  factor  in  causing  indigestion  and  diarrhoea. 

Occasionally,  from  continued  ill-health,  the  milk  of  the  mother  or  wet- 


INTESTINAL   CATARRH  OF  INFANCY.  735 

nurse  does  not  agree  with  the  nursling.  Examined  with  the  microscope, 
it  is  found  to  contain  colostrum.  Under  such  circumstances  if  a  healthy 
wet-nurse  be  employed  the  diarrhoea  ceases.  It  is  very  important  that  any 
woman  furnishing  breast-milk  to  an  infant  should  lead  a  quiet  and  regular 
life,  with  regular  meals  and  sleep.  K.  B.  Grilbert  ^  relates  striking  cases  in 
which  venereal  excesses  on  the  part  of  wet-nurses  were  immediately  followed 
by  fatal  diarrhoea  in  the  infants  whom  they  suckled. 

One  not  a  resident  would  scarcely  be  able  to  appreciate  the  difficulty 
which  is  experienced  in  a  large  city  in  obtaining  proper  diet  for  young  chil- 
dren, especially  those  of  such  an  age  that  they  require  milk  as  the  basis  of 
their  food.  Milk  from  cows  stabled  in  the  city  or  having  a  limited  pastur- 
age near  the  city,  and  fed  upon  a  mixture  of  hay  with  garden  and  distillery 
products,  the  latter  often  largely  predominating,  is  unsuitable.  It  is  defici- 
ent in  nutritive  properties,  prone  to  fermentation,  and  from  microscopical  and 
chemical  examinations  which  have  been  made  it  appears  that  it  often  con- 
tains deleterious  ingredients.  If  milk  be  obtained  from  distant  farms,  where 
pasturage  is  fresh  and  abundant — and  in  New  York  City  this  is  the  usual 
source  of  the  supply — considerable  time  elapses  before  it  is  served  to  cus- 
tomers, so  that,  particularly  in  the  hot  months  of  July  and  August,  it  fre- 
quently has  begun  to  undergo  lactic-acid  fermentation  when  the  infants 
receive  it.  That  dispensed  to  families  in  the  morning  is  the  milking  of  the 
previous  morning  and  evening.  The  use  of  this  milk  in  midsummer  by 
infants  under  the  age  of  ten  months  frequently  gives  rise  to  more  or  less 
diarrhoea. 

The  ill-success  of  feeding  with  cow's  milk  has  led  to  the  pi'eparation  of 
various  kinds  of  food  which  the  shops  contain,  but  no  dietetic  preparation 
has  yet  appeared  which  agrees  so  well  with  the  digestive  function  of  the 
infant,  and  is  at  the  same  time  sufficiently  nutritive,  as  the  breast-milk  of 
healthy  mothers  or  wet-nurses. 

In  New  York  City  improper  diet,  unaided  by  the  conditions  which  hot 
weather  produces,  is  a  common  cause  of  diarrhoea  in  young  infants,  for  at  all 
seasons  we  meet  with  this  diarrhoea  in  infants  who  are  bottle-fed ;  but  when 
the  atmospheric  conditions  of  hot  weather  and  the  use  of  food  unsuitable  for 
the  age  of  the  infant  are  both  present  and  operative,  this  diarrhoea  so  increases 
in  frequency  and  severity  that  it  is  proper  to  designate  it  the  summer  epidemic 
of  the  cities.  Several  years  since,  before  the  New  York  Foundling  Asylum 
was  established,  the  foundlings  of  New  York,  more  than  a  thousand  annually, 
were  taken  to  the  almshouse  on  Blackwell's  Island  and  consigned  to  the  care 
of  pauper-women,  who  were  mostly  old,  infirm,  and  filthy  in  their  habits  and 
apparel.  Their  beds,  in  which  the  foundlings  were  also  placed  alongside  of 
them,  were  seldom  clean,  not  properly  aired  and  washed,  and  under  the  beds 
were  various  garments  and  utensils  which  these  pauper-women  had  brought 
with  them  as  their  sole  property  from  their  miserable  abodes  in  the  city. 
With  such  surroundings  the  air  which  these  infants  breathed  day  and  night 
manifestly  contained  poisonous  emanations,  while  their  diet  was  equally 
improper,  for  it  was  prepared  by  these  women  from  such  milk  and  farinaceous 
food  as  were  furnished  to  the  almshouse.  When  assigned  to  duty  in  the  alms- 
house, this  service  being  at  that  time  a  branch  of  Charity  Hospital,  I  was 
informed  that  all  the  foundlings  died  before  the  age  of  two  months  ;  one  only 
was  pointed  out  as  a  curiosity  which  had  been  an  exception  to  the  rule.  The 
disease  of  which  they  perished  was  diarrhoea,  and  this  malady  in  the  summer 
months  was  especially  severe  and  rapidly  fatal.  The  unpleasant  experiences 
in  this  institution  furnished  additional  evidence,  were  any  wanting,  that  foul 
air  and  improper  diet  are  the  two  important  factors  in  causing  the  summer 
^  Louisville  Med.  Journal,  Aug.  19,  1882. 


736  LOCAL  DISEASES. 

diarrhoea  of  infants.  Since  tliat  beneficent  charity,  the  New  York  Foundling 
Asylum,  in  East  Sixty-eighth  street,  came  into  existence,  providing  pure  air 
and,  for  a  considerable  proportion  of  the  foundlings,  breast-milk,  many  of 
these  waifs  have  been  rescued  from  death. 

Affe. — Age  is  a  predisposing  cause  of  intestinal  catarrh,  since  most  cases 
occur  under  the  age  of  three  years.  A  large  majority  of  the  summer  diar- 
rhoeas of  the  cities  occur  under  the  age  of  two  years.  The  following  table 
embraces  all  the  cases  that  came  to  one  of  the  city  dispensaries  during  my 
service  between  the  months  of  May  and  October,  inclusive : 

Age.  Cases. 

5  months  or  under 58 

5  months  to  12  months 212 

12  months  to  18  months 174 

18  months  to  24  months 9.3 

24  months  to  36  months 36 

Total      573 

Dentition. — Statistics  show  that  by  far  the  largest  number  of  cases  occur 
during  the  period  of  first  dentition ;  hence  the  prevalent  opinion  among  fam- 
ilies that  dentition  causes  the  diarrhoea.  It  is  the  common  belief  among  the 
poor  of  New  York  that  diarrhoea  occurring  during  dentition  is  conservative, 
and  should  not  be  checked.  They  believe  that  an  infant  cutting  its  teeth  suf- 
fers less,  and  may  be  saved  from  serious  illness,  if  it  have  frequent  stools. 
Every  summer  I  see  infants  reduced  to  a  state  of  imminent  danger  through- 
the  continuance  of  diarrhoea  during  several  weeks,  nothing  having  been  done 
to  check  it  in  consequence  of  this  absurd  belief.  The  progressive  loss  of  flesh 
and  strength  and  wasting  of  the  features  do  not  excite  alarm,  under  the  blind- 
ing influence  of  this  theory,  till  the  diarrhoea  has  continued  so  long  and 
become  so  severe  that  it  is  with  difiieulty  controlled,  and  the  patient  is  in  a 
state  of  real  danger  when  the  physician  is  flrst  summoned.  The  following 
statistics,  which  comprise  cases  occurring  during  my  service  in  one  of  the 
city  dispensaries,  show  the  preponderance  of  cases  during  the  age  when  dental 
evolution  is  occurring : 

Cases. 

Xo  teeth  and  no  marked  turgescence  of  gums 47 

Cutting  incisors 106 

Cutting  anterior  molars      41 

Cutting  canines 40 

Cutting  last  molars , 20 

All  the  teeth  cut 28 

Total 282 

It  so  happens  that  the  period  of  dental  evolution  corresponds  with  that  of 
the  most  rapid  development  and  the  greatest  functional  activity  of  the  gastric 
and  intestinal  follicles,  and  the  predisposition  which  exists  to  diarrhoeal  mala- 
dies at  this  age  must  be  attributed  to  this  cause  rather  than  to  dentition. 

Symptoms. — The  intestinal  catarrh  of  infancy  commonly  begins  gradually 
with  languor,  fretfulness,  and  slight  rise  of  temperature.  The  diarrhoea  at 
first  usually  attracts  little  attention  from  its  mildness.  The  stools,  while  they 
are  thinner  than  natural,  vary  in  appearance,  being  yellow,  brown,  or  green. 
Infants  with  milk  diet  usually  pass  green  and  acid  stools  containing  particles 
of  undigested  casein.  The  tongue  in  the  commencement  of  the  attack  is  moist 
and  covered  with  a  slight  fur.  At  a  more  advanced  stage  it  may  be  moist, 
but  is  often  dry,  and  in  dangerous  forms  of  the  malady,  accompanied  by  pros- 
tration, the  buccal  surface  is  red  and  the  sums  more  or  less  swollen  and  some- 


INTESTINAL   CATARRH  OF  INFANCY.  737 

times  ulcerated.  Vomiting  is  common.  It  may  commence  simultaneously 
with  the  diarrhoea,  especially  when  food  that  is  indigestible  and  irritating  to 
the  stomach  has  been  given,  but  more  frequently  this  symptom  does  not 
appear  until  the  diarrhoea  has  continued  a  few  days.  I  preserved  memoranda 
of  the  date  when  vomiting  began  in  the  cases  treated  in  two  consecutive 
years,  and  found  that  ordinarily  it  was  toward  the  close  of  the  first  week. 
When  it  is  an  early  and  prominent  symptom  it  appears  to  be  due  to  the 
presence  iu  the  stomach  of  imperfectly  digested  or  fermented  and  acid  food, 
which,  when  ejected,  gives  a  decidedly  acid  reaction  with  appropriate  tests. 
It  contains  coagulated  casein  and  undigested  particles  of  whatever  food  has 
been  given.  In  many  patients  the  progressive  loss  of  flesh  and  strength  is 
largely  due  to  the  indigestion  and  vomiting,  by  which  the  food,  which  is  so 
much  required  for  proper  nourishment,  is  lost. 

Emesis  occurring  at  a  late  stage  of  infantile  diarrhoea  is  often  due  to 
commencing  spurious  hydrocephalus,  which  is  not  an  infrequent  complica- 
tion, as  we  will  see,  of  protracted  cases.  Perhaps  when  a  late  symptom  it 
may  sometimes  have  an  uraemic  origin,  for  the  urine  is  usually  quite  scanty 
in  advanced  cases.  It  seems  probable,  however,  that  deleterious  effects 
from  non-elimination  of  urea  are  to  a  considerable  extent  prevented  by  the 
diarrhoea. 

The  fecal  evacuations  may  remain  nearly  uniform  in  appearance  during 
the  disease,  but  in  many  patients  they  vary  in  color  and  consistence  at  differ- 
ent periods.  In  the  same  case  they  may  be  brown  and  offensive  at  one  time, 
green  at  another,  and  again  they  may  contain  masses  of  a  putty-like  appear- 
ance, the  partly-digested  casein  or  altered  epithelial  cells.  The  stools  some- 
times consist  largely  of  mucus,  with  or  without  occasional  streaks  of  blood, 
indicating  the  predominance  of  inflammation  in  the  colon.  The  stools  are 
sometimes  yellow  when  passed,  but  become  green  on  exposure  to  the  air 
from  chemical  reaction  due  to  admixture  with  the  urine  or  to  the  agency  of 
the  microbe  mentioned  above  that  produces  green  coloring  matter. 

The  character  of  the  alvine  discharges  is  interesting.  In  addition  to 
undigested  casein  I  have  found  epithelial  cells,  single  or  in  clusters  (some- 
times regularly  arranged  as  if  detached  in  mass  from  the  villi),  fibres  of 
meat,  crystalline  formations,  mucus,  and  occasionally  blood,  as  stated  above. 
In  one  instance  I  observed  an  appearance  resembling  three  or  four  crypts  of 
Lieberkiihn  united,  probably  thrown  off  by  ulceration.  If  the  stools  are 
green,  colored  masses  of  various  sizes,  but  mostly  small,  are  also  seen  under 
the  microscope. 

The  pulse  is  accelerated  according  to  the  severity  of  the  attack.  The 
heat  of  the  surface  is  at  first  generally  increased,  though  but  slightly  in 
ordinary  cases ;  but  when  the  vital  powers  begin  to  fail  from  the  continuance 
of  the  diarrhoea,  the  warmth  of  the  surface  diminishes.  In  advanced  cases 
approaching  a  fatal  termination  the  face  and  extremities  are  pallid  and  cool, 
and  the  pulse  gradually  becomes  more  frequent  and  feeble.  The  skin  is 
usually  dry,  and,  as  already  stated,  the  urinary  secretion  diminished.  In 
severe  cases  attended  by  frequent  alvine  discharges  the  infant  does  not  pass 
urine  oftener  than  once  or  twice  daily.  The  imperfect  action  of  the  skin 
and  kidneys  is  noteworthy. 

Protracted  cases  of  diarrhoea  are  frequently  complicated  by  two  cuta- 
neous eruptions — erythema  extending  over  the  perineum  and  frequently  as 
far  as  the  thighs  and  lower  part  of  the  abdomen,  due  to  the  acid  and  irritat- 
ing character  of  the  stools ;  and  boils  upon  the  forehead  and  scalp.  The 
latter  sometimes  extend  to  the  pericranium,  and  in  case  of  recovery  leave 
permanent  cicatrices.  This  furuncular  affection  of  the  scalp  has  seemed  to 
me  useful  in  consequence  of  the  external  irritation  which  it  causes,  since  it 
47 


738  LOCAL  DISEASES. 

occurs  at  a  time  when,  on  account  of  tlie  feeble  heart's  action  and  languid 
circulation,  passive  congestion  of  the  vessels  of  the  brain  and  meninges  is 
liable  to  be  present. 

Patients  who  are  weak  and  wasted  in  consequence  of  protracted  diarrhoea, 
remaining  almost  constantly  in  the  recumbent  position,  often  have  an  occa- 
sional dry  cough  which  continues  till  the  close  of  life.  It  is  due  to  hypo- 
static congestion  in  the  lungs,  usually  limited  to  the  posterior  and  inferior 
portions  of  the  lobes,  extending  but  a  little  way  into  the  lungs.  It  is  the 
result  of  prolonged  recumbency  with  feeble  heart's  action  and  feeble  pulmo- 
nary circulation.  Infants  reduced  by  chronic  diseases,  lying  day  after  day 
in  their  cribs,  with  little  movement  of  their  bodies,  are  very  liable  to  this 
passive  congestion  of  depending  portions  of  their  lungs,  toward  which  the 
blood  gravitates,  and  into  which  but  little  air  enters  in  consequence  of  their 
distance  and  position  and  the  feeble  respirations.  The  hypersemia  which 
results  is  of  a  passive  character,  a  venous  congestion,  and  the  aifected  lobules 
have  a  dusky-red  color.  This  congestion,  continuing,  soon  results  in  pneu- 
monia of  the  catarrhal  form,  subacute  and  of  a  low  grade,  for  pulmonary 
lobules  in  which  the  blood  remains  stagnant  soon  exhibit  augmented  cell- 
proliferation,  perhaps  from  the  irritating  eifects  of  the  elements  of  the  blood 
now  withdrawn  from  the  circulation.  j 

I  have  made  or  procured  a  considerable  number  of  microscopic  examina- 
tions in  these  cases  of  hypostatic  pneumonia,  and  the  solidification  of  the 
pulmonary  lobules  has  been  found  to  be  due  to  the  exaggerated  development 
of  the  epithelial  cells  in  the  alveoli,  together  with  venous  congestion.  The 
affected  lobules,  whether  in  a  stage  of  hypostatic  congestion  or  the  more 
advanced  stage  of  hypostatic  pneumonia,  when  examined  at  the  autopsy 
were  somewhat  softer  than  in  health,  of  dark  color,  and  many  of  the  lobules 
could  be  inflated  by  strong  force  of  the  breath  ;  but  in  protracted  cases  the 
alveoli  in  central  parts  of  the  inflamed  area  resisted  insufiiation.  The  lung 
in  hypostatic  pneumonia,  even  when  it  is  inflated,  still  feels  firmer  between 
the  fingers  than  the  normal  lung. 

Hypostatic  pneumonia  is  so  common  in  hospitals  for  infants  that  some 
physicians  whose  observations  have  been  chiefly  in  such  institutions  have 
almost  ignored  other  forms  of  pulmonary  inflammation.     Billard  many  years 

ago   wrote :  " The  pneumonia   of   young  children  is   evidently  the 

result  of  stagnation  of  blood  in  their  lungs.  Under  these  circumstances  the 
blood  may  be  regarded  as  a  kind  of  foreign  body."  Of  all  the  chronic  and 
exhausting  diseases  of  infancy,  no  one  has,  according  to  my  observations, 
been  so  frequently  complicated  by  hypostatic  pneumonia  as  the  disease  which 
we  are  considering,  although  it  does  not  usually  give  rise  to  any  more  promi- 
nent symptom  than  an  occasional  cough.  Limited  to  a  small  and  almost 
immovable  part  of  the  lung,  it  does  not  ordinarily  accelerate  respiration  or 
render  it  painful,  and  the  cough  is  also  apparently  painless. 

When  the  progressive  loss  of  flesh  and  strength  has  continued  several 
weeks  and  the  patient  is  much  exhausted,  another  complication  is  liable  to 
occur,  known  as  spurious  hydrocephalus  or  the  hydrocephaloid  disease,  the 
anatomical  characters  of  which  will  be  described  in  the  proper  place.  The 
commencement  of  spurious  hydrocephalus  is  announced  by  gradually  in- 
creasing drowsiness,  perhaps  preceded  by  a  period  of  fretfulness.  Vomiting 
and  rolling  the  head  are  occasional  early  symptoms  of  this  complication.  As 
the  drowsiness  increases  the  pupils  become  less  sensitive  to  light  than  in 
their  normal  state,  and  are  usually  contracted.  When  the  drowsiness  becomes 
profound  and  constant  the  pupils  remain  contracted  as  in  sound  sleep  or  in 
opium  narcotism.  The  functional  activity  of  the  organs  is  now  also  dimin- 
ished, the  vomiting  ceases,  the  stools   become  less  frequent,  the  buccal  sur- 


INTESTINAL   CATARRH  OF  INFANCY.  739 

face  dry,  and  the  urine  scanty,  while  the  pulse  is  frequent  and  feeble. 
Spurious  hydrocephalus  either  continues  till  death  or  by  stimulation  the 
patient  may  emerge  from  it.     When  profound  the  usual  result  is  death. 

Although  infantile  diarrhoea  in  its  commencement  may  be  promptly 
arrested  by  proper  hygienic  and  medicinal  treatment,  if  it  continue  a  few 
weeks  the  anatomical  changes  which  occur  are  such  that  recovery,  if  it  take 
place,  is  necessarily  slow  and  gradual.  Improvement  is  shown  by  better 
digestion,  stools  fewer  and  of  better  appearance,  less  frequent  vomiting,  a 
more  cheerful  countenance,  and  the  absence  of  symptoms  which  indicate  a 
complication.  Many  recover  after  days  of  anxious  watching  and  perhaps 
after  many  fluctuations. 

Death  may  occur  early  from  a  sudden  aggravation  of  symptoms  and  rapid 
sinking,  or  the  attack  may  be  so  violent  from  the  first  that  the  infant  quickly 
succumbs  ;  but  more  frequently  death  takes  place  after  a  prolonged  sickness. 
Little  by  little  the  patient  loses  flesh  and  strength  till  a  state  of  marked 
emaciation  is  reached.  The  eyes  and  cheeks  are  sunken,  the  bony  projections 
of  the  face,  trunk,  and  limbs  become  prominent,  and  the  skin  lies  in  wrinkles 
from  the  wasting.  The  altered  expression  of  the  face  makes  the  patient 
look  older  than  the  actual  age.  The  joints  in  contrast  with  the  wasted 
extremities  seem  enlarged  and  the  fingers  and  toes  elongated.  The  stools 
diminish  in  frequency  from  diminished  peristaltic  and  vermicular  action,  and 
vomiting,  if  previously  present,  now  ceases.  A  feeble,  quick,  and  scarcely 
appreciable  pulse,  slow  respiration,  and  diminished  inflation  of  the  lungs, 
sightless  and  contracted  pupils,  over  which  the  eyelids  no  longer  close, 
announce  the  near  approach  of  death.  The  drowsiness  increases  and  the 
limbs  become  cool,  while  perhaps  the  head  is  hot.  The  infant  no  longer  has 
the  ability  to  suckle,  or  if  bottle-fed  the  food  placed  in  the  mouth  flows  back 
or  is  swallowed  with  apparent  indiff"erence.  So  low  is  its  vitality  that  it  lies 
pallid  and  almost  motionless  for  hours  or  even  days  before  death,  and  death 
occurs  so  quietly  that  the  moment  of  its  occurrence  is  scarcely  appreciable. 

Anatomical  Characters. — Since  the  prominent  and  essential  symptoms 
of  the  disease  which  we  are  considering  pertain  to  the  digestive  a25paratus, 
it  is  evident  that  the  lesions  which  attend  and  characterize  it  are  to  be  found 
in  this  part  of  the  system.  Lesions  elsewhere,  so  far  as  they  are  appreciable 
to  us,  are  secondary  and  not  essential.  I  have  witnessed  a  large  number 
of  autopsies  of  infants  who  have  perished  from  diarrhoea,  chiefly  in  institu- 
tions, and  they  have  been  sufficiently  mai'ked  and  uniform  to  enable  us  to 
designate  it  an  entero-colitis.  Several  years  since  I  preserved  records  of  the 
autopsical  appearances  in  the  intestinal  catarrh  of  infants,  most  of  them  being 
cases  of  summer  diarrhoea.  The  number  aggregated  eighty-two.  Since  then 
I  have  witnessed  many  autopsies  in  institutions  in  cases  of  this  disease,  and 
the  lesions  observed  were  similar  to  those  in  the  eighty-two  cases. 

The  question  may  properly  be  asked.  Can  inflammatory  hyperasmia  of  the 
intestinal  mucous  membrane  be  distinguished  from  simple  congestion  if  there 
be  no  ulceration  and  no  appreciable  thickening  of  the  intestine  ?  It  is  pos- 
sible that  occasionally  I  have  recorded  as  inflammatory  what  was  simply  a 
congestive  lesion,  but  I  do  not  think  I  have  incorporated  a  sufficient  number 
of  such  cases  to  vitiate  the  statistics.  In  a  large  proportion  of  the  cases  there 
was  evident  thickening  of  the  intestinal  mucous  membrane  or  other  unequivocal 
evidence  of  inflammation.  The  following  is  an  analysis  of  the  82  cases  :  The 
duodenum  and  jejunum  presented  the  appearance  of  inflammatory  hyperasmia 
in  12  cases :  the  hyperasmia  was  usually  in  patches  of  variable  extent  or  of 
that  form  described  by  the  term  arborescent.  In  51  cases  the  duodenal  and 
jejunal  mucous  membrane  was  pale  and  without  any  other  appearance 
characteristic   of   catarrh  or  inflammation.     In  the  remaininsj  19  cases  the 


740  LOCAL  DISEASES. 

appearance  of  the  duodenum  and  jejunum  was  not  recorded,  so  that  it  was 
probably  normal :  on  the  other  hand,  in  the  ileum  inflammatory  lesions 
were  present  as  a  rule.  In  49  cases  I  found  the  surface  of  the  ileum  dis- 
tinctly hypertemic,  and  in  that  portion  of  it  nearest  the  ileo-ctecal  valve, 
including  the  valve  itself,  the  inflammation  had  evidently  been  the  most 
intense,  since  in  this  portion  the  hyperasmia  and  thickening  of  the  mucous 
membrane  were  most  marked.  In  16  cases  the  surface  of  the  ileum  appeared 
nearly  or  quite  normal ;  in  14  hyperaemia  in  the  small  intestines  in  patches, 
streaks,  or  arborescence  was  recorded,  but  the  records  do  not  state  in  which 
division  of  the  intestines  they  were  observed. 

Billard.  with  other  observers,  has  noticed  the  frequency  and  intensity 
of  the  inflammatory  lesions  in  entero-colitis  in  the  terminal  portion  of  the 
small  intestines,  and  thickening,  in  many  cases,  of  the  ileo-ceecal  valve,  and  he 
asks  whether  the  vomiting  which  is  so  common  and  often  obstinate  in  this 
disease  may  not  be  sometimes  due  to  obstruction  to  the  passage  of  fecal 
matter  at  the  valve  in  consequence  of  its  hypertemia  and  swelling;  but  he 
has  not  observed  any  retained  fecal  matter  above  it,  such  as  we  find  in  any 
part  of  the  colon,  or  any  other  appearance  which  indicated  sufiicient  obstruc- 
tion to  cause  symptoms.  But  it  seems  not  improbable  that  the  reason  why 
the  inflammatory  lesions  are  more  pronounced  at  and  immediately  above  the 
valve  than  in  other  parts  of  the  small  intestine  is  that  the  fecal  matter,  so 
commonly  acid  and  irritating  in  this  disease,  is  somewhat  delayed  in  its 
passage  downward  at  this  point. 

Small  superficial  circular  or  oval  ulcers  were  observed  in  the  ileum  in 
4  ca^es,  in  2  of  which  they  were  found  also  in  the  lower  part  of  the  jejunum. 
In  1  case  the  records  state  that  ulcers  were  in  the  jejunum,  but  do  not  men- 
tion whether  they  were  also  in  the  ileum.  In  1  case,  in  which  there  was  much 
thickening  of  the  ileum  next  to  the  ileo-ca3cal  valve,  many  small  granulations 
had  sprouted  up  from  the  submucous  connective  tissue,  so  that  the  mucous 
surface  appeared  as  if  studded  with  small  warts. 

Softening  of  the  mucous  membrane  was  also  apparent  in  certain  cases. 
The  firmness  of  its  attachment  to  the  parts  underneath  varied  considerably 
in  diff"erent  specimens.  I  was  able  in  cases  in  which  there  was  considerable 
softening  to  detach  readily  the  mucous  membrane  with  the  nail  or  handle 
of  the  scalpel  within  so  short  a  period  after  death  that  it  was  probable  that 
the  change  of  consistence  was  cadaveric.  In  some  cases  the  vessels  of  the 
submucous  tissue  were  injected  and  this  tissue  infiltrated. 

In  all  the  cases,  except  one,  lesions  were  present  indicating  inflammation 
of  the  mucous  membrane  of  the  colon.  In  .39  hyperaemia,  thickening,  and 
other  signs  of  inflammation  extended  over  nearly  or  quite  the  entire  colon  ; 
in  14  the  colitis  was  confined  to  the  descending  portion  entirely  or  almost 
entirely ;  in  28  cases  the  records  state  that  inflammatory  lesions  were  found 
in  the  colon,  but  their  exact  location  is  not  mentioned.  In  18  of  the  autopsies 
the  mucous  membrane  of  the  colon  was  found  ulcerated. 

Therefore,  according  to  these  statistics — and  autopsies  which  I  have  wit- 
nessed that  are  not  embraced  in  them  disclosed  similar  lesions— colitis  is 
present,  almost  without  exception,  in  eases  of  summer  diarrhoea,  associated 
with  more  or  less  ileitis.  The  portion  of  the  colon  which  presents  the  most 
marked  inflammatory  lesions  is  that  in  and  immediately  above  the  sigmoid 
flexure — that  portion,  therefore,  in  which  any  fermenting  fecal  matter  has 
reached  its  greatest  degree  of  fermentation,  and  consequently  contains  the 
most  irritating  elements,  and  where,  next  to  the  caput  coli,  it  is  longest 
delayed  in  its  passage  downward. 

The  solitary  glands  of  both  the  large  and  small  intestines  and  Peyer's 
patches  undergo  hyperplasia.     In  cases  of  short  duration  and  in  parts  of  the 


INTESTINAL   CATABBH  OF  INFANCY.  741 

intestine  where  the  inflammatory  action  has  been  mild,  the  solitary  glands 
present  a  vascular  appearance,  like  the  surrounding  membrane,  and  are 
slightly  enlarged.  The  enlargement  is  most  apparent  if  the  intestine  be 
viewed  by  transmitted  light,  when  not  only  are  the  glands  seen  to  be 
swollen,  but  their  central  dark  points  are  distinct.  If  a  higher  grade  of 
intestinal  catarrh  or  a  catarrh  more  protracted  have  occurred,  the  volume 
of  these  follicles  is  so  increased  that  they  rise  above  the  common  level  and 
present  a  papillary  appearance.  Peyer's  patches  are  also  distinct  and  punc- 
tate. The  enlargement  of  Peyer's  patches,  like  that  of  the  solitary  glands, 
is  due  to  hyperplasia,  the  elementary  cells  being  largely  increased  in  number. 

The  small  ulcers  which,  as  we  have  seen  from  the  above  statistics,  are 
present  in  a  certain  proportion  of  cases  in  the  mucous  membrane  of  the 
colon,  and  more  rarely  in  that  of  the  small  intestine  when  the  inflammation 
has  been  protracted  and  of  a  severe  type,  appear  to  occur  in  the  solitary 
glands  and  in  the  mucous  membrane  surrounding  them.  While  some  of 
these  glands  in  a  specimen  are  simply  tumefied,  others  are  slightly  ulcerated, 
and  others  still  nearly  or  quite  destroyed.  The  ulcers  are  usually  from  one 
to  three  lines  in  diameter,  circular  or  oval,  with  edges  slightly  raised  from 
infiltration.  Rarely,  I  have  seen  minute  coagula  of  blood  in  one  or  more 
ulcers,  and  I  have  also  observed  ulcers  which  have  evidently  been  larger  and 
have  partially  healed.  When  ulcers  are  present  they  commonly  occtir  in  the 
descending  colon,  or  if  occurring  elsewhere  they  are  most  abundant  in  this 
situation. 

According  to  my  observations,  these  ulcers  are  found  chiefly  in  infants 
over  the  age  of  six  months — during  the  time,  therefore,  when  there  is  great- 
est functional  activity  and  most  rapid  development  of  the  solitary  glands. 
Peyers  patches,  though  frequently  prominent  and  distinct,  have  not  been 
ulcerated  in  any  of  the  cases  observed  by  me. 

The  appendix  vermiformis  participates  in  the  catarrh  when  it  occurs  in 
the  caput  eoli,  its  mucous  membrane  being  hyperaemic  and  thickened.  In 
certain  rare  cases  the  inflammation  is  so  intense  that  a  thin  film  of  fibrin  is 
exuded  in  places  upon  the  surface  of  the  colon.  It  is  liable  to  be  overlooked 
or  washed  away  in  the  examination.  The  rectum  usually  presents  no  infiam- 
matory  lesions,  or  but  slight  lesions  in  comparison  with  those  in  the  colon. 
It  remains  of  the  normal  pale  color,  or  is  but  slightly  vascular  in  most 
patients,  even  when  there  is  almost  general  colitis.  Hence  the  infrequency 
of  tenesmus.  If  tenesmus  be  present,  probably  the  rectum  participates  in 
the  inflammation. 

As  might  be  expected  from  the  nattire  of  the  disease,  the  secretion  of 
mucus  from  the  inte.stinal  surface  is  augmented.  It  is  often  seen  forming  a 
layer  upon  the  intestinal  surface,  and  it  appears  in  the  stools  mixed  with  epi- 
thelial cells  and  sometimes  with  blood  and  pus. 

The  mesenteric  glands  in  cases  which  have  run  the  most  protracted  course 
and  ended  fatally  are  found  more  or  less  enlarged  from  hyperplasia.  They 
are  frequently  as  large  as  a  pea  or  larger,  and  of  a  light  color,  the  color  being 
due  not  only  to  the  hyperplasia,  but  in  part  to  the  anaemia.  Occasionally, 
when  patients  have  been  much  reduced  from  the  long  continuance  of  diar- 
rhoea, and  are  in  a  state  of  marked  cachexia  before  death,  we  find  certain  of 
these  glands  caseous. 

The  state  of  the  stomach  is  interesting,  since  indigestion  and  vomiting  are 
so  commonly  present.  I  have  records  of  the  appearance  of  this  organ  in  59 
cases,  in  42  of  which  it  seemed  normal,  having  the  usual  pale  color  and  ex- 
hibiting only  such  changes  as  occur  in  the  cadaver.  In  the  remaining  17 
cases  the  stomach  was  more  or  less  hyperjemic.  and  in  3  of  them  points  of 
ulceration  were  observed  in  the  mucous  membrane. 


742  LOCAL  DISEASES. 

All  physicians  familiar  with  this  disease  have  remarked  the  frequency  of 
stomatitis.  In  protracted  and  grave  cases  it  is  a  common  complication.  The 
buccal  surface  in  these  cases  is  more  vascular  than  natural,  and  if  the  vital 
powers  are  much  reduced  superficial  ulcerations  are  not  infrequent,  oftener 
upon  the  gums  than  elsewhere.  The  gums  are  frequently  spongy,  more  or 
less  swollen,  bleeding  readily  when  rubbed  or  pressed.  Thrush  is  a  com- 
mon complication  of  protracted  diarrhoea  in  infants  under  the  age  of  three  or 
four  months,  but  is  infrequent  in  older  infants.  Occurring  in  those  over  the 
age  of  six  or  eight  months,  it  has  an  unfavorable  prognostic  significance,  indi- 
cating a  form  of  diarrhoea  which  commonly  eventuates  in  death. 

The  belief  has  long  been  prevalent  in  the  past  that  the  liver  is  also  in 
fault.  The  green  color  of  the  stools  was  supposed  to  be  due  to  vitiated  bile. 
But  usually  in  the  post-mortem  examinations  which  I  have  made  I  have 
found  that  the  green  coloration  of  the  fecal  matter  did  not  appear  at  the 
point  where  the  bile  enters  the  intestines,  but  at  some  point  below  the  ductus 
communis  choledochus.  in  the  jejunum  or  ileum.  The  green  tinge,  at  first 
slight,  becomes  more  and  more  distinct  on  tracing  it  downward  in  the  intes- 
tine.    The  manner  in  which  it  is  produced  has  been  treated  of  elsewhere. 

1  have  notes  of  the  appearance  and  state  of  the  liver  in  32  fatal  cases. 
Nothing  could  be  seen  in  these  examinations  which  indicated  any  anatomical 
change  in  this  organ  that  could  be  attributed  to  the  diarrhoeal  malady.  The 
size  and  weight  of  the  liver  varied  considerably  in  infants  of  the  same  age, 
but  probably  there  was  no  greater  difference  than  usually  obtains  among 
glandular  organs  in  a  state  of  health.  The  following  was  the  weight  of  this 
organ  in  20  cases  : 

Age.  Weight.  '         Age.  Weight. 

4  weeks 5    ounces.  I  10  months 6f  ounces. 

2  months 3J       "  |  13       "  6         " 

2       "        3*       "  14       "  9         " 

4       "        5"       "  15       "  6 


5  "  6J 

5  "  9 

7  "  4* 

7  "  6" 

7  "  6i 

9  "  8 


15  "  7* 

15  "  9* 

16  "  6" 

19  "  U 

20  "  9i 

23  "  15 


In  none  of  these  cases  did  the  size,  weight,  or  appearance  of  this  organ  seem 
to  be  difi^erent  from  that  in  health  or  in  other  diseases,  except  in  one  in  which 
fatty  degeneration  had  occurred,  but  this  was  probably  due  to  tuberculo.sis, 
which  was  also  present.  In  most  of  these  cases  the  liver  was  examined 
microscopically,  and  the  only  noteworthy  appearance  observed  was  the 
variable  amount  of  oil-globules  in  the  hepatic  cells.  In  some  specimens  the 
oil-globules  were  in  excess,  in  others  deficient,  and  in  others  still  they  were 
more  abundant  in  one  part  of  the  organ  than  in  another.  Little  importance 
was  attached  to  these  differences  in  the  quantity  of  oily  matter. 

Hypostatic  congestion  of  the  posterior  portions  of  the  lungs,  ending  if  it 
continue  in  a  form  of  subacute  catarrhal  pneumonia  and  giving  rise  to  an 
occasional  painless  cough,  has  been  described  in  the  preceding  pages.  The 
character  of  the  cough  in  connection  with  the  wasting  might  excite  suspicions 
of  the  presence  of  tubercles  in  the  lungs ;  but  tubercles  are  rare  in  this  dls- 
ease,  and  when  present  I  should  suspect  a  strong  hereditary  predisposition. 
They  occurred  in  only  1  of  the  82  cases. 

The  state  of  the  eneephalon  in  those  patients  in  whom  spurious  hydro- 
cephalus occurs  is  interesting.  In  protracted  cases  of  diarrhoea  the  brain 
wastes  like  the  body  and  limbs.     In  the  young  infant,  in  whom  the  cranial 


INTESTINAL   CATARRH  OF  INFANCY.  743 

bones  are  still  ununited,  the  occipital  and  sometimes  the  frontal  bones  become 
depressed  and  overlapped  by  the  parietal,  the  depression  being  of  course  pro- 
portionate to  the  diminution  in  size  of  the  encephalon.  The  cranium  becomes 
quite  uneven.  In  other  children,  with  the  cranial  bones  consolidated,  serous 
effusion  occurs  according  to  the  degree  of  waste,  thus  preserving  the  size  of 
the  encephalon.  The  effusion  is  chiefly  external  to  the  brain,  lying  over  the 
convolutions  from  the  base  to  the  vertex.  Its  quantity  varies  from  one  or 
two  drachms  to  an  ounce  or  more.  Along  with  this  serous  effusion,  and  ante- 
dating it,  passive  congestion  of  the  cerebral  veins  and  sinuses  is  also  present. 
This  congestion  is  the  obvious  and  necessary  result  of  the  feebleness  of  the 
heart's  action  and  the  loss  of  brain-substance. 

Diagnosis. — In  the  adult  abdominal  tenderness  is  an  important  diag- 
nostic symptom  of  intestinal  catarrh,  but  in  the  infant  this  symptom  is  lack- 
ing or  is  not  in  general  appreciable,  so  that  it  does  not  aid  in  diagnosis. 
When  the  diagnosis  of  the  disease  is  established,  the  symptoms  do  not 
usually  indicate  what  part  of  the  intestinal  surface  is  chiefly  involved,  but 
it  may  be  assumed  that  it  is  the  lower  part  of  the  ileum  and  the  colon.  The 
presence  of  mucus  or  of  mucus  tinged  with  blood  in  the  stools  shows  the 
predominance  of  colitis. 

Prognosis. — Although  this  disease  largely  increases  the  death-rate  of 
young  children,  most  cases  can  be  cured  if  proper  hygienic  and  medicinal 
measures  be  early  applied.  It  is  obvious,  from  what  has  been  stated  in  the 
foregoing  pages,  that  cholera  infantum  is  the  form  of  this  malady  which 
involves  greatest  danger.  Except  in  such  cases  there  is  sufficient  forewarn- 
ing of  a  fatal  result,  for  if  death  occur  it  is  after  a  lingering  sickness,  with 
fluctuations  and  gradual  loss  of  flesh  and  strength.  Patients  often  recover 
from  a  state  of  great  prostration  and  emaciation,  provided  that  no  fatal  com- 
plications arise.  The  eyes  may  be  sunken,  the  skin  lie  in  folds  from  the 
wasting,  the  strength  may  be  so  exhausted  that  any  other  than  the  recumbent 
position  is  impossible,  and  yet  the  patient  may  recover  by  removal  to  the 
country,  by  change  of  weather,  or  by  the  use  of  better  diet  and  remedies. 
Therefore  an  absolutely  unfavorable  prognosis  should  not  be  made  except  in 
eases  that  are  complicated  or  that  border  on  collapse.  The  most  dangerous 
symptoms,  except  those  which  indicate  commencing  or  actual  collapse,  arise 
from  the  state  of  the  bi'ain.  Rolling  the  head,  squinting,  feeble  action  or 
permanent  contraction  of  the  pupils,  spasmodic  or  irregular  movements  of 
the  limbs,  indicate  the  near  approach  of  death,  as.  do  also  coldness  of  face 
and  extremities  and  inability  to  swallow.  It  is  obvious  also,  in  making  the 
prognosis  in  ordinary  cases,  that  we  should  consider  the  age  of  the  patient, 
and  if  the  diarrhoea  be  that  of  the  summer  season,  the  state  of  the  weather, 
the  time  in  the  summer,  whether  in  the  beginning  or  near  its  close,  and  the 
surroundings,  especially  in  reference  to  the  impurity  of  the  air,  as  well  as 
the  patient's  condition. 

Cholera  Infantum,  or  Choleriform  Diarrhoea. 

This  is  the  most  severe  form  of  infantile  diarrhoea.  It  receives  the  name 
which  designates  it  from  the  violence  of  its  symptoms,  which  closely  resemble 
those  of  Asiatic  cholera.  It  is,  however,  quite  distinct  from  that  disease. 
It  is  characterized  by  frequent  stools,  vomiting,  great  elevation  of  tempera- 
ture, and  rapid  and  great  emaciation  and  loss  of  strength.  It  commonly 
occurs  under  the  age  of  two  years.  It  sometimes  begins  abruptly,  the  pre- 
vious health  having  been  good ;  in  other  cases  it  is  preceded  by  the  ordinary 
form  of  diarrhoea.  The  stools  have  been  thinner  than  natural  and  somewhat 
more  frequent,  but  not  such  as  to  excite  alarm,  when  suddenly  they  become 


744  LOCAL  DISEASES. 

more  frequent  and  watery,  and  the  parents  are  surprised  and  frightened  by 
the  rapid  sinking  and  real  danger  of  the  infant. 

The  first  evacuations,  unless  there  have  been  previous  diarrhoea,  may 
contain  fecal  matter,  but  subsequently  they  are  so  thin  that  they  soak  into 
the  diaper  like  urine,  and  in  some  cases  they  scarcely  produce  more  of  a  stain 
than  does  this  secretion.  Their  odor  is  peculiar — not  fecal,  but  musty  and 
offensive  ;  occasionally  they  are  almost  odorless.  Commencing  simultaneously 
with  the  watery  evacuations  or  soon  after  is  another  symptom — irritability  of 
the  stomach,  which  increases  greatly  the  prostration  and  danger.  Whatever 
drinks  are  swallowed  by  the  infant  are  rejected  immediately  or  after  a  few 
moments,  or  retching  may  occur  without  vomiting.  The  appetite  is  lost  and 
the  thirst  is  intense.  Cold  water  is  taken  with  avidity,  and  if  the  infant 
nurse  it  eagerly  seizes  the  breast  in  order  to  relieve  the  thirst.  The  tongue 
is  moist  at  first,  and  clean  or  covered  with  a  light  fur,  pulse  accelerated,  res- 
piration either  natural  or  somewhat  increased  in  frequency,  and  the  surface 
warm,  but  its  temperature  is  speedily  reduced  in  severe  cases.  The  internal 
temperature  or  that  of  the  blood  is  always  very  high.  In  ordinary  cases  of 
cholera  infantum  the  thermometer  introduced  into  the  rectum  rises  to  or 
above  105°,  and  I  have  seen  it  indicate  107°.  Although  the  infant  may  be 
restless  at  first,  it  does  not  appear  to  have  any  abdominal  pain  or  tenderness. 
The  restlessness  is  apparently  due  to  thirst  or  to  that  unpleasant  sensation 
which  the  sick  feel  when  the  vital  powers  are  rapidly  reduced.  The  urine  is 
scanty  in  proportion  to  the  gravity  of  the  attack,  as  it  ordinarily  is  when  the 
stools  are  frequent  and  watery. 

The  emaciation  and  loss  of  strength  are  more  rapid  than  in  any  other  dis- 
ease which  I  can  recall  to  mind,  unless  in  Asiatic  cholera.  In  a  few  hours 
the  parents  scarcely  recognize  in  the  changed  and  melancholy  aspect  of 
the  infant  any  resemblance  to  the  features  which  it  previously  exhibited. 
The  eyes  are  sunken,  the  eyelids  and  lips  are  permanently  open  from  the 
feeble  contractile  power  of  the  muscles  which  close  them,  while  the  loss  of  the 
fluids  from  the  tissues  and  the  emaciation  are  such  that  the  bony  angles 
become  more  prominent  and  the  skin  in  places  lies  in  folds. 

As  the  disease  approaches  a  fatal  termination,  which  often  occurs  in  two 
or  three  days,  the  infant  remains  quiet,  not  disturbed  even  by  the  flies  which 
alight  upon  its  face.  The  limbs  and  face  become  cool,  the  eyes  bleared, 
pupils  contracted,  and  the  urine  scanty  or  suppressed.  In  some  instances, 
when  the  patient  is  near  death,  the  respiration  becomes  accelerated,  either 
from  the  effect  of  the  disease  upon  the  respiratory  centres  or  from  pulmonary 
conge.stion  resulting  from  the  feeble  circulation.  As  the  vital  powers  fail  the 
pulse  becomes  progressively  more  feeble,  the  surface  has  a  clammy  coldness, 
the  contracted  pupils  no  longer  respond  to  light,  and  the  stupor  deepens,  from 
which  it  is  impossible  to  arouse  the  infant. 

In  the  more  favorable  cases  cholera  infantum  is  checked  before  the  occur- 
rence of  these  grave  symptoms,  and  often  in  cases  which  are  ultimately  fatal 
there  is  not  such  a  speedy  termination  of  the  malady  as  is  indicated  in  the 
above  description.  The  choleriform  diarrhcea  abates  and  the  case  becomes 
one  of  the  ordinary  summer  complaint. 

Anatomical  Characters. — Rilliet  and  Barthez,  who  of  foreign  writers 
treat  of  cholera  infantum  at  greatest  length,  describe  it  under  the  name  of 
gastro-intestinal  choleriform  catarrh.  "  The  perusal,"  they  remark,  "  of 
anatomico-pathological  descriptions,  and  especially  the  study  of  the  facts, 
show  that  the  gastro-intestinal  tube  in  subjects  who  succumb  to  this  disease 
may  be  in  four  different  states :  (a)  either  the  stomach  is  softened  without 
any  lesion  of  the  digestive  tube ;  (b)  or  the  stomach  is  softened  at  the  same 
time  that  the  mucous  membrane  of  the  intestine,  and  especially  its  follicular 


INTESTINAL  CATARRH  OF  INFANCY.  745 

apparatus,  is  diseased ;  (c)  or  the  stomach  is  healthy,  while  the  follicular 
apparatus  or  the  mucous  membrane  is  diseased ;  (cZ)  or,  finally,  the  gastro- 
intestinal tube  is  not  the  seat  of  any  lesion  appreciable  to  our  senses  in  the 
present  state  of  our  knowledge,  or  it  presents  lesions  so  insignificant  that  they 
are  not  sufiicient  to  explain  the  gravity  of  the  symptoms. 

'•  So  far,  the  disease  resembles  all  the  catarrhs,  but  what  is  special  is  the 
abundance  of  serous  secretion  and  the  disturbance  of  the  great  sympathetic 
nerve. 

'•  The  serous  secretion,  which  appears  to  be  produced  by  a  perspiration 
(analogous  to  that  of  the  respiratory  passages  and  of  the  skin)  rather  than 
by  a  follicular  secretion,  shows,  perhaps,  that  the  elimination  of  substances  is 
effected  by  other  organs  than  the  follicles ;  perhaps,  also,  we  ought  to  see  a 
proof  that  the  materials  to  eliminate  are  not  the  same  as  in  simple  catarrh. 
Upon  all  these  points  we  are  constrained  to  remain  in  doubt.  ^Ye  content 
■ourselves  with  pointing  out  the  fact."  ^ 

On  the  1st  of  August,  1861,  I  made  the  autopsy  of  an  infant  sixteen 
months  old  which  died  of  cholera  infantum  with  a  sickness  of  less  than  one 
day.  The  examination  was  made  thirty  hours  after  death.  Nothing  unusual 
was  observed  in  the  brain,  unless  perhaps  a  little  more  than  the  ordinary 
injection  of  vessels  at  the  vertex.  No  marked  anatomical  change  was 
observed  in  the  stomach  and  intestines,  except  enlargement  of  the  patches  of 
Peyer  as  well  as  of  the  solitary  and  mesenteric  glands.  Mucous  membrane 
pale.  In  this  and  the  following  cases  there  was  apparently  slight  softening 
of  the  intestinal  mucous  membrane,  but  whether  it  was  pathological  or 
cadaveric  was  uncertain,  as  the  weather  was  very  warm.  The  liver  seemed 
healthy.  Examined  by  the  microscope,  it  was  found  to  contain  about  the 
normal  number  of  oil-globules. 

The  second  case  was  that  of  an  infant  seven  months  old,  wet-nursed,  who 
died  July  26,  1862,  after  a  sickness  also  of  about  one  day.  He  was  pre- 
viously emaciated,  but  without  any  marked  ailment.  The  post-mortem 
examination  was  made  on  the  28th.  The  brain  was  somewhat  softer  than 
natural,  but  otherwise  healthy.  There  was  no  abnormal  vascularity  of  the 
membranes  of  the  brain,  and  no  serous  effusion  within  the  cranium.  The 
mucous  membrane  of  the  intestines  had  nearly  the  normal  color  throughout, 
but  it  seemed  somewhat  thickened  and  softened ;  the  solitary  glands  of  the 
colon  were  prominent.     The  patches  of  Peyer  were  not  distinct. 

In  the  New  York  Protestant  Episcopal  Orphan  Asylum  an  infant  twenty 
months  old,  previously  healthy,  was  seized  with  cholera  infantum  on  the 
24th  of  June,  1864.  The  alvine  evacuations,  as  is  usual  with  this  disease, 
were  frequent  and  watery  and  attended  by  obstinate  vomiting.  Death 
occurred  in  slight  spasms  in  thirty-six  hours.  The  exciting  cause  was  prob- 
ably the  use  of  a  few  currants  which  were  eaten  in  a  cake  the  day  before, 
some  of  which  fruit  was  contained  in  the  first  evacuations.  The  brain  was 
not  examined.  The  only  pathological  changes  which  were  observed  in  the 
stomach  and  intestines  were  slightly  vascular  patches  in  the  small  intestines 
and  an  unusual  prominence  of  the  solitary  glands  in  the  colon.  The  glands 
resembled  small  beads  imbedded  in  the  mucous  membrane.  The  lungs  in 
the  above  cases  were  healthy,  excepting  hypostatic  congestion. 

Since  the  date  of  these  autopsies  I  have  made  others  in  cases  which  ter- 
minated fatally  after  a  brief  duration,  and  have  uniformly  found  similar 
lesions — to  wit,  the  gastro-intestinal  surface  either  without  vascularity  or 
scantily  vascular  in  streaks  or  patches,  sometimes  presenting  a  whitish  or 
soggy  appearance  and  somewhat  softened,  while  the  solitary  glands  were 
enlarged  so  as  to  be  prominent  upon  the  surface.     In   cases  which  continue 

^  Maladies  des  Enfants. 


746  LOCAL  DISEASES. 

longer  evident  inflammatory  lesions  soon  appear  which  are  identical  with 
those  which  have  already  been  described  in  our  remarks  relating  to  the  ordi- 
nary form  of  diarrhoea. 

During  my  terra  of  service  in  the  New  York  Foundling  Asylum  in  the 
summer  of  1884  an  infant  died  after  a  brief  illness  with  all  the  symptoms 
of  cholera  infantum,  and  the  intestines  were  sent  to  William  H.  Welch,  now 
of  Johns  Hopkins  Hospital,  for  microscopic  examination.  His  report  was 
as  follows  :  "  I  found  undoubted  evidence  of  acute  inflammation.  There  was 
an  increased  number  of  small  round  cells  (leucocytes)  in  the  mucous  and 
submucous  coats.  This  accumulation  of  new  cells  was  most  abundant  in 
and  around  the  solitary  follicles,  which  were  greatly  swollen.  Clumps  of 
lymphoid  cells  were  found  extending  even  a  little  into  the  muscular  coat. 
The  epithelial  lining  of  the  intestine  was  not  demonstrable,  but  this  is  usu- 
ally the  case  with  post-mortem  specimens  of  human  intestine,  and  justifies 
no  inferences  as  to  pathological  changes.  The  glands  of  Lieberkiihn  were 
rich  in  the  so-called  goblet-cells,  and  some  of  the  glands  were  distended  with 
mucus  and  desquamated  epithelium,  so  as  to  present  sometimes  the  appear- 
ance of  little  cysts.  This  was  observed  especially  in  the  neighborhood  of 
the  solitary  follicles.  The  blood-vessels,  especially  the  veins  of  the  sub- 
mucous coat,  were  abnormally  distended  with  blood.  I  searched  for  micro- 
organisms, and  found  them  in  abundance  upon  the  free  surface  of  the  intes- 
tine, in  mucous  accumulations  there,  and  also  in  the  mouths  of  the  glands 
of  Lieberkiihn.  Both  rod-shaped  and  small  round  bacteria  were  found.  I 
attach  no  special  importance  to  finding  bacteria  upon  the  surface  of  the 
intestine.  The  general  result  of  the  examination  is  to  confirm  the  view  that 
cholera  infantum  is  characterized  by  an  acute  intestinal  inflammation." 

Nature. — Cholera  infantum  appears  from  its  symptoms  and  lesions  to 
be  the  most  severe  form  of  intestinal  catarrh  to  which  infants  are  liable. 
The  alvine  discharges,  to  which  the  rapid  prostration  is  largely  due,  probably 
consist  in  part  of  intestinal  secretions,  and  in  part  of  serum  which  has  trans- 
uded from  the  capillaries  of  the  intestines.  That  the  intestinal  mucous 
membrane  sometimes  presents  a  pale  appearance  at  the  autopsy  of  an  infant 
who,  previously  well,  has  died  of  cholera  infantum  after  a  sickness  of  twenty- 
four  or  forty-eight  hours,  is  perhaps  due  to  the  great  amount  of  liquid  secre- 
tion and  transudation  in  which  the  inflamed  surface  is  bathed.  Moreover, 
it  is.  I  believe,  a  recognized  fact  that  the  hyperemia  of  an  acutely  inflamed 
surface  when  of  short  duration  frequently  disappears  in  the  cadaver,  as  that 
of  scarlet  fever  and  erysipelas.  The  early  hyperplasia  of  the  solitary  and 
mesenteric  glands,  and  the  hyperaemia  and  thickening  of  the  surface  of  the 
ileum  and  colon  in  those  who  have  survived  a  few  days,  aflFoi'd  additional 
proof  of  the  inflammatory  character  of  the  malady. 

The  opinion  has  been  expressed  by  certain  observers  that  cholera  infan- 
tum is  identical  with  thermic  fever  or  sunstroke.  There  is  indeed  a  resem- 
blance to  thermic  fever  as  regards  certain  important  symptoms.  In  cholera 
infantum  the  temperature  is  from  105°  to  108°  ;  in  sunstroke  it  is  also  very 
high,  often  running  above  108°.  Great  heat  of  head,  contracted  pupils, 
thin  fecal  evacuations,  embarrassed  respiration,  scanty  urine,  and  cerebral 
symptoms  are  common  toward  the  close  of  cholera  infantum,  and  they  are 
the  prominent  symptoms  in  sunstroke.  Nevertheless,  I  cannot  accept  the 
theory  which  regards  these  maladies  as  identical,  and  which  removes  cholera 
infantum  from  the  list  of  intestinal  diseases.  In  cholera  infantum  the  gastro- 
intestinal symptoms  always  take  the  precedence,  and  are,  except  in  advanced 
cases,  always  more  prominent  than  other  symptoms.  It  does  not  commence 
as  by  a  stroke,  like  coi(p  de  soleil,  but  it  comes  on  more  gradually,  though 
rapidly,  and  it  often  supervenes  upon  a  diarrhoea  or  some  error  of  diet.     In 


INTESTINAL   CATARRH  OF  INFANCY.  14:1 

the  commencement  of  cholera  infantum  the  infant  is  usually  not  drowsy, 
and  is  often  wide  awake  and  restless  from  the  thirst.  Contrast  this  with  the 
alarming  stupor  of  sunstroke.  Sunstroke  only  occurs  during  the  hours  of 
excessive  heat,  but  cholera  infantum  may  occur  at  any  hour  or  in  any  day 
during  the  hot  weather,  provided  that  there  be  sufficient  dietetic  cause. 
Again,  intestinal  inflammation  is  not  common  in  sunstroke,  while  it  is  the 
common  or,  as  I  believe,  the  essential,  lesion  of  cholera  infantum.  These 
facts  show,  in  my  opinion,  that  the  two  maladies  are  essentially  and  entirely 
distinct.  Nevertheless,  cases  of  apparent  sunstroke  sometimes  occur  in  the 
infant,  and  if  the  bowels  are  at  the  same  time  relaxed  the  disease  may  be 
regarded  as  cholera  infantum,  and  if  fatal  is  usually  reported  as  such  to  the 
health  authorities.  Cases  of  this  kind  I  have  occasionally  observed  or  they 
have  been  reported  to  me,  although  they  are  not  common. 

With  the  exception  of  the  organs  of  digestion  no  uniform  lesions  are 
observed  in  any  of  the  viscera  in  cholera  infantum,  except  such  as  are  due  to 
change  in  the  quantity  and  fluidity  of  the  blood  and  its  circulation.  Writers 
describe  an  anaemic  appearance  of  the  thoracic  and  abdominal  viscera,  and 
occasionally  passive  congestion  of  the  cerebral  vessels.  The  cerebral  symp- 
toms usually  present  toward  the  close  of  life  in  unfavorable  cases  of  cholera 
infantum  are  often  due  to  spurious  hydrocephalus,  which  we  have  described 
above ;  but  as  the  urinary  secretion  is  scanty  or  suppressed,  cerebral  symp- 
toms may  in  certain  cases  be  due  to  uremia. 

Diagnosis. — This  form  of  the  summer  diarrhoea  is  diagnosticated  by  the 
symptoms,  and  especially  by  the  frequency  and  character  of  the  stools.  The 
stools  have  already  been  described  as  frequent,  often  passed  with  considerable 
force,  deficient  in  fecal  matter,  and  thin,  so  as  to  soak  into  the  diaper  almost 
like  urine.  The  vomiting,  thirst,  rapid  sinking,  and  emaciation  serve  to  dis- 
tinguish cholera  infantum  from  other  diarrhoea]  maladies. 

When  Asiatic  cholera  is  prevalent  the  difi'erential  diagnosis  between  the 
two  is  difficult  if  not  impossible. 

Prognosis. — Cholera  infantum  is  one  of  those  diseases  in  regard  to  which 
physicians  often  injure  their  reputation  by  not  giving  sufficient  notice  of  the 
danger,  or  even  by  expressing  a  favorable  opinion  when  the  case  soon  after 
ends  fatally.  A.  favorable  prognosis  should  seldom  be  expressed  without 
qualification.  If  the  urgent  symptoms  be  relieved,  still  the  disease  may  con- 
tinue as  an  ordinary  intestinal  inflammation,  which  in  hot  weather  is  formid- 
able and  often  fatal.  If  the  stools  become  more  consistent  and  less  frequent 
without  the  occurrence  of  cerebral  symptoms,  while  the  limbs  are  warm  and 
the  pulse  good,  we  may  confidently  express  the  lopinion  that  there  is  no  pres- 
ent danger. 

The  DURATION  of  true  cholera  infantum  is  short.  It  either  ends  fatally, 
or  it  begins  soon  to  abate  and  ceases,  or  it  continues,  and  is  not  to  be  distin- 
guished in  its  subsequent  course  from  an  attack  of  summer  diarrhoea  begin- 
ning in  the  ordinary  manner. 

Treatment  of  Infantile  Diarrhoea. — Obviously,  efficient  preventive 
measures  consist  in  the  removal  of  infants  so  far  as  practicable  from  the  ope- 
ration of  the  causes  which  produce  the  disease.  Weaning  just  before  or  in 
the  hot  weather  should,  if  possible,  be  avoided,  and  removal  to  the  country 
should  be  recommended,  especially  for  those  who  are  deprived  of  breast-milk 
during  the  age  when  such  nutriment  is  required.  If  for  any  reason  it  is 
necessary  to  employ  artificial  feeding  for  infants  under  the  age  of  ten  months, 
that  food  should  obviously  be  used  which  most  closely  resembles  human  milk 
in  digestibility  and  in  nutritive  properties. 

It  is  also  very  important  that  the  infant  receive  its  food  in  proper  quan- 
tity and  at  proper  intervals,  for  if  the  mother  or  nurse  in  her  anxiety  to  have 


748  LOCAL  DISEASES. 

it  thrive  feed  it  too  often  or  in  too  large  quantity,  the  surplus  food  which  it 
cannot  digest,  if  not  vomited,  undergoes  fermentation,  and  consequently 
becomes  irritating  to  the  gastro-intestinal  surface.  The  physician  should  be 
able  to  give  advice  not  only  in  reference  to  the  frequency  of  feeding,  but  also 
in  regard  to  the  quantity  of  food  which  the  infant  requires  at  each  feeding. 
Correct  knowledge  and  advice  in  this  matter  aid  in  the  prevention  and  cure  of 
the  diarrhoeal  maladies  of  infancy.  The  reader  is  referred  to  the  chapters 
relating  to  the  feeding  of  infants. 

The  indications  for  treatment  are  :  1st.  To  provide  the  best  possible  food 
which  will  afford  sufficient  nutriment  and  be  easily  digested  ;  2d.  To  aid  the 
digestive  functions  of  the  infant ;  3d.  To  employ  such  medicinal  agents  as  can 
be  safely  given  to  check  the  diarrhoea  and  cure  the  intestinal  catarrh  ;  4th.  To 
procure  fresh  air,  which  is  especially  needed  if  the  diarrhoea  be  that  of  the 
summer  season. 

The  infant  with  intestinal  catarrh,  the  prominent  symptom  of  which  is 
diarrhoea,  is  thirsty,  and  is  therefore  likely  to  take  more  nutriment  in  the 
liquid  form  than  it  requires  for  its  sustenance.  If  wet-nursed  it  craves  the 
breast,  or  if  weaned  it  craves  the  bottle  at  short  intervals.  No  more  nutri- 
ment should  be  allowed  than  is  required  for  nutrition,  and  the  thirst  may 
be  best  relieved  by  a  little  cold  boiled  water  to  which  the  white  of  egg  is 
added. 

In  the  dietetic  treatment  of  the  summer  diarrhoea  of  the  bottle-fed  infant, 
in  which  not  only  diarrhoea  but  indigestion  and  vomiting  are  prominent  symp- 
toms, I  at  first  withhold  cow's  milk  and  allow  only  barley  gruel,  described  in 
a  previous  page,  to  which  the  reader  is  referred. 

The  occasional  cases  of  infantile  diarrhoea  which  result  from  taking  cold 
require  to  be  treated  by  the  use  of  bland  and  easily-digested  diet,  and  med- 
icines that  are  soothing  and  such  as  restrain  the  evacuations  and  relieve  pain ; 
prominent  among  which  remedies  are  bismuth  and  an  opiate,  with  the  digest- 
ive ferments. 

We  have  seen  that  the  two  factors  which  produce  the  microbic  diarrhoea 
of  infancy,  of  which  the  summer  epidemic  of  the  cities  is  the  type,  are 
improper  food  and  foul  air.  It  is  therefore  obvious  that  measures  should  be 
employed  to  render  the  atmosphere  in  which  the  infant  lives  as  free  as  pos- 
sible from  noxious  effluvia.  Cleanliness  of  the  person,  of  the  bedding,  and  of 
the  house  in  which  the  patient  resides,  the  prompt  removal  of  all  refuse  ani- 
mal or  vegetable  matter,  whether  within  or  around  the  premises,  and  allowing 
the  infant  to  remain  a  considerable  part  of  the  day  in  shaded  localities  where 
the  air  is  pure,  as  in  the  parks  or  suburbs  of  the  city,  are  important  measures. 
In  New  York  great  benefit  has  resulted  from  the  floating  hospital  which  every 
second  day  during  the  heated  term  carries  a  thousand  sick  children  from  the 
stifling  air  of  the  tenement-houses  down  the  bay  and  out  to  the  fresh  air  of 
the  ocean. 

But  it  is  difficult  to  obtain  an  atmosphere  that  is  entirely  pure  in  a  large 
city  with  its  many  sources  of  insalubrity  ;  and  all  physicians  of  experience 
agree  in  the  propriety  of  sending  infants  affected  with  the  summer  diarrhoea 
to  localities  in  the  country  which  are  free  from  malaria  and  sparsely  inhab- 
ited, in  order  that  they  may  obtain  the  benefits  of  purer  air.  Many  are  the 
instances  each  summer  in  New  York  City  of  infants  removed  to  the  country 
with  intestinal  inflammation,  with  features  haggard  and  shrunken,  with  limbs 
shrivelled  and  the  skin  lying  in  folds,  too  weak  to  raise  (or  at  least  hold) 
their  heads  from  the  pillow,  vomiting  nearly  all  the  nutriment  taken,  with 
stools  frequent  and  thin,  resulting  in  great  part  from  molecular  disintegration 
of  the  tissues — presenting,  indeed,  an  appearance  seldom  observed  in  any 
other  disease  except  in  the  last  stages  of  phthisis — and  returning  in  late 


INTESTINAL  CATARRH  OF  INFANCY.  749 

autumn  with  tte  cheerfulness,  vigor,  and  rotundity  of  health.  The  localities 
usually  preferred  by  the  physicians  of  this  city  are  the  elevated  portions  of 
New  Jersey  and  Northern  Pennsylvania,  the  Highlands  of  the  Hudson,  the 
central  and  northern  parts  of  New  York  State,  and  Northern  New  England. 
Taken  to  a  salubrious  locality  and  properly  fed,  the  infant  soon  begins  to 
improve  if  the  disease  be  still  recent,  unless  it  be  exceptionally  severe.  If 
the  disease  have  continued  several  weeks  at  the  time  of  the  removal,  little 
benefit  may  be  observed  from  the  country  residence  until  two  or  more  weeks 
have  elapsed. 

An  infant  weakened  and  wasted  by  the  summer  diarrhoea,  removed  to  a 
cool  locality  in  the  country,  should  be  warmly  dressed  and  kept  indoor  when 
the  heavy  night  dew  is  falling.  Patients  sometimes  become  worse  from  inju- 
dicious exposure  of  this  kind,  the  intestinal  catarrh  from  which  they  are  suf- 
fering being  aggravated  by  taking  cold  and  perhaps  rendered  dysenteric. 

Sometimes  parents,  not  noticing  the  immediate  improvement  which  they 
have  been  led  to  expect,  return  to  the  city  without  giving  the  country  fair 
trial,  and  the  life  of  the  infant  is  then,  as  a  rule,  sacrificed.  Returned  to 
the  foul  air  of  the  city  while  the  weather  is  still  warm,  it  sinks  rapidly  from 
an  aggravation  of  the  malady.  Occasionally,  the  change  from  one  rural 
locality  to  another,  like  the  change  from  one  wet-nurse  to  another,  has  a  salu- 
tary effect.  The  infant,  although  it  has  recovered,  should  not  be  brought 
back  while  the  weather  is  still  warm.  One  attack  of  the  disease  does  not 
diminish,  but  increases,  the  liability  to  a  second  seizure. 

Medicinal  Treatment. —  Opiates. — It  is  evident  that  opiates  are  less  used 
than  formerly  in  the  treatment  of  the  microbic  diarrhoeas  of  infancy.  A 
proper  appreciation  of  the  pathology  of  these  diarrhoeas  naturally  leads  to 
the  belief  that  the  opiates  are  less  important  as  curative  agents  than  they 
were  formerly  supposed  to  be.  Opiates  diminish  the  peristalsis  and  the  num- 
ber of  stools,  but  they  do  not  destroy  the  microbes  or  the  ptomaines.  Their 
use  should,  I  think,  be  limited  to  cases  of  restlessness,  of  tenesmus,  and  of 
frequent  watery  stools.  They  may  be  useful  in  controlling  symptoms  till 
other  remedies  have  time  to  act.  One  drop  of  laudanum  or  fifteen  drops 
of  paregoric  may  be  given  to  an  infant  of  ten  months  and  repeated  in  three 
hours.  I  prefer  paregoric  to  any  other  opiate  in  the  treatment  of  the  sum- 
mer diarrhoeas  of  infancy,  since  they  are  attended  by  marked  prostration,  and 
this  agent  is  highly  stimulating,  from  the  camphor  which  it  contains.  Fret- 
fulness  without  diarrhoea  is,  as  a  rule,  best  relieved  by  one  of  the  bromides. 

Antiseptics. — Although  the  pathology  of  microbic  diarrhoea  suggests  the 
use  of  antiseptics,  my  observations  have  not  been  favorable  to  the  use  of 
salol,  naphthaline,  or  corrosive  sublimate.  They  have  seemed  to  me  to  do 
more  harm  than  good.  Guaita  employs  sodium  benzoate.  He  administers 
in  twenty-four  hours  one  drachm  or  a  drachm  and  a  half  in  three  ounces  of 
water,  with,  it  is  stated,  good  results.^  The  antiseptic  which  is  more  largely 
used  than  any  other,  and  which  more  than  any  other  has  the  confidence  of 
the  profession — and  justly  so- — is  the  subnitrate  of  bismuth.  It  undergoes 
a  chemical  change  in  the  stomach  and  intestines,  becoming  a  bismuth  sulphide 
and  causing  dark  stools.  It  may  be  combined  with  pepsin,  in  doses  of  six 
to  eight  grains  for  an  infant  of  six  months. 

Irrigation  of  the  Stomach. — Physicians  of  experience  in  New  York  and 
elsewhere  recommend  irrigation  of  the  stomach  with  warm  water  in  the 
treatment  of  malnutrition  and  gastro-intestinal  catarrh.  It  removes  from  the 
stomach  thick  curds  that  digest  with  difiiculty,  as  well  as  other  aliment  that 
may  be  undergoing  gastric  digestion.  It  has  not,  perhaps,  been  sufiiciently 
employed  to  determine  its  full  value,  but  from  what  I  have  seen  of  its  eff'ects 
1  N.  Y.  Med.  Record,  May  31,  1884. 


750  LOCAL  DISEASES. 

I  am  not  able  to  recommend  it.  The  nutriment  should  be  given  so  prepared 
and  with  such  aids  to  digestion  that  the  heavy  casein  curds  do  not  form  in 
the  stomach.  Moreover,  the  gastric  juice  is  the  one  of  the  digestive  fex-- 
ments  that  is  especially  destructive  to  microbes,  so  that  it  is  needed  in  the 
stomach  for  its  germicide  as  well  as  digestive  action.  We  have  seen  from 
the  observations  of  Dr.  Mas  Einhart  that  after  two  hours  the  stomach 
digestion  of  properly  prepared  milk  or  milk  and  barley  gruel  is  completed 
and  the  stomach  in  a  state  to  receive  more  food.  For  these  reasons  irriga- 
tion of  the  stomach,  habitually  practised  even  in  cases  of  indigestion  or 
catarrh,  seems  to  me  more  likely  to  be  injurious  than  beneficial.  On  the 
other  hand,  when  the  stools  are  fermenting  and  imperfectly  digested,  and  are 
accompanied  by  tenesmus,  irrigation  of  the  rectum  with  a  pint  of  hot  water 
to  which  one  teaspoonful  of  acid  boraci  and  one  of  bismuth  nitrate  are  added 
frequently  gives  considerable  relief. 

Alkalies. — Acids,  especially  the  lactic  and  butyric  products  of  faulty 
digestion,  often  collect  in  the  stomach  and  intestines.  These  acids,  which  are 
active  irritants,  should  be  neutralized,  while  we  endeavor  to  prevent  their 
production  by  improving  the  diet  and  aiding  the  digestion.  In  a  few  days 
the  inflammatory  irritation  of  the  mucous  follicles  causes  an  exaggerated 
secretion  of  mucus,  which  is  alkaline,  and  which  neutralizes  the  acids  to  a 
considerable  extent.  It  is  especially  useful  when  the  infant  has  acid  vomit- 
ing and  acid  stools.  Lime-water,  the  sodium  bicarbonate,  and  the  various 
preparations  of  chalk  ai-e  the  antacids  which  may  be  employed  to  neutralize 
the  acids,  given  midway  between  the  nursings  or  feedings.  An  alkali  is 
incompatible  with  pepsin,  and,  as  pepsin  preparations  are  needed  to  assist 
digestion,  they  should  not  be  given  at  the  same  time  with  the  alkali. 

Astringents. — The  vegetable  astringents  were  formerly  much  used  in  the 
treatment  of  the  diarrhoeal  diseases  of  infancy,  but  they  are  now  seldom  pre- 
scribed for  these  cases.  Even  the  mineral  astringents,  acetate  of  lead  and 
nitrate  of  silver,  have  gone  out  of  use  in  the  treatment  of  the  infantile  diar- 
rhoeas.    The  pepsin  preparations  and  bismuth  have  taken  their  place. 

Stimulants. — The  diarrhoea,  if  severe,  soon  produces  symptoms  of  pros- 
tration or  heart  failure,  so  that  alcoholic  stimulation  is  needed.  Brandy  or 
whiskey  is  the  best  stimulant  in  this  disease  :  from  ten  to  twenty-five  drops, 
according  to  the  age,  may  be  given  every  second  hour. 

Occasionally  it  is  proper  to  commence  the  treatment  bj^  the  employment 
of  some  gentle  purgative,  especially  when  the  diarrhoea  begins  abruptly  after 
the  use  of  irritating  and  indigestible  food.  A  single  dose  of  castor  oil  or 
syrup  of  rhubarb,  or  the  two  mixed,  will  remove  the  irritating  substance,  and 
afterward  remedies  designed  to  control  the  disease  can  be  more  successfully 
employed. 

Some  physicians  of  large  experience,  as  Prof.  Henoch  of  Berlin,  recom- 
mend small  doses  of  calomel,  as  a  twelfth  or  twentieth  of  a  grain,  three  or 
four  times  daily.  If  it  be  useful,  it  probably  acts  as  a  germicide,  but  we 
have,  it  seems  to  me,  more  efficient  and  safer  remedies. 

It  is  very  important  in  the  treatment  of  the  summer  diarrhoea  to  aid 
digestion  while  we  employ  an  antiseptic,  and  the  following  are  formulae 
which  I  have  employed  with  apparently  the  best  results : 

K.   Acidi  hydrochlorici  dil.,  ^^vj  ; 

Pepsini  puri,  in  lamellis,  3j  ; 

Bismuthi  subnitrat.,  ^ij  ; 

Syrupi,  fjij  ; 

Aquae,  fgxiv. — Misce. 

Shake  bottle.     Give  one  teaspoonful  before  each  feeding  or  nursing  to  an  infant 
of  ten  months  ;  half  a  teaspoonful  to  an  infant  of  five  months. 


INTESTINAL   CATARRH  OF  INFANCY.  751 

R .  Pepsini  saccharati,  Hi~ij  ; 

Bismuthi  subnitrat.,  gij. — Misce. 

Divide  in  chart  No.  xii. 
Give  one  powder  before  each  nursing  or  feeding  to  an  infant  of  ten  months. 

R .  Pepsini  puri,  in  lamellis,  ,^j  ; 

Bismuthi  subnitrat. ,  5ss  ; 

Vini  pepsini,  N.  F. ,  ^ss  ; 

Aquae  destillat.,  5iiiss. — Misce. 
Shake  bottle.     Give  one  teaspoonful  before  each  feeding  to  an  infant  at  or  above 

the  age  of  six  months ;  lialf  a  teaspoonful  between  the  ages  of  two  and  six 
months. 

B.  Pepsini  puri,  in  lamellis,  gj  ; 

Bismuthi  subnitrat.,  5ss. — Misce. 

Give  as  much  as  goes  on  a  ten-cent  piece  or  a  five-cent  nickel  piece  before  each 
nursing  or  feeding. 

If  the  diarrhoea  and  vomiting  have  ceased,  but  the  digestion  be  slow  and 
incomplete,  the  following  prescriptions  will  be  found  useful : 

R.   Bismuth,  subnitrat.,  ^ij  ; 

Fairchild'  s  essence  of  pepsin  or  Wyeth'  s  \  /     ^ .  _ 

elixir  of  digestive  ferments,  /  ^     3i  > 

Aquse  destillat.,  ^ij. — Misce. 

Shake  bottle.     Give  one  teaspoonful  every  two  hours. 

R.  Pepsini  puri,  in  lamellis,  f^j  ; 

Vini  pepsini,  N.  F.,  ^ss  ; 

Aquse  destillat.,  ^iiiss. — Misce. 

Give  half  a  teaspoonful  to  one  teaspoonful,  according  to  the  age,  before  each 
feeding. 

If  cerebral  symptoms  appear,  as  rolling  the  head,  drowsiness,  etc.,  indi- 
cating the  commencement  of  spurious  hydrocephalus,  an  alcoholic  stimulant, 
as  whiskey  or  brandy,  is  required  ;  and  although  there  may  be,  at  times,  great 
restlessness,  explicit  and  positive  directions  should  be  given  to  withhold 
opiates  if  they  have  been  previously  employed.  One  of  the  bromides,  with 
an  alcoholic  stimulant  or  the  aniseed  cordial  of  the  National  Formulary,  to 
allay  restlessness,  would  be  the  proper  remedy  in  addition  to  bismuth  and 
pepsin  if  symptoms  of  heart  failure  or  spurious  hydrocephalus  occur. 

External  Treatment. — In  the  gastro-intestinal  catarrh  of  the  cool  months, 
produced  by  exposure  to  cold,  light  and  mildly  stimulating  applications  over 
the  abdomen  are  sometimes  useful,  as  a  light  poultice  of  flaxseed  to  which 
one-sixteenth  or  one-twentieth  part  of  mustard  is  added,  or  a  poultice  of 
flaxseed  the  under  surface  of  which  is  covered  with  1  part  of  oil  of  cloves 
and  8  parts  of  camphorated  oil.  But  in  those  forms  of  gastro-intestinal 
catarrh  due  to  improper  feeding  or  insanitary  conditions,  and  having  a  bac- 
terial origin,  external  measures  are  commonly  useless,  and  in  the  summer 
months  they  might  do  injury  by  increasing  the  warmth. 


752  LOCAL  DISEASES. 

CHAPTER    IX. 

ENTERITIS  AND  COLITIS  IN  CHILDHOOD. 

Intestinal  inflammation  in  childhood  differs  materially  from  the  form 
or  type  which  it  commonly  presents  in  infancy.  Its  causes,  symptoms,  and 
extent  vary  in  important  particulars  in  the  two  periods.  In  childhood  there 
is  not  ordinarily  such  extensive  inflammation  of  the  mucous  membrane  of  the 
intestines  as  we  have  seen  is  present  in  the  majority  of  cases  in  infancy,  and 
it  may  therefore  be  properly  treated  as  two  diseases,  according  to  the  seat 
of  the  morbid  process — to  wit,  enteritis  and  colitis.  Both  these  affections  in 
childhood  resemble  so  closely  the  form  which  they  exhibit  in  adult  life  that 
no  extended  description  is  needed  in  this  connection. 

Causes. — A  main  cause  is  sudden  reduction  of  temperature  by  exposure 
to  cold  or  to  currents  of  air,  which  checks  perspiration  and  causes  determina- 
tion of  blood  from  the  surface  to  the  viscera.  These  inflammations  are  also 
caused  sometimes  by  irritating  substances  in  the  intestines.  I  have  known 
fecal  accumulations,  and  even  rarely  worms,  to  produce  severe  dysentery  in 
the  child,  accompanied  by  the  characteristic  tenesmus  and  muco-sanguineous 
stools,  and  ceasing  as  soon  as  the  offending  substances  were  expelled.  The 
use  of  unripe  or  stale  vegetables,  if  there  be  a  strong  predisposition  to 
mucous  inflammation,  may  be  a  sufficient  cause,  and  some  of  the  most  dan- 
gerous cases  are  due  to  the  accumulation  in  the  intestines  of  seeds  and  the 
parenchyma  of  fruits.  But  the  most  common  cause  is  that  mentioned — to 
wit,  sudden  exposure  to  cold  when  the  body  is  heated,  a  danger  to  which 
children  are  especially  liable  on  account  of  the  easy  disturbance  of  the  cir- 
culatory system  in  them,  and  their  heedless  exposure  of  themselves  unless 
incessantly  watched.  Enteritis  and  colitis  are  also  frequently  secondary  dis- 
eases occurring  in  childhood  as  complications  or  sequelae  of  the  eruptive 
fevers,  especially  measles. 

Symptoms. — The  alvine  discharges  in  enteritis  and  colitis  in  childhood  are 
such  as  occur  in  these  diseases  at  a  more  advanced  age.  In  enteritis  they 
are  thin  and  of  the  natural  color,  or  occasionally  green  ;  in  colitis  they  are 
more  consistent  than  in  enteritis  and  are  largely  muco-sanguineous.  Some- 
times in  enteritis,  if  the  inflammation  be  not  intense,  the  diarrhoea  is  slow  in 
appearing,  or  it  may  be  slight,  so  as  not  to  attract  special  attention.  The 
disease  may  then  resemble  remittent  fever,  for  which  it  is  at  times  mistaken. 
The  upper  part  of  the  small  intestines  is  less  frequently  affected  than  the 
lower.  If  there  be  duodenitis,  the  flow  of  bile  is  occasionally  impeded  from 
tumefaction  of  the  mouth  of  the  common  bile-duct,  and  the  icteric  hue 
appears.  In  both  enteritis  and  colitis  there  is  abdominal  tenderness,  with 
more  or  less  constant  pain  if  the  disease  be  severe,  and  in  colitis  tormina  and 
tenesmus.  The  pulse  is  accelerated,  the  heat  of  surface  augmented,  the  face 
flushed  and,  except  in  mild  eases,  expressive  of  pain.  In  many  children  at 
the  commencement  of  the  inflammation  the  nervous  system  is  profoundly 
affected,  as  indicated  by  headache,  stupor,  twitching  of  the  limbs,  and  some- 
times by  convulsions.  The  chief  danger  at  the  commencement  of  the  dis- 
ease is,  indeed,  from  this  source.  Sometimes  irritability  of  the  stomach 
occurs  and  the  food  is  rejected,  though  much  less  frequently  than  in  the 
intestinal  inflammation  of  infancy.  Anorexia  and  thirst  are  common  symp- 
toms. If  the  inflammation  continue,  there  is  soon  perceptible  emaciation, 
with  loss  of  strength.  The  eyes  become  hollow,  the  face  pallid,  and  the 
surface  cool.     Death  may  occur  at  an  early  period,  the  vital  powers  succumb- 


ENTERITIS  AND   COLITIS  IX  CHILDHOOD.  753 

ing  from  the  intensity  of  the  inflammation.  In  other  cases  the  acute  dis- 
ease ends  in  a  subacute  or  chronic  inflammation ;  the  patient  becomes  grad- 
ually more  reduced,  till  he  dies  in  a  state  of  extreme  emaciation,  such  as  we 
often  observe  in  the  entero-colitis  of  infancy ;  or  from  this  state  he  may 
recover  by  degrees,  though  perhaps  with  an  irritable  state  of  the  bowels, 
which  continues  for  months.  In  a  majority  of  cases,  however,  enteritis  and 
colitis  in  childhood,  if  properly  treated,  soon  begin  to  yield,  and  they  termi- 
nate favorably  in  one  or  two  weeks. 

Diagnosis. — It  is  not  difficult  to  determine  the  existence  of  the  inflam- 
mation. This  is  indicated  by  the  fever,  abdominal  tenderness,  and  the  relaxed 
state  of  the  bowels.  Whether  the  disease  be  enteritis  or  colitis  is  determined 
by  the  character  of  the  stools,  the  seat  of  the  tenderness,  and  the  presence  or 
absence  of  tenesmus. 

Prognosis. — It  has  been  stated  above  that  enteritis  and  colitis  in  chil- 
dren commonly  terminate  favorably.  The  result  depends  not  only  on  the 
extent  and  severity  of  the  inflammation,  but  the  constitution  and  previous 
health.  The  inflammation  is  more  serious  when  secondary  than  when  pri- 
mary. Extensive  and  great  tenderness  of  the  abdomen,  features  pallid,  anx- 
ious, and  expressive  of  suffering,  pulse  frequent  and  feeble,  should  excite  the 
most  serious  apprehensions.  Frequent  vomiting  also  denotes  a  grave  form 
of  the  disease.  Stupor,  and  especially  convulsive  movements,  show  that  the 
nervous  centres  are  afiected.  and  should  make  us  guarded  in  the  prognosis. 
Improvement  in  the  disease  on  which  to  base  a  favorable  prediction  is  appa- 
rent in  the  diminution  of  the  tenderness,  improvement  in  the  pulse  and 
character  of  the  stools,  a  more  cheerful  countenance,  and  less  disrelish  of 
food. 

Treatment. — This  should  be  similar  to  that  employed  for  the  adult. 
In  enteritis  at  the  commencement  of  the  disease,  if  there  be  reason  to  sus- 
pect the  presence  of  any  irritating  substance  in  the  intestines,  and  ordi- 
narily in  colitis,  it  is  advisable  to  commence  treatment  by  the  use  of  some 
simple  evacuant,  like  castor  oil.  After  this  our  reliatice,  so  far  as  internal 
treatment  is  concerned,  must  be  mainly  on  opiates  and  antiphlogistic  medi- 
cines. One  of  the  best  remedies  of  this  class  is  the  Dover's  powder,  which 
may  be  given  to  a  child  five  years  old  in  doses  of  three  grains  every  three 
hours.  A  corresponding  dose  of  any  of  the  other  opiates  may  be  given,  but 
with  less  sudorific  effect.  In  colitis  the  occasional  administration  of  a  laxa- 
tive should  not  be  neglected  if  the  stools  be  entirely  or  mainly  muco-sanguin- 
eous.  It  should  be  employed  so  as  to  prevent  accumulation  of  fecal 
matters  in  the  colon  which  would  serve  as  an  irritant  and  increase  the 
inflammation.  The  dose  should  be  small,  merely  sufiicient  to  produce  fecal 
evacuation,  and  repeated  as  required,  daily  or  less  frequently.  The  laxatives 
commonly  preferred  are  magnesia,  rhubarb,  or  castor  oil.  The  physician 
may  prescribe  an  opiate  mixture  containing  sufficient  of  the  laxative  to  have 
the  effect  desired,  though  ordinarily  it  is  better  to  prescribe  the  two  sepa- 
rately, so  that  the  laxative  can  be  given  or  withheld  according  to  circum- 
stances, while  the  opiate  is  continued  more  regularly.  Except  that  there  be 
some  irritating  substance  which  requires  removal,  the  effect  of  laxatives  is 
injurious  instead  of  beneficial.  Instead  of  a  laxative  given  by  the  mouth, 
the  use  of  a  clyster  of  glycerin  and  sweet  oil  in  tepid  water  is  often  prefer- 
able. The  following  prescriptions  may  be  employed  for  a  child  of  five 
years : 

R.   Pulv.  opii,  gr.  v  ; 

Bismuth,  subnitrat.,  gij. — Misce. 

Divid.  in  pulveres  Xo.  sx.     Give  one  powder  every  two  to  four  hours. 
48 


754  LOCAL  DISEASES. 

R.  Pulv.  ipecac,  comp.,  gj  ; 

Bismuth,  subnitrat.,  gij. — Misce. 

Divid.  in  pulveres  No.  xxiv.     Give  one  powder  as  above. 

R .  Tine,  opii  deodorat.,  ^ss  ; 

Bismuth,  subnitrat.,  ^ij  ; 

Aq.  menth.  piperit., 
Syr.  zingiberis,  da.  ^j. — Misce. 

Shake  bottle.     Give  one  teaspoonful  from  two  to  four  hours. 

The  local  treatment  which  is  found  most  beneficial  consists  in  the  use  of 
emollient  applications  covered  with  oil-silk,  and  made  suificiently  irritating 
by  mustard  or  otherwise  to  cause  constant  redness. 

The  diet  should  be  bland  and  unirritating.  In  the  first  stage  of  the 
inflammation  rice-  or  barley-water  or  arrowroot  boiled  in  water  and  similar 
drinks  should  constitute  the  main  diet.  When  the  active  inflammation  has 
abated,  and  at  any  period  of  the  disease  if  there  be  a  tendency  to  prostra- 
tion, more  nourishing  food  should  be  given.  Milk  and  animal  broths  may 
then  be  allowed.  In  cases  which  are  protracted  or  attended  with  symptoms 
of  exhaustion  alcoholic  stimulants  are  required. 


CHAPTER    X. 

CONSTIPATION. 

The  gastro-intestinal  portion  of  the  digestive  apparatus  has  a  double 
function.  First,  it  receives  and  retains  the  food  during  the  process  of  diges- 
tion ;  it  furnishes  the  most  important  of  the  liquids  by  which  digestion  is 
effected  ;  and  it  absorbs  those  products  of  digestion  which  are  required  for  the 
nutrition  of  the  body,  while  it  serves  as  a  barrier  against  the  admission  of 
refuse  matter.  Secondly,  it  has  an  excretory  function,  so  that  a  large  part 
of  the  waste  and  noxious  products  of  the  system  are  eliminated  from  its 
surface.  Having,  therefore,  a  relation  so  close  and  fundamental  to  the  gen- 
eral nutrition,  it  is  necessary,  for  the  normal  activity  of  the  organs  and  the 
maintenance  of  health,  that  its  functions  be  regularly  and  fully  pei'formed. 
But  retention  of  fecal  matter  beyond  the  normal  period  is  one  of  the  most 
common  ailments  both  in  infancy  and  childhood,  and  occasionally  it  consti- 
tutes a  grave  disease.  The  reader  is  referred  to  page  130  for  remarks  relating 
to  constipation  of  the  newly-born. 

Constipation  is  of  two  kinds — namely,  symptomatic  and  idiopatMc. 

Symptomatic  Constipation. — Causes. — Many  of  these  are  obstructive. 
The  more  common  of  them  are  the  following :  (a)  Congenital  stenosis,  or 
occlusion  of  the  anus  or  rectum.  The  anus  is  not  formed  or  it  terminates 
in  a  cul-de-sac,  while  the  lower  end  of  the  large  intestine  forms  another 
cul-de-sac.  These  two  cul-de-sacs,  lying  opposite  to  each  other,  one  look- 
ing upward  and  the  other  downward,  may  be  separated  from  each  other  by  a 
small  interspace,  a  fibrous  septum,  so  that  relief  can  be  obtained  by  a  punc- 
ture or  incision,  or  they  may  be  widely  separated,  so  that  there  is  no  possible 
mode  of  relief,  and  death  is  inevitable  unless  the  fecal  matter  escape  through 
a  congenital  fistulous  passage  upon  one  of  the  adjacent  mucous  surfaces; 
which  mode  of  relief  was  present  in  40  per  cent,  of  the  cases  of  this 
obstruction    collected   by  Leichtenstern.     Exceptionally,  this   malformation 


CONSTIPATION.  755 

occurs  in  the  sigmoid  flexure,  while  the  rectum  is  normal.  The  stenosis,  if 
slight,  may  produce  little  delay  in  the  evacuations,  except  when  hardened 
masses  or  coarse,  indigestible  substances  descend  upon  it,  and  it  may  there- 
fore, with  careful  selection  of  diet,  cause  little  inconvenience  for  a  length- 
ened period,  while  much  stenosis  causes  early  obstructive  symptoms. 

Earely  the  stenosis  is  at  the  ileo-caecal  orifice.     (See  page  130.) 

(Jj)  Intestinal  Displacements. — These  produce  obstructions  of  a  very  pain- 
ful and  dangerous  kind.  Intussusception  and  external  heirnia  are  too  well 
known  to  require  description.  Both  are  likely  to  produce  complete  obstruc- 
tion if  not  soon  relieved,  but  there  are  cases  of  intussusception  in  children 
in  which  the  displaced  intestine  remains  pervious,  and  the  evacuations  occur 
with  more  or  less  regularity;  and'the  same  is  true  of  one  form  of  hernia — 
namely,  the  congenital — which,  although  painful,  seldom  produces  serious 
obstruction. 

Painful  and  dangerous  occlusion  and  consequent  arrest  of  alvine  evac- 
uations occasionally  result  from  the  imprisonment  of  a  loop  of  intestine  in  an 
opening,  usually  congenital,  in  the  mesentery  or  diaphragm,  or  from  the 
knotting  of  one  portion  of  intestine  with  another,  as  described  by  Leichten- 
stern,  or  again  from  the  twisting  of  the  intestine.  Epstein  and  Soyka  ^  relate 
the  case  of  a  new-born  infant  that  died  in  the  second  week  after  birth  with 
symptoms  of  obstruction.  At  the  autopsy  a  portion  of  the  small  intestine 
with  its  mesentery  was  found  twisted  upon  its  axis  from  right  to  left,  without 
any  marked  evidence  of  inflammation. 

(c)  Substances  which  have  been  swallowed  or  substances  whose  nuclei 
have  been  swallowed,  and  which  consist  of  a  deposit  of  carbonate  and  phos- 
phate of  lime,  or  substances  which  have  been  produced  entirely  in  the  sys- 
tem, and  which,  lodged  in  narrow  parts  of  the  intestine,  cause  obstruction. 
Such  substances,  some  of  which  occur  most  frequently  in  children  and  others 
in  elderly  people,  produce  acute  constipation.  Indigestible  matter  contained 
in  the  food,  as  seeds  or  the  parenchymatous  portions  of  fruits,  occasionally 
collects  in  considerable  quantity  and  obstructs  the  intestine.  A  large  gall- 
stone, having  escaped  from  the  common  bile-duct,  sometimes  lodges  in  the 
intestine,  either  at  the  ileo-csecal  valve  or  more  rarely  at  some  other  point, 
and  retards  the  passage  of  fecal  matter.  But  this  seldom  occurs  in  children. 
In  one  instance,  and  in  only  one,  have  I  known  obstinate  constipation  to  be 
produced  by  worms.  The  patient  was  a  girl  of  about  four  years,  in  whom 
constipation  came  on  suddenly,  and  was  accompanied  by  distention  of  abdo- 
men and  great  suff'ering.  This  continued  nearly  one  week,  when  a  mass  of 
intertwined  round-worms  was  expelled,  with  immediate  relief.  The  records 
of  medicine  also  contain  cases  in  which  neoplasms,  growing  from  the  coats 
of  the  intestines  internally,  have  attained  such  a  size  as  to  retard  the  evac- 
uations. 

(cZ)  Abscesses  and  tumors,  especially  when  occurring  in  the  pelvis,  also 
sometimes  cause  constipation  by  pressing  upon  the  intestine  and  obstructing 
or  narrowing  the  passage  through  it.  Thus,  in  1868,  Mr.  Thomas  Smith 
related  to  the  London  Pathological  Society  the  case  of  an  infant,  aged  four- 
teen months,  in  whom  both  alvine  and  urinary  evacuations  were  retarded  by 
a  cancerous  tumor  growing  between  the  rectum  and  bladder,  and  ending  fatally 
in  three  months  after  the  occurrence  of  the  first  symptoms. 

(e)  Peritonitis,  during  its  continuance,  is  known  to  constipate  the  bowels. 
It  is  supposed  that  inflammatory  oedema  occurs  around  the  muscular  fibres 
of  the  middle  coat,  by  which  their  contractility  is  impaired.  Hence  the  lax 
state,  the  meteorism,  and  inaction  of  the  intestines  in  this  disease.  When 
the  peritonitis  abates  the  normal  action  is  restored,  and  the  evacuations  occur 
^  Centralb.  f.  d.  med.  Wissenseh.,  April  24,  1879. 


756  LOCAL  DISEASES. 

regularly  if  the  free  surface  of  the  peritoneum  have  undergone  no  unfavor- 
able change.  But,  unfortunately,  peritonitis  often  produces  more  lasting 
injury,  so  as  to  interfere  seriously  with  the  intestinal  movements  and  produce 
an  habitually  torpid  state  of  the  bowels.  This  occurs  from  adventitious 
bands  of  inflammatory  origin  which  lie  across  the  intestines,  compressing 
them  at  the  points  of  contact  and  restraining  their  movements,  and  from 
adhesion  of  the  intestinal  loops. 

The  most  marked  cases  which  I  have  observed  of  this  were  children  who 
had  had  tubercular  peritonitis.  Interesting  examples  of  constipation  from 
this  cause  might  be  related. 

Occasionally  a  false  band,  the  result  of  peritonitis,  lies  across  the  intestines, 
without  restraining  their  movements  and  producing  no  marked  symptoms, 
and  probably  no  symptoms  at  all,  until  a  loop  happens  to  pass  underneath 
it,  when,  if  not  soon  released,  it  is  liable  to  become  strangulated,  with  com- 
plete obstruction  to  the  passage  of  fecal  matter.  This  displacement  might 
properly  be  classified  with  the  internal  hernias  described  above.  In  my  own 
person  at  the  age  of  twelve  years  such  an  accident  occurred  about  two  months 
after  the  peritonitis.  Upon  the  abatement  of  the  inflammation  a  sensation  of 
traction  had  been  noticed  in  the  umbilical  region  almost  daily  during  exercise, 
and  the  displacement  was  indicated  by  the  extreme  pain  which  characterizes 
such  cases,  and  which  ceased  suddenly  when  the  parts  were  released  after 
about  eighteen  hours. 

(/)  While  it  is  important  that  the  diet  and  glandular  secretions  should 
be  such  that  the  feculent  matter  may  have  proper  consistence  for  easy  pro- 
pulsion along  the  intestinal  tube,  the  important  agent  by  which  alvine 
evacuations  are  effected  is  obviously  muscular  contraction.  The  muscular 
fibres  of  the  intestines  produce  the  vermicular  and  peristaltic  movements 
by  which  excrement  is  carried  forward,  and  the  abdominal  muscles  by 
their  powerful  contraction  are  the  chief  agents  of  expulsion.  Now.  any 
pathological  state  which  impairs  the  innervation  of  these  muscles  or  renders 
it  abnormal,  destroying  the  proper  balance  between  '•  exciting  and  inhibiting 
impulses,"  is  likely  to  cause  constipation.  Hence  meningitis,  myelitis,  and 
certain  other  diseases  of  the  cerebro-spinal  axis,  rachitis,  general  weakness, 
etc.,  are  commonly  attended  by  a  sluggish  state  of  the  intestines. 

Idiopathic  Constipation — Causes.  —  These  are  quite  numerous.  The 
more  prominent  of  them  are  the  following :  First,  too  little  liquid  in  the 
excrement,  so  that  it  is  too  firm  for  ready  evacuation.  Thei'e  may  be  too 
little  liquid  taken  in  the  ingesta  or  too  scanty  secretion  of  the  liquids  which 
mix  with  the  food,  as  those  of  the  pancreas,  liver,  and  mucous  follicles,  or 
there  may  be  too  great  an  absorption  of  liquid  through  the  coats  of  the 
intestines,  and  too  active  an  excretion  of  water  from  the  skin,  kidneys,  or 
lung.  The  firmer  the  fecal  matter  the  greater  the  tendency  to  constipation. 
Those  who  lose  a  large  amount  of  water,  as  in  diabetes,  night-sweats,  or  from 
occupations  which  expose  to  heat  or  from  residence  in  a  hot  climate,  are 
especially  liable  to  constipation,  except  as  the  loss  of  liquid  is  compensated 
by  an  increased  amount  of  drink. 

The  character  of  the  food,  apart  from  the  amount  of  liquid  which  it  con- 
tains, obviously  has  a  marked  influence  upon  the  consistence  and  frequency 
of  the  stools.  Occasionally,  the  intestines  act  sluggishly  from  insufficiency 
of  food.  Thus,  the  infant  sometimes  hangs  an  unusually  long  time  on  the 
breast,  and  the  mother  or  wet-n^^rse  believes  it  to  be  a  hearty  nurser,  when 
there  is  really  a  deficiency  of  milk,  and  the  stools  are  scanty  and  infrequent 
from  lack  of  material.  Again,  constipation  is  not  uncommon  in  infants  who 
nurse  heartily  and  seem  to  obtain  a  sufficient  quantity  of  milk,  and  the  cause 
of  it  is  not  in  the  state  of  the  digestive  organs,  but  in  the  milk.     We  find 


CONSTIPATION.  757 

that  now  and  then  breast-milk  has  a  constipating  effect,  although  we  discover 
nothing  to  cause  this  result  in  the  mother's  diet  or  health.  The  comparison 
of  ordinary  milk  with  colostrum  may  furnish  a  clew  to  the  explanation. 
Colostrum  is  known  to  be  more  laxative  than  ordinary  milk,  and  it  differs 
from  it  chemically  in  containing  more  butter,  sugar,  and  salts.  Hence  the 
theory  seems  plausible  that  when  breast-milk  is  constipating  these  elements 
occur  in  less  than  the  normal  quantity.  And  we  shall  see  hereafter  that 
treatment  suggested  by  this  theory  obviates  the  constipation. 

The  use  of  a  diet  which  consists  chiefly  of  assimilable  substances,  as 
animal  food,  and  from  which,  after  the  digestive  process,  little  coarse  and 
stimulating  residuum  remains,  is  obviously  liable  to  produce  a  sluggish  state 
of  the  bowels.  On  the  other  hand,  coarse  food,  as  fruits  with  their  seeds, 
coarsely-ground  meal,  etc.,  which  stimulates  the  peristaltic  action  and  the 
secretions,  increases  the  number  and  frequency  of  the  alvine  discharges. 

Habit  also  exerts  a  decided  influence  upon  defecation.  One  who,  for 
whatever  reason,  neglects  or  resists  the  desire  for  a  stool  soon  becomes  less 
conscious  of  the  daily  recurring  need  and  establishes  a  constipated  habit. 
Constipation  is  more  liable  to  occur  in  those  who  lead  a  quiet  life  than  in 
those  who  are  active.  A  constipated  habit  is  established  in  many  school- 
children by  neglecting  or  repressing  the  desire  for  a  stool  during  school- 
hours. 

But  there  are  cases  in  which  there  seems  to  be  a  constitutional  tendency 
to  constipation — a  tendency  quite  independent  of  the  usual  conditions.  Thus 
I  have  met  children  who  were  bright  and  active,  free  from  obstruction  or 
disease  which  might  retard  the  evacuations,  apparently  far  from  having 
sluggish  muscular  contractility,  and,  so  far  as  I  could  see,  with  proper  diet, 
and  yet  with  defecation,  except  as  it  was  produced  by  measures  employed, 
occurring  no  oftener  than  each  second,  third,  or  fourth  day. 

But  it  must  be  borne  in  mind  that  what  is  constipation  in  one  child  may 
not  be  in  another,  for  occasionally  one  does  well  with  only  one  evacuation 
every  second  or  third  day,  while  a  large  majority  require  daily  defecation  in 
order  to  the  maintenance  of  perfect  health. 

In  the  adult  the  sacculi  or  pouches  which  occur  in  the  walls  of  the  colon, 
produced  by  contraction  of  the  longitudinal  bands  acting  at  I'ight  angles  to 
the  direction  of  the  circular  fibres,  and  consisting  of  the  internal  and  exter- 
nal tunics  without  the  muscular,  become  the  receptacles  for  fecal  matter  in 
those  who  are  constipated,  and  obviously  tend  to  increase  the  constipation. 
In  children  these  sacculi  are  much  less  developed  relatively,  and  in  young 
infants,  whose  intestines  lack  the  longitudinal  bands,  are  absent,  so  that  this 
anatomical  condition,  by  which  the  passage  of  fecal  matter  is  delayed,  is 
unimportant  as  a  cause  of  constipation  in  the  young. 

On  page  131  we  have  stated  that  Gautier  of  Geneva,  Switzerland,  has 
called  attention  to  an  anal  fissure  as  a  cause  of  constipation  in  the  newly- 
born  and  in  older  children.  The  constipation  occurs  from  the  endeavor  to 
resist  defecation  on  account  of  the  pain. 

We  have  also  remarked  on  page  131  that  constipation  has  a  tendency  to 
perpetuate  itself,  since  retained  feculent  matter  becomes  more  consistent  and 
firmer,  and  the  contractile  power  of  the  muscular  tunic  becomes  weakened 
by  long  distention.  Obviously,  also,  an  abnormal  length  of  the  large  intes- 
tine, so  that  it  doubles  on  itself,  whether  congenital  or  the  result  of  con- 
stipation, and  a  malposition  which  diminishes  the  space  occupied  by  the  colon, 
and  therefore  increases  its  flexures,  have  a  tendency  to  produce  constipation. 

Symptoms. — When  there  is  a  mechanical  cause  which  retards  the  pas- 
sage of  fecal  matter  the  acuteness  of  symptoms  and  the  suffering  are  gen- 
erally proportionate  to  the   degree  of  obstruction.     Symptomatic  constipa- 


758  LOCAL  DISEASES. 

tion  occurring  in  an  obstructive  disease,  whether  adhesions,  peritoneal  bands, 
intussusception,  knots  or  twisting  of  the  intestine,  incarceration  in  a  false 
passage,  or  from  biliary  or  intestinal  stones  or  fecal  masses,  is  attended  by 
severe  symptoms,  such  as  intense  colicky  pain,  vomiting,  loss  of  appetite, 
and  rapid  prostration.  The  ingesta  accumulate  above  the  point  of  obstruc- 
tion, producing  distention  of  the  intestine  with  fecal  matter  and  gas.  while 
below  the  point  of  obstruction  the  intestine  is  soon  empty.  The  symptoms 
indeed  have  the  severity  and  the  state  involves  the  danger  present  in  ordinary 
strangulated  hernia,  while,  from  being  internal,  and  therefore  less  accessible 
for  treatment,  the  danger  is  even  greater.  If  the  intestinal  tract  be  narrowed, 
whether  by  a  false  ligament,  the  result  of  an  old  peritonitis,  or  other  cause, 
and  there  be  still  perviousness,  so  that  excrementitious  matter  passes  by  the 
obstruction,  though  slowly  and  with  more  or  less  difficulty,  the  patient  may 
be  comparatively  comfortable  if  the  food  be  such  that  no  hard  masses 
remain  ;  but  according  to  the  degree  of  stenosis  and  the  amount  and  coarse- 
ness of  the  fecal  matter  symptoms  occur  referable  to  the  obstruction.  If  the 
excrement  be  propelled  with  difficulty  through  the  narrowed  part,  the  mus- 
cular coat  above  the  obstruction  gradually  becomes  more  developed  from 
hypertrophy  of  the  muscular  fibres,  just  as  the  heart  enlarges  from  obstruc- 
tive disease  of  its  valves,  while  below  the  obstruction  the  intestine  atrophies 
and  its  calibre  diminishes  from  disuse.  Colicky  pains,  accumulation  of  fecal 
matter  above  the  obstruction,  distention  of  abdomen,  eructation  of  gas,  vom- 
iting, impaired  appetite,  and  consequent  decline  of  the  general  health,  are 
common  results.  There  is  constant  danger  in  these  cases  that  the  narrow 
passage  may  become  obstructed  by  fecal  matter  if  it  happen  to  contain  hard 
masses  or  coarse,  indigestible  substances.  The  gravest  form  of  constipation 
is  obviously  that  due  to  mechanical  agencies  which  act  as  obstacles,  but  as 
the  obstacles  are  numerous,  differently  located,  and  of  different  character,  so 
there  is  great  difference  in  the  gravity  of  the  cases. 

Idiopathic  constipation  generally  comes  on  gradually.  It  at  first  attracts 
little  attention  and  is  neglected.  The  symptoms  of  course  vary  greatly 
according  to  the  degree  and  stage  of  constipation.  In  mild  cases  the  reten- 
tion is  only  in  the  rectum  or  rectum  and  sigmoid  flexure,  and  there  are  no 
marked  symptoms  except  a  sensation  of  fulness  or  distention  of  these  parts, 
which  one  or  two  evacuations  relieve.  Between  these  mild  cases  and  the 
graver  forms  of  constipation  there  is  every  intermediate  grade,  attended  by 
symptoms  proportionately  severe.  It  is  surprising  sometimes  to  observe  how 
long  patients  live  with  extreme  constipation,  though  with  constant  suffering 
and  ill-health ;  and  I  wish  it  especially  to  be  noticed  in  this  connection  that 
a  large  proportion  of  the  fatal  cases  of  idiopathic  constipation  occurring  in 
adults  and  recorded  in  the  literature  of  the  profession  began  in  early  life, 
even  in  infancy,  at  which  time  they  probably  might  have  been  relieved  by 
proper  remedies  and  a  life  of  suffering  prevented.  This  important  practical 
fact  shows  the  need  of  greater  attention  on  the  part  of  parents  and  nurses  to 
the  state  of  the  bowels  in  children,  that  their  sluggish  action  may  be  cor- 
rected before  it  becomes  habitual  and  those  anatomical  changes  of  distention 
and  muscular  paralysis  occur  which  are  with  difficulty  corrected. 

A  case  quite  remarkable  and  of  recent  date  occurred  in  the  practice  of  Dr. 
Strong  1  of  Westfield,  N.  Y.  : 

Case. — This  patient  at  the  age  of  two  years  usually  had  one  stool  in  two  weeks, 
and  several  years  later  only  one  in  six  weeks.  When  an  adult  he  was  treated  by 
Dr.  Strong,  who  found  great  distention  of  the  abdomen,  so  that  the  lower  ribs  were 
pressed  outward  in  nearly  a  horizontal  direction,  and  the  thoracic  organs  upward, 
so  that  the  apex-beat  of  the  heart  was  about  one  inch  above  the  nipple.  At  this 
^  Amer.  Journ.  of  Med.  ScL,  1874  and  1876. 


CONSTIPATION.  759 

time  months  elapsed  between  the  stools,  the  longest  intervals  being  eighteen  months 
and  sixteen  days.  Defecation  when  it  did  occur  lasted  from  two  to  four  days,  and 
was  attended  by  violent  gastric  and  intestinal  pain,  vomiting,  and  prostration.  At 
one  of  these  prolonged  stools  forty  pounds  of  feces,  resembling,  as  it  usually  did, 
chewed  brown  paper,  were  evacuated,  the  quantity  being  accurately  ascertained  by 
weighing  the  patient  before  and  afterward.  He  had  appetite  and  was  able  to  do 
certain  kinds  of  farm-work  during  the  year  preceding  his  death,  which  occurred  at 
the  age  of  twenty-eight  years.  At  the  autopsy  the  colon  was  found  to  have  a 
length  of  six  feet  and  three  inches  and  a  circumference  of  thirteen  inches,  while 
the  lungs  were  pressed  upward  and  backward  as  when  compressed  by  a  pleuritic 
exudation. 

While  such  extreme  cases  are  infrequent,  all  physicians  of  experience  are 
consulted  from  time  to  time  by  adults  who  have  had  habitual  constipation 
from  their  earliest  recollection  ;  and  these  cases,  that  aggregate  so  large  a 
number,  might,  there  is  little  reason  to  doubt,  have  been  prevented  for  the 
most  part  during  childhood  when  the  habit  was  being  formed. 

In  long-continued  constipation,  in  which  there  is  a  large  fecal  accumula- 
tion, not  only  is  the  diameter  of  the  colon  increased,  as  stated  above,  but  this 
part  of  the  intestine  becomes  elongated.  This  may  lead  to  change  in  its 
position,  the  curves  of  the  sigmoid  flexure  extending  farther  to  the  right, 
and  the  central  part  of  the  transverse  colon  by  its  weight  curving  downward. 
This  abnormal  lengthening  and  the  consequent  curvatures  have  a  tendency 
to  increase  the  constipation,  as  has  been  stated  above  in  our  remarks  relating 
to  the  etiology. 

In  these  cases  of  extreme  constipation,  which  fortunately  are  rare  in  chil- 
dren, as  they  are  also  in  adults,  the  distention  of  the  colon  at  the  ileo-ca3cal 
orifice  has  a  tendency  to  widen  this  orifice,  so  that  the  valve,  which  in  the 
ordinary  state  prevents  the  return  of  any  substance  which  has  once  passed 
by  it,  is  liable  to  become  insufficient.  The  adjacent  folds  which  constitute 
the  valve  become  separated,  so  that,  if  vomiting  and  antiperistaltic  move- 
ments occur,  fecal  matter  may  pass  from  the  colon  toward  the  stomach.  In 
aggravated  cases,  in  which  there  is  retention  of  a  large  amount  of  fecal  mat- 
ter, distention,  muscular  paralysis,  etc.,  similar  to  those  which  we  have  seen 
produced  in  the  colon,  are  liable  to  occur,  though  to  a  less  extent,  in  the 
small  intestines,  especially  in  the  ileum. 

Retained  excrementitious  matter  accumulating  in  large  masses  evidently 
becomes  an  irritant,  so  that  by  its  pressure  it  excites  muscular  contractions, 
which  if  inefi"ectual  in  propelling  the  mass  cause  colicky  pains.  The  retained 
fecal  matter  also  undergoes  more  or  less  decomposition,  producing  gases  which 
by  increasing  the  distention  also  increase  the  pain. 

Any  irritating  substance  applied  to  a  mucous  surface  is  liable  to  excite 
increased  secretion  from  the  mucous  follicles  or  from  the  glands  whose  ori- 
fices connect  with  the  mucous  membrane  at  the  point  of  irritation.  Many 
familiar  examples  will  at  once  be  recalled  to  mind,  as  the  defluxion  from  the 
nostrils  from  the  use  of  snuffs  and  increased  mucous  secretion  and  salivation 
from  objects  held  in  the  mouth.  In  the  same  way,  retained  excrement,  form- 
ing hard  masses  which  press  upon  the  intestinal  surface,  excite  a  secretion, 
and  not  infrequently  produce  thereby  a  diarrhoea  which  is  conservative,  and 
which  may  for  the  time  unload  the  bowels,  or  it  may  remove  a  part  of  the 
scybalae,  while  the  rest  remain.  Hence  we  sometimes  hear  patients  speak  of 
having  irregular  evacuations,  constipation  alternating  with  diarrhoea.  In 
aggravated  cases  the  pressure  of  impacted  feces  sometimes  produces  inflam- 
mation of  the  surface,  when,  in  addition  to  abdominal  pain,  there  are  tender- 
ness on  pressure  and  some  (usually  quite  moderate)  elevation  of  tempera- 
ture. In  cases  which  have  terminated  fatally  after  a  longer  or  shorter 
time  destruction  of  the  mucous  surface  has  been  found  in  places  in  conse- 


760  LOCAL  DISEASES. 

quence  of  the  pressure  and  inflammation.  We  can  readily  believe,  that,  as 
in  cases  of  typhoid  ulcerations,  if  the  ulcers  reach  a  certain  depth  they  may 
also  give  rise  to  localized  peritonitis,  and  that  occasionally  perfoi'ation  may 
result  at  the  ulcerated  or  gangrenous  point.  The  expulsion  of  hardened 
masses  which  have  collected  in  the  rectum  is  slow  and  painful,  and  accom- 
panied by  more  or  less  tenesmus,  which  not  infrequently  causes  a  portion  of 
the  mucous  membrane  at  the  anal  orifice  to  descend  below  the  sphincter  ani 
and  protrude,  by  which  hemorrhoids  are  produced.  Occasionally,  as  I  have 
observed  in  certain  cases,  the  entire  circumference  of  the  rectal  mucous  mem- 
brane, to  the  distance  of  half  an  inch  or  more  above  the  anus,  becomes  so 
loosened  from  its  attachment  to  the  connective  tissue  that  it  descends  below 
the  sphincter  ani  and  protrudes  during  each  defecation.  But  this  displace- 
ment, known  as  prolapsus  recti,  more  commonly  results  in  children  from  pro- 
tracted intestinal  catarrh,  attended  by  diarrhoea,  loss  of  flesh,  and  by  dimin- 
ished tonicity  of  the  tissues. 

A  beautiful  and  conservative  provision  in  the  system  is  that  by  which 
vicarious  functions  are  established  to  relieve  organs  which  imperfectly  per- 
form their  part.  While  the  intestinal  surface  is  to  a  great  degree  elimina- 
tive,  so  that  noxious  and  eff"ete  products  are  largely  expelled  from  the  system 
in  the  stools,  it  possesses  also  in  high  degree  an  absorbent  function,  as  all 
who  employ  rectal  alimentation  are  aware.  Now,  if  the  intestine  fail  to  per- 
form its  function  of  defecation  and  feculent  matter  collect  within  it  and 
begin  to  exert  pressure  upon  the  intestinal  surface,  more  or  less  of  the  liquid 
portion  is  taken  up  by  the  vessels,  and,  entering  the  general  circulation,  finds 
a  mode  of  escape  through  other  emunctories.  The  general  ill-health  or 
languor,  the  furred  tongue,  headache,  and  foul  breath  which  characterize  these 
cases  are,  no  doubt,  due  to  the  absorption  into  the  blood  or  retention  in  it  of 
noxious  products  contained  in,  and  which  in  part  constitute,  the  feculent 
matter.  '  The  fact  that  patients  may  live  for  years  with  tolerable  appetite, 
and  with  only  one  dejection  every  second  or  third  week,  receives  explanation 
in  the  fact  that  other  organs,  as  the  lungs,  kidneys,  skin,  etc.,  act  as  depur- 
ants  for  such  excrementitious  matter  as  can  be  taken  up  in  a  liquid  or  gas- 
eous form  by  the  intestinal  surface. 

In  infants,  constipation,  even  when  slight  and  temporary,  often  causes  fret- 
fulness,  which  is  indicated  by  the  character  of  their  cries  and  the  movement 
of  the  thighs  over  the  abdomen.  Continuing  for  a  time,  it  causes  more  or 
less  fever,  and  in  those  young  children  who  are  liable  to  eclampsia  it  predis- 
poses to  an  attack,  and  it  may  be  the  chief  cause. 

Treatment. — If  there  be  reason  to  suspect  the  presence  of  a  mechanical 
obstacle  which  prevents  normal  defecation,  a  careful  examination  should  be 
made  in  order  to  discover,  if  possible,  its  nature  and  location.  Often  it  is 
of  such  a  nature  that  it  cannot  be  removed,  but  its  constipating  effects  may 
sometimes  be  in  a  measure  obviated.  In  one  of  the  published  cases  in  which 
constipation  continued  from  early  childhood  to  adult  life,  and  finally  proved 
fatal,  its  cause  was  ascertained  to  be  a  septum  in  the  rectum,  which  probably 
might  have  been  relieved  by  surgical  measures.  In  all  cases  of  constipation 
which  the  history  shows  may  be  produced  by  mechanical  causes,  whether  the 
obstruction  be  complete  and  the  colicky  pains  and  other  symptoms  severe,  or 
there  be  occasional  scanty  evacuations  with  but  slight  or  moderate  suff'ering, 
the  history  of  the  patient  should  be  obtained  in  order  to  ascertain  if  there 
had  been  at  any  previous  time  symptoms  of  peritonitis  or  other  pathological 
state  which  might  throw  light  on  the  etiology.  The  abdomen  and  the  usual 
sites  of  hernia  should  be  carefully  explored  by  palpation,  and  the  rectum  by 
the  finger,  large-sized  catheter,  or  rectal  tube.     A  thorough  examination  thus 


CONSTIPATION.  761 

instituted,  painless  to  the  patient,  will  usually  enable  the  practitioner  to  deter- 
mine either  the  exact  or  probable  obstacle  if  any  be  present. 

The  proper  treatment  of  symptomatic  constipation  obviously  requires  the 
removal,  so  far  as  possible,  of  the  primary  disease  or  the  cause,  whether  it  be 
obstructive  or  otherwise.  We  need  not  stop  to  consider  the  special  meas- 
ures which  are  required,  and  will  pass  to  the  consideration  of  the  treatment 
of  idiopathic  constipation. 

Hygienic  Measures. — We  have  already  alluded  to  the  fact  that  habit  has  a 
powerful  control  over  the  action  of  the  intestines,  so  that  it  is  important  to 
obtain  a  daily  alvine  evacuation  at  a  certain  hour,  and  by  establishing  the 
habit  the  need  will  usually  be  experienced  when  that  hour  arrives  each  day. 
Many  cases  which  become  troublesome  and  obstinate  might  no  doubt  have 
been  prevented  had  this  physiological  law  been  heeded  and  a  daily  evacuation 
obtained  at  a  certain  hour.  The  constipated  habit,  mild  and  not  yet  fully 
established,  is  more  liable  to  be  overlooked  when  it  occurs  in  childhood  than 
in  infancy,  for  the  infant  is  closely  and  constantly  under  observation,  and  it 
soon  presents  symptoms,  as  fever  and  fretfulness,  if  it  do  not  have  the  regu- 
lar evacuation,  while  children  over  the  age  of  four  or  five  years  tolerate  better 
a  sluggish  state  of  the  bowels,  and  are  likely  to  be  constipated  for  a  consider- 
able time  before  the  fact  is  ascertained.  They  therefore  require  more  atten- 
tion in  this  regard  than  is  usually  bestowed  by  parents. 

The  nature  of  the  diet  is  obviously  important,  since  certain  kinds  of  food 
are  more  laxative  than  others.  Chicken  tea  and,  to  a  certain  extent,  beef 
and  mutton  tea,  are  laxative,  and  made  plainly  are  therefore  useful  in  con- 
nection with  other  articles.  The  apple  scraped  or  baked,  or  apple  sauce,  may 
be  given  to  quite  young  children,  and  for  those  that  are  older  certain  dry 
fruits,  as  prunes  and  figs,  are  laxatives.  Unfermented  cider  in  its  season, 
which  has  been  found  so  useful  for  adults,  may  also  be  given  to  children  in 
moderate  quantity,  at  least  to  those  who  have  reached  the  age  of  two  or 
three  years. 

Oatmeal  is  more  laxative  than  most  other  kinds  of  amylaceous  food. 
Made  into  a  gruel  and  strained,  it  may  be  given  to  the  nursing  infant,  and 
unstrained  to  those  who  are  older.  Bread  or  pudding  from  coarsely-ground 
or  unbolted  flour  or  meal,  and  vegetables  which  contain  saline  and  fibrous 
substances,  have  a  stimulating  and  laxative  effect  on  the  surface  of  the  intes- 
tines, and  therefore  are  useful  for  constipated  children  of  the  age  of  two  or 
three  years  and  upward.  Also  farinaceous  food  treated  by  diastase  may  be 
employed. 

There  can  be  no  doubt  that  the  free  use  of  water  in  the  ingesta  materially 
aids  in  relieving  costiveness.  In  one  of  the  numbers  of  the  London  Lancet 
a  physician  asks  the  profession  how  to  cure  obstinate  constipation  in  adults. 
Among  the  replies,  one  physician  suggests  drinking  a  tumblerful  of  cold 
water  on  retiring  to  bed  and  another  tumblerful  in  the  morning ;  and  there 
can,  I  think,  be  little  doubt  that  the  laxative  eff'ect  of  broths,  gruels,  fruits, 
and  mineral  waters  is  partly  due  to  the  amount  of  water  which  they  contain. 
One  of  the  chief  causes  of  constipation,  we  have  seen,  is  too  great  firmness 
or  consistence  of  the  stools,  due  to  absorption  of  the  water  ;  and  if  a  larger 
quantity  of  water  be  swallowed  during  or  after  the  meals  than  is  removed  by 
absorption,  so  that  the  stools  have  their  normal  or  less  than  normal  consist- 
ence, this  cause  of  constipation  is  removed.  An  excess  of  water  introduced 
into  the  system  is  to  a  great  extent  eliminated  by  the  kidneys,  and  in  hot 
Tveather  by  the  skin,  and  to  a  certain  extent  exhaled  from  the  lungs  ;  but 
experience  shows  that  if  the  amount  of  liquid  received  be  so  great  that  the 
Tassels  in  the  coats  of  the  intestines  continue  in  a  state  of  repletion,  only  a 


762  LOCAL  DISEASES. 

certain  part  of  it  is  absorbed,  while  the  rest  descends  and  mixes  with  the 
excrementitious  matter  and  acts  as  a  laxative. 

Another  safe  and  effectual  aid  in  overcoming  habitual  constipation 
is  frequent  kneading  of  the  abdomen.  My  attention  was  first  particularly 
directed  to  this  in  the  treatment  of  the  case  related  above,  in  which  obsti- 
nate constipation,  occurring  in  a  child  of  three  years  from  peritoneal  bands 
and  adhesions,  was  to  a  great  extent  corrected  by  friction  over  the  abdo- 
men for  three  or  four  minutes  at  a  time,  with  cod-liver  oil  three  or  four 
times  daily.  The  manipulation  probably  did  the  good,  and  not  the  oil,  but 
the  use  of  one  of  the  oils  for  inunction  renders  the  kneading  less  painful 
and  ensures  its  more  thorough  performance  by  the  nurse.  All  obstetricians 
in  certain  emergencies  stimulate  the  uterine  muscular  fibres  to  contraction  by 
kneading  the  abdomen,  and  it  is  probable  that  the  muscular  fibres  of  the 
intestines  are  stimulated  in  a  similar  manner,  so  that  the  intestinal  move- 
ments are  increased  by  which  feculent  matter  is  carried  forward. 

The  external  application  of  cold,  so  effectual  in  contracting  the  uterine 
muscular  fibi'es,  also  stimulates  the  contractile  power  of  the  muscular  fibres 
of  the  intestines.  Cold-water  bathing,  the  sudden  application  of  a  clotK 
wrung  out  of  cold  water  to  the  abdomen,  and  in  certain  obstinate  cases  even 
the  douche,  may  be  used  to  stimulate  the  muscular  coat  of  the  intestines  and 
the  abdominal  muscles  to  greater  activity.  Trousseau  says  :  '■  Before  leaving 
the  subject  of  the  treatment  of  constipation,  let  me  refer  to  the  application 
of  cold  .to  the  abdomen — a  minor  method  which  I  have  seen  recommended, 
and  have  myself  prescribed  with  astonishing  success.  On  rising  in  the  morn- 
ing let  there  be  placed  on  the  abdomen  a  compress  of  several  folds  soaked  in 
cold  water,  and  let  it  be  separated  from  the  clothes  by  a  sheet  of  gutta-percha 
or  caoutchouc.  This  compress  ought  to  remain  on  for  three  or  four  hours." 
This  recommendation  by  Trousseau  is  for  adults,  who  are  much  less  suscept- 
ible to  the  influence  of  cold  than  children.  So  prolonged  an  application  of 
cold  and  wet  to  a  child,  even  the  most  robust,  would  involve  danger,  while  its 
application  during  the  brief  period  occupied  in  an  ordinary  bath,  with  proper 
exercise  afterward  or  with  other  measures  to  prevent  chilling,  could  have  no 
ill-effect. 

Therapeutic  Measures. — For  temporary  constipation  and  many  cases  that 
are  habitual  enemata  should  be  employed,  since  they  promptly  unload  that 
part  of  the  intestines  in  which  feculent  matter  is  ordinarily  retained,  while 
they  do  not  impair  the  appetite  or  produce  the  prostration  which  so  often 
results  from  purgatives.  For  temporary  constipation  a  warm  clyster  may  be 
given,  and  it  commonly  is  more  agreeable  to  the  patient  than  one  of  lower 
temperature  than  the  body.  Among  the  enemata  which  have  been  found 
useful  are  castile  soap  with  molasses  and  water,  salt  and  water,  the  various 
oils,  as  sweet  oil  with  or  without  castor  oil,  linseed  oil  alone  or  with  molasses, 
and  the  gruels,  as  that  of  oatmeal  or  cornmeal  made  thin.  The  belief  that 
the  frequent  use  of  warm  clysters  produces  a  relaxing  effect  is  probably  cor- 
rect, so  that  if  it  be  necessary  to  employ  clysters  often  in  consequence  of  the 
torpid  state  of  the  intestines,  cool  water,  the  effect  of  which  is  tonic  and  stim- 
ulating, should  be  used.  I  prefer  the  use  of  glycerin  and  water  as  a  laxative 
enema.  For  ordinary  constipation  in  an  infant  the  injection  into  the  rectum 
of  one  teaspoonful  of  glycerin  and  one  teaspoonful  of  water  from  a  gutta- 
percha or  glass  syringe,  at  a  certain  hour  each  day,  will  rarely  fail  to  give 
relief. 

For  infants,  a  clyster  of  one  or  two  ounces  usually  sufiices,  administered 
by  a  gutta-percha  or  glass  syringe,  while  for  older  patients  a  proportionately 
larger  quantity  is  required,  administered  by  preference  through  a  Davidson, 
India-rubber,  or  a  fountain  syringe.     In  certain  long-continued,  aggravated 


CONSTIPATION.  763 

cases  the  frequent  injection  of  a  large  quantity  of  tepid  water  is  indispensa- 
ble in  order  to  wasli  away  the  accumulation  of  fecal  matter.  Thus  in  1854, 
Mr.  Gay  exhibited  to  the  London  Pathological  Society  a  boy  of  seven  years 
who  at  the  age  of  three  years  had  had  typhus  fever  with  dysenteric  stools. 
After  convalescence  he  had  habitual  obstinate  constipation,  so  that  when  Mr. 
Gray  began  treatment  there  had  been  no  fecal  evacuation  for  nearly  four 
months,  and  the  girth  of  the  bod}"  over  the  abdomen  was  forty-nine  inches, 
and  yet  the  appetite  and  general  health  were  not  seriously  impaired.  The 
shape  of  the  abdomen  and  the  examination  showed  great  distention  of  the 
rectal  ampulla  and  the  descending  colon.  Mr.  Gay  first  distended  the 
sphincter  ani,  so  that  it  admitted  a  speculum,  and  through  a  rectal  tube,  well 
introduced  into  the  colon,  the  excrement  was  repeatedly  washed  away,  so  that 
at  the  time  of  the  exhibition  of  the  boy  to  the  society  the  measurement  in 
girth  gave  only  twenty-four  inches.  Evidently  in  cases  like  the  above  no 
other  treatment  except  repeatedly  washing  out  the  intestines  with  warm  water 
would  have  answered,  and  the  dilatation  of  the  sphincter  ani  and  the 
introduction  of  the  speculum  to  facilitate  the  escape  of  fecal  matter  are 
noteworthy. 

Suppositories  may  sometimes  be  usefully  employed  in  place  of  enemata ; 
cocoanut  butter,  molasses  candy,  or  soap  cut  in  shape  of  a  pencil  may  be 
used  for  this  purpose.  In  the  adult,  long-continued  constipation  is  not  very 
rare  in  which  the  rectal  ampulla  becomes  so  impacted  that  it  is  necessary  to 
use  the  anal  curette,  the  handle  of  a  spoon,  or  the  finger  introduced,  in  order 
to  break  up  the  masses  and  allow  them  to  pass.  In  children  necessity  for 
such  treatment  is  much  more  rare,  but  there  are  occasional  cases,  like  that 
above  described  by  Mr.  Gay,  in  which  it  may  be  needed.  Dr.  Nagel  states 
that  the  evil  may  be  removed  by  the  introduction  of  a  suppository  of  brown 
gelatin.  This  is  steeped  in  water  for  twelve  hours,  and,  having  been  thus 
softened,  is  introduced  into  the  rectum  and  an  evacuation  obtained.  The 
doctor  attributes  the  laxative  eff'ect  to  the  hygrometric  action  of  the  gelatin. 
The  glycerin  suppository  of  the  shops  is  also  very  effectual. 

The  known  effect  of  the  galvanic  current  in  producing  contraction  of  the 
uterine  muscular  fibres  suggests  its  employment  to  relieve  constipation  by 
stimulating  the  muscles  of  the  abdomen  and  the  muscular  coats  of  the  intes- 
tines ;  and  those  who  have  employed  it  speak  favorably  of  its  use.  Habershon 
says  :  "  A  galvanic  current,  transmitted  through  the  abdominal  walls,  induces 

a  very  speedy  action,  or  rather  emptying,  of  the  colon A  case  of 

partial  paraplegia,  in  which  injections  did  not  act  satisfactorily  and  drastic 
purgatives  were  undesirable,  was  treated  by  a  galvanic  current  passed  through 
the  abdomen  every  morning.  In  a  few  hours  a  free  evacuation  was  produced 
without  any  discomfort."  But  the  constipation  of  children  very  seldom 
requires  the  use  of  galvanism. 

The  ordinary  purgatives  should  not  be  given  habitually  to  relieve  a  con- 
stipated habit.  They  are  liable  to  irritate  the  intestines,  causing  a  catarrh, 
or  else  the  intestines  become  accustomed  to  their  action  and  a  larger  dose  is 
needed  to  effect  purgation.  Given  habitually,  they  cannot  fail  also  to  disturb 
the  digestive  and  nutritive  processes.  One  or  two  doses  for  present  relief, 
both  in  habitual  and  temporary  constipation,  are  sometimes  required,  provided 
that  an  injection  is  for  any  reason  not  preferred.  For  this  purpose,  castor 
oil  or  a  few  grains  of  calomel  mixed  with  syrup  of  rhubarb,  the  syrup  of 
senna,  or  the  compound  liquorice-powder  of  the  German  Pharmacopoeia,  may 
be  administered  with  advantage.  But  for  habitual  constipation  I  strongly 
advise  to  discard  the  ordinary  purgative  medicines,  and,  if  the  measures  of 
a  dietetic  or  hygienic  character  recommended  above  are  not  sufiicient.  to 
employ  such  remedial  agents  as  promote,  or  at  least  do  not  impair,  nutrition. 


764  LOCAL  DISEASES. 

Probably  the  best  purgative  for  habitual  use  is  maltine  with  fluid  extract  of 
cascara  sagrada. 

Belladonna,  so  highly  recommended  by  Trousseau  and  others.  I  have  often 
administered  to  children,  especially  in  pertussis,  in  large  doses  during  several 
consecutive  days,  but  it  has  not  seemed  to  me  to  have  any  decided  laxative 
eflPect.  Though  it  may  be  useful  in  certain  mixtures  for  adults,  our  experi- 
ences in  this  country  with  reliable  preparations  certainly  have  not  been  such 
as  to  justify  its  employment  as  the  sole  or  main  remedy  for  constipation.  It 
diminishes  reflex  irritability,  and  may  render  the  action  of  purgatives  less 
painful,  but  from  its  known  physiological  efi'ects  we  cannot  believe  that  it 
increases  the  intestinal  secretions  or  the  action  of  the  muscular  fibres,  one  or 
the  other  of  which  results  we  expect  from  the  use  of  an  agent  which  is  really 
laxative.  On  the  other  hand,  nux  vomica  and  its  active  principle,  strychnia, 
are  doubtless  valuable  adjuncts  to  purgative  mixtures  from  their  eff"ect  in 
increasing  the  action  of  muscular  fibres. 

Physicians  are  not  infrequently  at  a  loss  what  to  prescribe  for  the  habitual 
constipation  of  nursing  infants,  which  is  by  no  means  infrequent.  But 
recollecting  that  colostrum  is  more  laxative  than  ordinary  milk,  and  that  it 
differs  from  it  in  containing  more  sugar,  salts  (largely  phosphates),  and  butter, 
we  have  a  hint,  as  stated  above,  as  to  what  is  probably  lacking  in  the  milk, 
and  what,  therefore,  should  be  supplied.  I  am  in  the  habit  of  giving  the  oil, 
sugar,  and  salts  in  the  following  formula,  and  usually  with  the  desired  laxa- 
tive effect : 

R.  01.  morrhuse,  2  parts  ; 

Aq.  calcis, 
Syr.  calcis  lactophos.,  da.  1  part. 

One-quarter,  one-third,  or  one-half  teaspoonful  may  be  given  with  each 
nursing,  or  a  larger  quantity,  as  a  teaspoonful  or  more,  three  times  daily. 
Breast-milk  with  this  addition  becomes  more  nearly  like  colostrum  in  its 
laxative  properties,  while  it  does  not  possess  those  properties  of  colostrum 
which  disturb  the  digestive  process.  I  know  no  agent  of  a  medicinal  nature 
which  meets  the  indication  so  well  as  this  for  infantile  constipation.  But  in 
my  practice  I  have  found  it  necessary,  in  not  a  few  instances,  to  rely  mainly 
on  enemata  of  glycerin  and  water  for  the  relief  of  the  constipated  habit  till 
the  infants  reached  the  age  when  a  mixed  diet  was  proper. 

The  habitual  constipation  of  older  children  may  ordinarily  be  relieved  by 
the  remedies  recommended  above,  but  occasionally  a  more  active  purgative 
effect  may  be  needed.  Since  the  portion  of  intestine  which  is  chiefly  impli- 
cated in  ordinary  forms  of  constipation  is  the  colon,  it  is  evident  that  if  it  be 
necessary  to  employ  frequently  any  of  the  active  purgatives  of  the  Phar- 
macopoeia, such  should  be  selected  as  produce  little  or  no  irritation  of  the  long 
tract  of  the  small  intestines,  while  they  stimulate  the  function  of  the  colon. 
The  aloetic  preparations  are  used  for  this  purpose,  as  the  tincture  of  aloes 
and  myrrh  or  the  simple  tincture  of  aloes,  which  may  be  given  in  dose  of 
part  of  a  teaspoonful  in  a  convenient  syrup  or  in  coffee  or  milk.  But  I  think 
a  preferable  remedy  is  maltine  with  fluid  extract  of  cascara  sagrada,  as 
recommended  above,  a  half  teaspoonful  of  which  may  be  given  daily,  if 
necessary,  to  a  child  of  eight  years. 


INTESTINAL    WORMS.  765 

CHAPTEE    XI. 

INTESTINAL  WORMS. 

The  belief  has  been  prevalent  in  the  profession  in  former  times,  and  is 
now  among  the  people,  that  worms  in  the  intestines  constitute  a  frequent 
disease,  especially  in  children.  As  pathology  and  the  means  of  diagnosticat- 
ing diseases  are  better  understood,  this  idea  has  been  gradually  abandoned 
by  physicians  and  the  intelligent  portion  of  the  community.  Still,  these 
parasites  must  be  considered  an  occasional  cause  of  serious  derangements, 
and  in  rare  instances  a  cause  even  of  death.  They  indeed  often  exist  in 
small  numbers  without  producing  any  appreciable  deviation  in  the  individual 
from  the  healthy  state  ;  but  the  most  common  and  best-known  species,  when 
they  have  once  effected  a  lodgement  in  the  intestines  of  man,  ordinarily  grow 
and  multiply  so  as  to  produce  symptoms  and  require  medicines  for  their 
expulsion. 

So  far  as  is  now  ascertained  by  observations  in  different  countries,  about 
fifty  animal  parasites  make  their  abode  in  man.  It  is  not  improbable  that 
the  number  will  yet  be  found  greater  by  observations  in  distant  uncivilized 
countries.  Of  these  fifty,  twenty-one  reside  in  the  alimentary  canal  (Heller), 
several  of  them  being  microscopic.  Of  those  occupying  the  intestines  only, 
the  following  species  are  specially  interesting  to  the  practising  physician  on 
account  of  their  relation — for  the  most  part  causative — to  certain  path- 
ological states  :  to  wit,  the  ascaris  lumbricoides,  or  round-worm  ;  the  oxyuris 
vermicularis,  or  thread-worm ;  the  bothriocephalus  latus  ;  and  three  species 
of  taenia,  or  the  tape-worm  ;  and  the  trichocephalus  dispar,  or  whip-worm. 

Ascaris  Lumbricoides. — The  round-worm  has  a  dingy  reddish  or  yellowish- 
red  color  and  a  cylindrical  form,  tapering  toward  both  extremities  from  the 
point  of  its  greatest  diameter,  which  is  a  little  posterior  to  the  middle.  The 
dead  worm  is  paler  than  the  living.  The  anterior  extremity  is  tipped  with 
three  nodules,  between  which  and  the  body  is  a  circular  groove.  Between 
these  nodules  anteriorly  is  the  aperture  of  the  mouth,  from  which  the  oesoph- 
agus extends  to  the  distance  of  one-fourth  to  one-third  of  an  inch.  The  intes- 
tine, which  has  a  light  browi>ish  color,  extends  from  the  oesophagus  to  near  the 
posterior  extremity  of  the  animal,  where  it  terminates  in  the  anus.  The  fe- 
males are  in  numerical  excess  of  the  males,  and  their  size  is  also  greater. 
The  shape  of  the  worm  is  like  that  of  the  common  earth-worm,  from  which 
it  derives  the  name  lumbricus,  but  it  is  somewhat  more  pointed  and  its  color 
paler  red.  The  tail  of  the  male  worm  is  curved  like  a  hook,  while  that  of 
the  female  is  straight. 

The  total  number  of  eggs  contained  in  a  fully-developed  female  has  been 
estimated  at  sixty  millions.  The  eggs  when  immature  are  conical  and  are 
attached  to  a  longitudinal  band ;  when  mature  they  are  oval,  with  dark  gran- 
ular contents  and  a  strong  double  shell,  and  their  diameter  is  about  gi^-  of 
an  inch.  They  are  expelled  in  countless  numbers  with  the  feces,  and  at  the 
time  of  expulsion  are  surrounded  by  an  albuminous  coating  stained  with  bile. 
Their  vitality  is  retained  under  apparently  very  unfavorable  circumstances, 
even  for  years.  They  hatch  after  they  have  been  repeatedly  frozen  or 
desiccated. 

The  ascaris  lumbricoides  inhabits  the  small  intestines,  where  it  is  rapidly 
developed  from  the  embryonic  state.  The  remark  made  by  Heller,  that  when 
found  in  the  colon  it  is  always  dead,  cannot  be  true,  for  many  live  worms  are 
expelled  in  the  stools. 


766  LOCAL  DISEASES. 

The  round-worm,  more  than  all  other  intestinal  worms,  is  inclined  to  wan- 
der away  from  its  usual  abiding-place — namely,  from  the  jejunum  and  ileum 
— producing  symptoms  of  more  or  less  gravity  referable  to  the  part  over 
which  it  crawls.  It  occasionally  enters  the  stomach,  from  which  it  is  vom- 
ited, or  it  ascends  the  oesophagus  into  the  fauces,  from  which  it  is  soon 
removed  by  the  eiforts  of  the  individual.  Cases  are  on  record — one  of  which 
Andral  witnessed — in  which  the  worm  entered  the  larynx,  producing  suffoca- 
tion and  speedy  death.  M.  Tonnelle  also  witnessed  such  a  case.  A  child 
nine  years  old  was  suddenly  seized  with  great  difficulty  of  respiration  and 
pain  in  the  upper  part  of  the  chest.  A  careful  examination  of  the  thorax 
gave  a  negative  result.  Death  occurred  in  from  twelve  to  fifteen  hours,  and 
at  the  post-mortem  examination  a  lumbricus  was  found  filling  the  cavity  of 
the  larynx.  M.  Blandin  also  witnessed  a  case  when  interne  of  the  Hopital  des 
Enfants.  An  infant  was  suffocated  by  one  of  these  worms,  which  had  pene- 
trated as  far  as  the  right  bronchus.  Very  rarely  they  crawl  from  the  fauces 
into  the  nasal  passages.  This  worm  is  so  strong  and  active  that  there  is  no 
recess  or  reflexion  of  the  mucous  membrane  of  the  digestive  apparatus  which 
it  could  possibly  penetrate  in  which  it  has  not  been  found.  It  has  been  dis- 
covered in  the  appendix  vermiformis,  in  the  pancreatic  duct,  in  the  common 
bile-duct,  and  even  in  the  gall-bladder.  The  number  of  these  worms  found 
in  the  intestines  varies.  There  may  be  only  one  worm  or  the  number  may  be 
incredibly  large.  Thus,  Barrier  relates  the  case  of  an  infant  thirty  months 
old  who  died  in  Hopital  Necker.  It  was  believed  to  be  tubercular.  Numer- 
ous tumors  which  could  be  felt  in  the  abdomen  were  supposed  to  be  tuber- 
cular masses.  On  making  the  post-mortem  examination  the  mesenteric  glands 
were  found  healthy,  but  the  intestines  throughout  their  entire  extent  were 
filled  with  lumbrici.  The  masses  which  during  life  were  supposed  to  be 
tubercular  glands  were  found  to  consist  of  worms.  The  caecum  especially 
was  greatly  distended  by  them.  The  intertwining  or  collection  in  balls  of 
these  worms  constitutes,  indeed,  one  of  the  chief  dangers,  as  it  renders  them 
so  much  the  more  difficult  of  expulsion. 

The  round-worm  possesses  no  organs  of  penetration ;  still,  if  the  intestine 
be  weakened  by  disease,  especially  by  ulceration,  it  may,  by  pressure  with  its 
head,  force  an  opening,  through  which  it  escapes  into  the  cavity  of  the  abdo- 
men, causing  peritonitis  and  death.  This  worm  is  commonly  found,  whether 
single  or  in  masses,  surrounded  by  mucus,  which- serves  as  a  partial  protec- 
tion to  the  intestines.  The  length  of  the  male  round  worm  is  about  four  to 
six  inches ;  that  of  the  female,  eight  to  ten  inches. 

The  portion  of  the  mucous  membrane  in  contact  with  lumbrici  is  often 
found  inflamed,  either  from  movements  of  the  worm  or  from  pressure  of  a 
mass  of  worms,  or  even  of  a  single  worm  in  a  confined  position,  as  the 
appendix  vermiformis.  This  inflammation,  continuing  and  increasing,  may 
end  in  ulceration,  and  thus  a  weakened  spot  be  produced  which  may  be  rup- 
tured by  simple  pressure  of  the  mouth  of  the  worm.  In  this  way  are  to  be 
explained  those  apparent  cases  of  perforation  which  have  led  some  observers 
to  believe  that  lumbrici  have  actually  the  power  of  penetrating  the  healthy 
coats  of  the  intestines.  The  perforation  is  obviously  most  liable  to  occur  in 
those  who  have  been  enfeebled  and  who,se  tissues  have  been  rendered  less 
firm  and  resisting  by  antecedent  disease,  as  by  typhoid  fever. 

M.  Gruersant  describes  a  case  in  which  the  appendix  vermiformis  con- 
tained an  ulcerated  opening  through  which  two  round-worms  had  partly 
passed  into  the  abdominal  cavity,  producing  fatal  perityphlitis.  The  effect 
of  their  impaction  in  this  narrow  cul-de-sac  was  much  like  that  of  a  bean  or 
a  seed  lodged  in  the  same  situation. 

The  ascaris  lumbricoides  has  occasionally  been  found  in  the  most  remark- 


INTESTINAL    WORMS.  767 

able  locations — namely,  in  abscesses  lying  without  the  intestines.  They 
have  been  known  to  effect  a  lodgement  in  the  liver  and  produce  an  abscess 
there,  no  doubt  by  crawling  up  and  distending  a  bile-duct.  Their  lodgement 
in  other  viscera  which  have  no  pervious  connections  with  the  intestinal  tract 
is  probably  accomplished  through  fistulous  openings  produced  by  inflamma- 
tion, which  they  had  no  part  in  causing,  as,  for  example,  in  the  bladder  and 
kidneys,  of  which  there  are  well-authenticated  cases.  Worm-cysts  in  the 
abdominal  walls  have  been  found  to  occur  in  most  instances  in  the  usual  site 
of  hernias — namely,  at  the  umbilicus  in  children  and  in  the  inguinal  region 
in  adults.  It  is  presumed,  therefore,  that  the  worms  had  entered  hernial 
protrusions,  from  which  they  had  passed  by  ulceration  into  the  abdominal 
walls,  and  had  there  become  encapsulated. 

The  oxyuris  vermicularis,  or  thread-worm,  so  called  from  its  resemblance 
to  pieces  of  ordinary  white  sewing-thread,  is  also  frequent  in  childhood  and 
not  infrequent  in  the  adult.  The  length  of  the  male  oxyuris  is  from  one- 
sixth  to  one-fifth  of  an  inch ;  that  of  the  female,  from  one-third  to  one-half 
an  inch.  The  posterior  extremity  of  the  male  is  blunt,  and  is  curved  or 
rolled  up  toward  its  abdomen ;  that  of  the  female  is  slender  and  pointed  like 
an  awl. 

The  head  of  this  worm  is  relatively  broad,  from  an  unusual  thickness  or 
fulness  of  the  cuticle,  and  the  mouth,  surrounded  by  '•  three  nodular  lips," 
is  situated  in  the  centre  of  the  extremity.  The  oesophagus  extends  back- 
ward from  the  mouth,  gradually  growing  larger  like  the  segment  of  a  long 
and  narrow  cone,  and  ending  in  a  globular  enlargement  which  has  been  desig- 
nated the  pharynx.  From  the  pharynx  the  intestine  runs  in  nearly  a  straight 
line  through  the  worm. 

The  eggs  are  numerous,  so  completely  filling  the  interior  of  the  female 
as  to  conceal  the  organs  from  view.  They  are  flattened  on  one  side,  but  are 
rounded  or  convex  on  other  parts  of  their  circumference.  One  end  is  more 
pointed  than  the  other,  as  in  the  eggs  of  birds.  Certain  of  the  eggs  in  the 
mature  female  are  seen  to  be  undergoing  segmentation  preparatory  to  hatch- 
ing, while  others  more  advanced  contain  tadpole-shaped  embryos,  and  others 
still  contain  worm-shaped  embryos  either  lying  within  the  shells  or  protrud- 
ing from  them.  The  hatching  and  growth  of  this  worm,  which  have  been 
observed  under  the  microscope,  are  very  rapid  under  favorable  circumstances. 
"I  once,"  says  Heller,  "saw  the  metamorphosis  from  the  tadpole-shaped 
embryo  to  the  worm-shaped  embryo  completed  in  about  one  hour,"  but  the 
usual  time  is  longer.  Leuekhart  saw  oxyurides  one-fourth  of  an  inch  in 
length  fourteen  days  after  the  eggs  had  been  swallowed. 

Oxyurides  may  be  developed  so  rapidly  from  eggs  swallowed  in  the 
ingesta  that  they  attain  nearly  or  quite  their  full  growth  while  still  in  the 
small  intestines,  so  that,  although  their  chosen  residence  is  in  the  large  intes- 
tines, some  of  them  are  not  infrequently  found  in  the  ileum,  and  even  in 
the  jejunum,  of  full  size  and  active.  The  part  of  the  intestinal  tract  which 
the  oxyurides  prefer,  and  in  which  the  largest  colony  of  them  reside,  is  the 
caecum  and  appendix  vermiformis,  and  not  in  the  rectum,  as  stated  in  most 
of  the  books;  and  in  this  situation,  where  they  have  been  little  disturbed, 
their  habits  and  the  relative  proportion  of  the  sexes  can  be  best  observed. 
But  they  are  ordinarily  found  both  in  the  caecum  and  rectum  in  the  same 
individual,  and  indeed  upon  all  parts  of  the  intervening  surface  of  the  colon. 

The  number  of  oxyurides  in  the  individual  varies  greatly.  They  are 
occasionally  so  numerous  upon  the  intestinal  surface  that  they  resemble  fur, 
and  when  they  are  so  abundant  they  are  commonly  found  above  the  ileo- 
caecal  valve  as  well  as  below  it.  The  males  are  smaller  and  apparently  more 
fragile  and  perishable  than  the  female.     Therefore  in  the  rectum  and  other 


768  LOCAL  DISEASES. 

exposed  situations  there  is  a  numerical  excess  of  the  females ;  but  in  reflex- 
ions of  the  intestines,  where  they  are  securely  lodged,  as  in  the  appendix 
vermiformis,  no  marked  difference  has  been  observed  in  the  relative  number 
of  the  two  sexes.  Since  the  males  are  more  delicate,  transparent,  and 
smaller  than  the  females,  they  are  more  likely  to  be  be  overlooked  in  a  hasty 
post-mortem  examination. 

The  term  tape-worm  is  applied  to  several  species  of  the  taenia  and  to  at 
least  two  species  of  the  bothriocephalus,  but  all  except  four — to  wit,  the 
taenia  solium,  taenia  saginata  or  medio-canellata,  taenia  elliptica  or  cucumer- 
ina,  and  the  bothriocephalus  latus— are  rare  in  Europe  and  North  America, 
and  are  therefore  of  little  interest  to  the  practising  physician. 

The  tape-worm  is  an  hermaphrodite,  each  segment  containing  the  two 
sexual  organs.  The  head,  or  scolex,  is  small,  or  about  the  size  of  a  pin's 
head,  and  segment  after  segment  is  produced  by  a  budding  process  from  the 
head.  The  segments  are  attached  to  each  other  at  their  extremities,  and  each 
segment  as  it  becomes  farther  and  farther  removed  from  the  head  by  the 
foi'mation  of  new  intervening  segments  at  the  upper  end  of  the  chain, 
becomes  also  larger  and  more  matured.  The  oldest  segments,  having 
attained  their  full  growth,  are  detached,  and  have  an  independent  existence. 
A  separation  of  the  chain  of  segments  at  any  point  does  not  compromise  the 
life  of  the  parasite.  If  only  the  head  remain  uninjured,  the  segmentation 
continues  from  it,  and  in  time  the  former  number  of  segments  and  former 
length  of  the  chain  are  restored.  This  worm  resides  in  the  small  intestines, 
the  larger  species  sometimes  extending  from  the  upper  part  of  the  jejunum 
to  near  the  ileo-caecal  valve. 

The  tsenia  solium  is  developed  from  an  embryo  known  as  the  cysticercus 
cellulosae  contained  in  the  muscles  of  the  hog.  It  has  also  been  found  in 
some  other  animals,  as  the  dog,  deer,  and  polar  bear.  It  is  a  vesicle  about 
the  size  of  a  pea  or  small  bean,  having  a  delicate  cell-wall,  and  is  nearly 
spherical,  except  as  its  shape  is  changed  by  compression  between  the  muscu- 
lar fibres.  At  one  point  of  the  cell-wall  is  a  depression,  attached  to  the 
inner  surfaces  of  which,  and  lying  within  the  cyst,  is  a  whitish,  pear-shaped, 
solid  body,  which  is  the  head  of  the  cysticercus,  and  is  identical  in  appear- 
ance and  character  with  the  head  of  the  taenia  solium  turned  inside  out. 
Many  experiments  have  shown  the  close  relationship  of  the  cysticercus  and 
taenia  solium — that  they  are  two  forms  of  existence  of  the  same  parasite. 
Segments  of  the  taenia  solium  have  been  repeatedly  fed  to  pigs,  and  the 
cysticercus  produced  in  their  muscles,  though  in  what  way  the  ovum  or 
embryo  passes  from  the  stomach  to  the  muscles  is  not  known.  On  the  other 
hand,  swine-flesh  containing  cysticerci  has  been  fed  to  animals  who  were 
soon  after  killed,  when  the  taenia  was  found  in  their  intestines.  It  is  evident 
that  this  parasite  occurs  only  in  those  who  eat  swine-flesh,  as  sausages,  either 
raw  or  but  slightly  cooked. 

The  head  of  this  species  of  taenia,  which  is  about  the  size  of  a  small  pin's 
head,  has  at  the  top  a  conical  protuberance,  upon  which  is  a  corona  of  hook- 
lets  arranged  in  two  circles,  the  booklets  of  the  outer  circle  being  smaller 
than  those  of  the  inner.  The  projecting  points,  however,  of  the  two  rows 
fall  together,  forming  one  circle.  The  booklets  are  inserted  into  depressions 
in  the  head,  and  many  of  them  have  fallen  out  in  most  specimens  which  we 
have  had  an  opportunity  of  examining.  The  depressions  in  which  the  hook- 
lets  are  lodged  are  often  dark  from  pigmentation.  Back  of  the  circle  of 
hooks  are  four  sucking  disks,  which  the  worm  is  able  to  protrude  and  move 
freely.  When  protruded  they  appear  as  small  tubercles  with  slender  pedi- 
cles. The  neck,  which  is  slender  and  about  one  inch  in  length,  shows  mark- 
ings from  commencing  segmentation,  and  it  is  succeeded  by  very  small  and 


INTESTINAL    WORMS.  769 

delicate  segments,  which  gradually  increase  in  size  as  the  distance  from  the 
head  increases. 

The  mature  segments  (proglottides)  vary  in  size  accordingly  as  they  are 
in  a  state  of  contraction  or  relaxation.  When  relaxed  their  length  is  about 
half  an  inch  and  breadth  one-quarter  of  an  inch.  The  genital  organs  are 
situated  on  the  margin  of  each  segment,  a  little  posterior  to  the  middle,  and 
there  is  an  alternation  in  their  location  between  the  right  and  left  margins  in 
the  chain  of  segments.  The  uterus  lies  in  the  centre  of  the  segment,  form- 
ing a  longitudinal  straight  line.  From  seven  to  twelve  branches  are  given 
ofi"  from  each  side  of  the  uterus,  and  these  divide  and  subdivide  like  the 
branches  of  a  tree.  The  male  genital  organs  lie  in  the  same  aperture  or 
pore  in  the  margin  of  the  segment,  with  which  the  uterus  and  ovaries 
connect. 

The  eggs  of  the  taenia  solium  are  globular,  with  a  diameter  of  about 
Y^th  of  an  inch,  and  with  thick  shells,  which  are  striated  like  mosaic-work 
by  lines  which  cross  each  other.  It  is  estimated  that  not  less  than  fifty  mil- 
lion eggs  are  contained  in  all  the  segments  of  a  matured  taenia. 

This  parasite  is  very  liable  to  abnormal  development.  In  some  instances 
two  or  more  segments  are  fused  together,  and  often  they  are  stunted  in  their 
growth,  or  they  contain  holes,  fissures,  and  flaws,  either  from  their  original 
development  or  produced  by  rupture  of  the  distended  uterus.  Again,  rarely, 
two  taenia  are  blended,  so  that  along  the  flat  side  of  one  chain  another  is 
united  by  the  margin,  so  that  a  section  of  the  double  parasite  resembles  the 
Roman  letter  T  or  Y.  The  nutrition  of  the  segments  is  maintained  through 
a  vessel  running  the  whole  length  of  the  worm  near  each  margin  and  having 
communicating  branches. 

The  tsenia  saginata,  designated  also  medlo-canellata^  is  much  larger,  stronger, 
and  thicker,  both  as  regards  the  head  and  segments,  than  the  taenia  solium. 
When  fully  matured  it  measures  eighteen  feet.  The  diameter  of  the  head  is 
nearly  one  line  (y-Q-g-  inch).  It  is  furnished  with  four  strong  sucking-disks, 
but  it  lacks  the  circlet  of  hooks  which  characterizes  the  taenia  solium.  Instead 
of  the  hooks  the  head  is  furnished  with  a  small  frontal  sucking-disk.  The 
heads  of  some  specimens  of  this  worm  are  free  from  pigment,  but  other 
specimens  present  various  shades  of  pigmentation,  from  a  slight  staining  to  a 
jet-black  color.  The  neck  is  short,  and  very  near  the  head  are  markings 
which  indicate  commencing  segmentation.  The  matured  segments  vary  in 
measurement  when  relaxed — from  a  length  of  eight  lines  and  breadth  of  two 
lines  to  a  length  of  nine  lines  and  breadth  of  three  lines.  As  in  the  taenia 
solium,  the  genital  pores  are  situated  on  the  margins  of  the  segments,  vary- 
ing irregularly  from  side  to  side,  and  the  uterus  has  lateral  branches  which 
divide  dichotomously.  There  is  but  little  diff"erence  in  the  sexual  apparatus 
of  the  taenia  solium  and  taenia  saginata,  but  the  eggs  of  the  latter  are  some- 
what larger  than  those  of  the  former,  and  are  oval. 

The  development  of  the  taenia  saginata  is  sometimes  irregular,  producing 
monstrosities,  as  in  the  taenia  solium.  The  embryos  of  this  parasite  occur 
chiefly  in  the  muscles  of  ruminating  animals,  as  the  ox,  sheep,  goat,  etc.,  and 
therefore  its  presence  in  man  is  attributable  to  the  use  of  the  flesh  of  these 
animals,  either  slightly  cooked  or  raw.  The  eysticercus  of  this  species 
appears  to  be  less  tenacious  of  life  than  that  of  the  taenia  solium,  and  when 
it  perishes  it  becomes  changed  into  a  greenish-yellow  pulp,  surrounded  by  the 
capsule  and  imbedded  in  the  muscular  or  other  tissue  where  it  had  lodged. 

It  is  easy  to  distinguish  this  worm  from  the  taenia  solium,  if  the  head  be 

found,  by  its  larger  size,  the  larger  size  of  its  sucking-disks,  and  the  absence 

of  the  circle  of  hooks.     The  segments  are  distinguished  by  their  greater  size 

and  greater  number  and  the  dichotomous  division  of  the  branches  of  the 

49 


770  LOCAL  DISEASES. 

uterus.  This  species  occurs  over  a  much  greater  area  of  the  earth's  surface 
than  the  tceuia  solium. 

The  tsenia  elUptica  or  cucumerina  is  a  more  delicate  worm  than  the  pre- 
ceding species,  measuring,  when  fully  grown,  from  seven  to  ten  or  eleven 
inches  in  length.  Upon  its  head  is  a  rostellum  or  beak,  which  the  worm  is 
able  to  thrust  forward,  and  on  which  are  about  sixty  hooks  irregulai'ly 
arranged.  The  anterior  portion  of  the  parasite  is  very  delicate,  like  a  thread, 
and  its  segments  are  small,  but,  as  in  the  other  species,  they  become  larger  as 
their  distance  from  the  head  increases.  The  matured  segments,  which  have 
a  reddish-white  color,  are  readily  detached,  and  when  separated  they  move 
about  actively.  This  taenia  is  also  an  hermaphrodite,  and  a  genital  pore  con- 
taining a  double  set  of  genital  organs  is  located  on  each  margin  of  the  seg- 
ment. The  taenia  elliptica  inhabits  the  small  intestines  of  the  dog  and  cat, 
and  many  children  in  diiFerent  localities  have  been  affected  with  it. 

Heller  states  that  the  segments  of  another  and  rare  species  of  taenia, 
which  were  expelled  from  a  child  of  nineteen  months,  are  preserved  in  the 
Museum  of  Pathological  Anatomy  in  Boston.  Nearly  in  the  middle  of  the 
posterior  half  of  each  segment  is  a  yellow  spot — namely,  the  receptaculum — 
full  of  ova,  and  therefore  the  name  flavo-punctata  has  been  applied  to  this 
worm.  Little  is  known  in  regard  to  the  taenia  nana  and  taenia  Madagascarien- 
sis,  since  they  occur  in  distant  countries. 

The  hothriocephalus  latus  is  the  largest  of  the  tape-worms,  attaining  the 
length  of  fifteen  to  twenty-four  feet.  It  is  one  of  the  most  important  of 
the  intestinal  parasites.  The  head  has  an  almond-shape  or  the  shape  of 
an  elongated  and  somewhat  flattened  globe,  its  length  being  about  one 
line  and  its  diameter  from  one-third  to  one-half  a  line.  Running  longi- 
tudinally along  each  flattened  side  of  the  head  is  a  groove  or  fissure  contain- 
ing the  apparatus  of  suction.  Those  segments  which  are  still  in  the  process 
of  growth  have  a  breadth  three  or  four  times  greater  than  their  length,  while 
the  matured  segments  are  nearly  square.  The  genital  pore  occurs  in  the 
centre  of  one  side  of  the  segment,  and  in  the  chain  of  segments  all  the  pores 
are  found  on  the  same  side.  A  brownish,  rosette-shaped  spot  is  observed  at 
the  site  of  each  ripe  pore,  produced  by  the  convolutions  of  the  uterus  and 
the  numerous  eggs  which  this  organ  contains. 

The  egg,  which  is  oval,  has  a  thin  shell,  a  light-brown  color,  and  at  one 
end  of  it  is  a  lid  or  operculum  which  is  separated  from  the  rest  of  the  egg  by  a 
well-defined  line.  At  the  hatching  an  embryo  provided  with  six  hooks  escapes 
from  the  lid.  When  it  has  separated  from  the  egg  it  is  provided  with  an 
albuminous  covering  from  which  cilia  radiate  in  all  directions,  by  the  move- 
ment of  which  it  is  propelled.  After  a  few  days  this  covering  is  lost,  and 
the  embryo  now  moves  about  by  amoeboid  extension  and  contraction.  It  is 
believed  that  in  this  embryonic  state  it  enters  an  aquatic  animal,  a  moUusk 
or  fish,  where  it  undergoes  further  development,  and  from  the  mollusk  it  is 
received  into  the  stomach  in  the  food. 

The  hothriocephalus  occurs  not  only  in  man,  but  also  in  some  of  the 
domestic  animals  which  eat  fish,  as  the  dog.  This  parasite  is  believed  to  be 
rare  outside  of  Europe,  and  in  Europe  it  is  chiefly  met  in  countries  bordering 
on  inland  lakes  and  seas. 

The  trichocejjhalus  dispar  is  comparatively  unimportant  to  the  physician, 
since  it  is  uncertain  whether  it  materially  impairs  the  health  or  produces 
symptoms.  It  inhabits  the  caecum,  but  in  rare  instances  it  has  been  found 
in  the  ileum  and  appendix  vermiformis.  The  number  of  these  parasites  is 
usually  small,  but  as  many  as  seventy  to  one  hundred  have  been  observed  in 
the  intestine  of  the  adult. 

The  trichocephalus  dispar  occurs  also  in  the  monkey,  and  a  very  similar 


INTESTINAL    WORMS.  771 

if  not  identical  worm  has  been  found  in  the  pig.  It  is  not  frequent  in 
children,  and  has  not  been  observed  in  the  very  young.  It  occurs  in  man 
in  every  part  of  the  globe,  and  in  some  countries,  as  Egypt,  Nubia,  and 
Syria,  it  is  said  to  be  very  common.  This  worm,  which  is  also  sometimes  desig- 
nated the  whip-worm  from  its  shape,  attains  the  length  of  one  and  a  half  to 
two  inches,  the  female  being  longer  than  the  male.  Its  anterior  two-thirds 
are  thin,  delicate,  and  flexible,  like  a  small  thread.  The  posterior  one-third, 
which  contains  the  generative  organs  and  intestinal  canal,  is  considerably 
thicker,  and  it  ends  abruptly.  On  the  under  surface,  extending  nearly  the 
whole  length  of  the  body,  is  a  longitudinal  band,  the  width  of  which  is  about 
one-third  the  circumference  of  the  body.  In  the  female  the  posterior  or 
thick  portion  of  the  worm  is  slightly  bent  or  curved  like  the  stock  of  a  hunt- 
ing-whip, while  that  of  the  male  is  rolled  in  the  spiral  form.  The  digestive 
tube  consists  of  an  oesophagus,  which  extends  through  the  anterior  thread- 
like part,  and  the  stomach  and  rectum,  which  lie  in  the  posterior  thick 
division.  The  genitals  of  the  female  lie  in  the  commencement  of  the  thick 
portion,  and  the  uterus,  when  distended  with  eggs,  occupies  nearly  the  whole 
of  this  section.  In  the  male  the  pore  which  contains  the  genitals  lies  in  the 
posterior  extremity  of  the  thick  part,  where  it  forms  a  cloaca  with  the  termi- 
nation of  the  intestinal  canal.  The  eggs,  which  are  numerous,  are  oval, 
brownish,  and  with  a  glistening  protuberance  at  each  extremity,  giving  them 
the  shape  of  a  lemon.  They  have  great  vitality,  hatching  after  repeated 
desiccation  and  freezing.  Their  development  from  the  egg  is  slow.  It  is 
believed  that  the  trichocephalus  is  produced  directly  from  the  egg,  which 
has  lodged  in  the  intestine,  and  therefore  does  not  have  or  require  an  inter- 
mediate stage  of  preparation  in  another  animal.  This  parasite  resides  in  the 
caecum,  but  when  many  are  present  some  are  found  in  the  ascending  colon, 
and  occasionally  a  few  are  observed  in  the  small  intestine. 

The  taenia  is  rare  in  early  life,  but  it  now  and  then  occurs  in  young  chil- 
dren. I  have  met  cases  in  this  city  under  the  age  of  five  years.  Rosen  and 
Bremser  report  cases  between  the  ages  of  six  and  eleven  years,  and  Hufe- 
land  one  at  the  age  of  six  months.  Wawruch  collected  206  observations  of 
taenia,  in  22  of  which  the  age  was  less  than  fifteen  years ;  the  youngest  was 
a  girl  of  three  years.  A  most  remarkable  case  of  t^nia  is  reported  in  the 
Gazette  medkale  of  Paris  in  1837.  M.  Mtiller  was  called  to  treat  a  foster- 
child  five  days  old  for  slight  constipation.  The  bowels  were  evacuated  by 
the  use  of  rhubarb,  manna,  and  a  few  grains  of  salt,  and  in  the  excrement 
a  foot  and  a  half  of  taenia  were  discovered.  This  worm  had  evidently  existed 
during  the  foetal  life  of  the  infant. 

A  similar  case  was  treated  by  Prof.  Skene  in  the  Long  Island  Hospital  in 
September,  1871,  and  reported  by  Dr.  Armor.'  The  infant  was  born  Septem- 
ber 3d  of  a  hearty  Irish  servant-girl.  On  the  7th  it  refused  to  nurse,  and 
was  observed  to  have  a  mild  form  of  tetanus.  On  the  8th,  small  doses  of 
calomel  having  been  given,  followed  by  castor  oil,  two  segments  of  a  taenia 
solium  were  passed  from  the  bowels,  and  on  subsequent  days  ten  more  seg- 
ments, after  which  the  tetanus  ceased.  The  remedies  employed  after  Sep- 
tember Sth  were  the  oil  of  male  fern  and  turpentine.  The  mother,  who  had 
presented  no  symptoms  of  tccnia.  was  ordered  an  emulsion  of  pumpkin-seeds, 
which  ■•  she  faithfully  took  for  twenty-four  hours,  at  the  end  of  which  she 
passed  over  seventy  segments  of  taenia."  This  case  is  interesting  as  throw- 
ing light  on  a  possible  mode  of  the  production  of  taenia  quite  different  from 
the  ordinary  and  recognized  mode,  and  also  as  showing  the  causative  relation 
of  intestinal  worms  to  tetanus  infantum. 

Causes. — It  is  obvious  that  intestinal  worms  are  developed  from  eggs  or 
^  Neio  York  Medical  Journal. 


772  LOCAL  DISEASES. 

embryos  which  are  introduced  into  the  stomach  in  the  ingesta.  The  eggs  of 
the  ascaris  lumbrieoides  have  been  found  by  Mosler  ^  in  drinking-water,  but  it 
is  probable  that  in  most  instances  they  are  contained  in  fruits  and  vegetables 
which  are  eaten  raw.  The  eggs  of  the  oxyuris  vermicularis  are  received 
from  some  one  who  is  himself  affected  with  the  disease.  Both  Zender  and 
Heller  state  that  they  have  frequently  discovered  ripe  eggs  of  this  worm 
around  the  nails  of  persons  who  were  troubled  with  oxyurides — a  fact  readily 
explained  from  the  itching  which  they  cause.  If  these  eggs  are  upon  the 
fingers  of  the  mother  or  nurse,  it  is  easy  to  understand  how  they  are  acquired 
by  the  child.  We  can  understand  also  why  this  worm  is  so  common  in 
degraded  and  filthy  families.  In  reference  to  the  etiology  of  the  tape- 
worm nothing  need  be  added  to  what  has  been  stated  above,  and  little  is 
known  in  reference  to  the  manner  in  which  the  eggs  of  the  trichocephalus 
are  received. 

Certain  conditions  of  the  intestinal  surface  favor  the  recurrence  of  worms. 
Thus  children  in  advanced  typhoid  fever  are  not  unfrequently  afi"ected  with 
the  ascaris  lumbrieoides. 

Symptoms  of  the  Ascaris  Lumbricoiues. — These  are  in  part  constitu- 
tional and  in  part  local,  due  to  the  mechanical  eiFect  of  the  entozoa  on  the 
coats  of  the  intestines.  Writers,  especially  Rilliet  and  Barthez,  have 
described  with  minuteness  the  symptoms  supposed  to  indicate  lumbrici. 
Those  of  a  constitutional  character  are  the  following :  Features  at  one  time 
flushed,  at  another  pallid,  and  in  some  children  of  a  leaden  hue  ;  lower  eye- 
lids swollen,  and  sometimes  surrounded  by  a  blue  semicircle  ;  thirst,  nausea, 
or  even  vomiting ;  appetite  diminished  or  augmented  or  variable ;  breath 
foul;  papillfe  of  the  tongue  red  and  projecting;  pulse  accelerated  and  irreg- 
ular. Rilliet  and  Barthez  state  that  they  observed  this  irregularity  of  the 
heart's  action  in  a  boy  three  years  old  at  the  time  he  was  passing  a  large 
number  of  lumbrici.  The  irregularity  afterward  disappeared.  Acceleration 
of  the  pulse  and  increase  in  temperature  are  common  symptoms  of  these 
worms,  and  hence  the  popular  belief  in  a  worm  fever.  This  fever  is  often 
remittent  and  mild,  but  occasionally  it  is  continuous  and  of  a  high  grade. 

The  symptoms  pertaining  to  the  nervous  system  are  important.  In  mild 
cases  these  may  be  absent,  as  when  there  are  few  lumbrici  and  the  child  is 
robust  and  over  the  age  of  five  years,  but  in  severe  cases  certain  neuropathic 
symptoms  are  frequently  present,  such  as  dilatation  of  the  pupils,  especially 
inequality  of  dilatation,  to  which  Munro  attached  diagnostic  value,  strabis- 
mus, twitching  of  the  muscles,  clonic  convulsions,  somnolence,  headache,  neur- 
algic pains,  delirium.  Rarely,  chorea,  deafness,  and  paralysis,  it  is  believed, 
may  result.'-^  Dr.  Leedom  ^  of  Montgomery  county,  Pa.,  relates  the  case  of  a 
boy  of  seven  years  who  had  night-blindness  due  to  a  large  number  of  lum- 
brici in  the  intestines.  By  the  employment  of  pinkroot  and  calomel  these 
were  passed  and  the  blindness  ceased.  Hypersesthesia  of  the  abdominal 
surface  was  present  in  a  case  which  I  attended,  and  which  subsided  as  soon  as 
the  lumbrici  were  expelled.  Grinding  the  teeth  in  sleep  and  picking  the  nos- 
trils are  symptoms  to  which  families  attach  great  value.  Observations,  how- 
ever, show  that  though  sometimes  due  to  worms  they  more  frequently  have 
another  cause. 

The  local  symptoms  or  disorders — in  other  words,  those  having  a  mechan- 
ical origin — are  colicky  pains,  experienced  chiefly  in  the  umbilical  region  ; 
stools  sometimes  natural ;  in  other  cases  diarrhoea  with  fecal  or  muco'san- 
guineous  stools  ;  flatulence.  M.  Davaine  at  a  recent  period  made  the  import- 
ant discovery  that  the  feces  of  patients  affected  with  worms  contain   the   ova 

^  Virchow's  Archiv,  1860.  2  Gaz.  de  Hopitaux,  1867. 

^  Amer.  Journ.  of  Med.  Sci.,  for  July,  1867. 


INTESTINAL    WORMS.  773 

of  the  particular  species  present  in  large  numbers.  These  ova,  which  have 
been  described  above,  can  be  seen  through  a  lens  magnifying  one  hundred  and 
fifty  diameters. 

In  exceptional  cases  there  are  local  symptoms,  due  to  the  presence  of 
these  worms  in  unusual  situations,  such  as  a  crawling  sensation  in  the  oesoph- 
agus ;  a  sense  of  constriction  in  this  tube  or  the  pharynx  ;  nausea  and  vomit- 
ing ;  a  cough,  especially  if  the  worm  have  crawled  to  the  upper  part  of  the' 
oesophagus ;  rarely  the  most  urgent  dyspnoea  and  probable  suffocation  if 
a  lumbricus  have  entered  the  larynx.  Earache  and  perhaps  convulsions  if 
the  worm  have  entered  the  Eustachian  tube  (case  Davaine,  p.  144).  The 
most  dangerous  symptoms  arise  from  the  crawling  of  the  worm  into  narrow 
openings. 

The  enteritis  and  colitis  to  which  these  worms  sometimes  give  rise  are 
ordinarily  mild,  but  in  rare  instances  ulceration  occurs,  which  may  be  attended 
by  profuse  and  even  fatal  hemorrhage.  Occasionally  very  painful  and 
dangerous  constipation  results  from  an  accumulation  of  worms  in  a  ball  or 
mass  too  large  to  be  expelled,  unless  with  much  delay  and  suffering,  prevent- 
ing the  passage  of  fecal  matter  and  producing  severe  abdominal  pains.  The 
symptoms  in  these  cases  resemble  closely  those  of  intussusception.  A  marked 
example  of  constipation  produced  in  this  way  occurred  in  a  family  with  whom 
I  am  acquainted,  and  who  then  resided  in  the  interior  of  this  State.  A  little 
girl  of  three  or  four  years  was  suddenly  affected  with  obstinate  constipation. 
The  physicians  prescribed  active  purgatives,  calomel  among  others,  and  finally 
croton  oil  and  various  injections,  without  relief.  There  was  great  pain  with 
distention  of  the  abdomen,  and  death  seemed  inevitable,  when  after  the  lapse 
of  several  days  a  free  evacuation  occurred,  and  in  the  stool  was  a  mass  of 
worms  firmly  intertwined. 

Children  often  have  lumbrici  without  any  appreciable  impairment  of  the 
general  health,  but  their  presence  may  intensify  the  symptoms  of  inter- 
current diseases  and  greatly  increase  the  danger.  Thus  I  recollect  two 
children  of  three  and  three  and  a  half  years  with  pneumonia  who  at  the 
same  time  had  lumbrici,  one  passing  in  the  course  of  a  few  days  thirty  and 
the  other  twelve  of  these  entozoa.  Both  presented  well-marked  physical 
signs  of  pneumonia,  and.  though  they  recovered,  the  fever  and  nervous 
symptoms  were  apparently  aggravated  by  the  intestinal  affection.  One  had 
convulsions  in  the  commencement  of  the  inflammation,  fullowed  by  profound 
stupor  and  amaurosis  lasting  two  or  three  days. 

Often  the  symptoms  due  to  lumbrici  coexist  with  those  of  a  protracted 
and  distinct  intestinal  disease.  Thus,  as  we  have  seen,  the  intestinal  secre- 
tions of  typhoid  fever  and  of  chronic  diarrhoeal  maladies  afford  a  nidus  for 
the  growth  of  worms,  and  accordingly  at  an  advanced  stage  of  these  diseases 
lumbrici  are  common. 

The  symptoms  produced  b}"  the  oxyurh  verinicularis  are  somewhat  differ- 
ent. These  worms  do  not  usually  cause  the  fever,  disturbed  digestion,  the 
colicky  pains,  or  the  dangerous  nervous  symptoms  which  arise  from  the 
presence  of  lumbrici.  Nor  do  they,  like  lumbrici,  endanger  life  by  crawling 
into  unusual  situations.  In  one  recent  case  I  could  detect  no  other  cause 
of  chorea  than  the  presence  of  oxyurides,  and  eclampsia  has  been  attributed 
to  them,  but  such  a  result  is  exceptional,  if  indeed  the  cause  be  rightly 
assigned. 

Although  the  caecum  is  the  chosen  abode  of  this  worm,  and  here  more 
than  elsewhere  it  exists  in  its  normal  state,  it  is  not  certain  that  it  produces 
any  appreciable  symptoms  in  this  part  of  the  intestinal  tract. 

The  symptoms  which  render  this  the  most  annoying  of  all  the  intestinal 
parasites  are  produced  by  these  oxyurides,  chiefly  the  females,  which  descend 


774  LOCAL  DISEASES. 

into  the  rectum,  where  by  their  active  movements  they  produce  intense  itch- 
ing. A  small  number  of  worms  cause  little  inconvenience,  but  when  many 
are  present  in  the  folds  of  the  rectum  their  crawling  produces  such  intense 
pruritus  that  the  patient  can  with  difficulty  remain  quiet.  Usually  this 
symptom  is  most  marked  in  the  early  evening,  when  the  child  is  warm  in 
bed.  It  sometimes  causes  onanism  in  the  girl  as  well  as  boy.  This  symptom 
may  be  nearly  or  quite  absent  during  the  day,  but  it  returns  so  regularly  at 
night  as  to  resemble  and  be  mistaken  for  a  periodical  nervous  affection.  So 
eminent  a  physician  as  Cruveilhier  confesses  that  he  has  made  this  mistake 
of  diagnosis.  In  the  female  child  the  oxyuris  occasionally  passes  from  the 
rectum  to  the  vulva,  producing  leucorrhoea. 

In  many  instances  tape-worms  exist  in  children  as  well  as  adults  who 
thrive  and  present  no  symptoms,  but  in  other  instances  there  is  more  or  less 
disturbance  of  the  digestive  function,  with  an  uncomfortable  sensation  in  the 
abdomen.  This  sensation  is  more  noticed  after  fasting  or  after  the  use  of 
certain  kinds  of  food,  and  it  is  diminished  by  a  full  meal.  Great  hunger  and 
a  feeling  of  faintness  are  also  common,  according  to  authorities,  but  I  have 
not  particularly  remarked  them  in  children.  Irregular  action  of  the  bowels, 
vomiting  and  various  nervous  symptoms,  as  itching  of  the  nostrils  and  anus, 
headache,  tinnitus  aurium,  cardialgia,  numbness,  deafness,  blindness,  etc. 
have  with  more  or  less  correctness  been  attributed  to  the  tape-worm.  Cer- 
tainly, such  symptoms  occasionally  arise  from  this  cause,  for  they  cease  with 
the  expulsion  of  the  worm.^  Intermittent  colicky  pains  in  the  umbilical 
region  were  the  only  marked  symptoms  in  a  child  with  taenia  which  I 
recently  treated.  Since  the  cysticercus  cellulosse  is  the  embryonic  form  of 
the  taenia  solium,  it  is  quite  possible  that  individuals  possessing  the  latter 
may  be  infected  from  its  ova  with  the  former,  so  that  symptoms  which  have 
been  attributed  to  the  intestinal  parasite  have  sometimes  been  due  to  the 
encysted  embryo.  We  are  unacquainted  with  the  symptoms  of  the  tricho- 
eephalus,  if  any  occur,  and  this  worm  is  very  rare  in  children. 

Diagnosis.  —  Bremser  long  since  made  the  remark — and  it  has  been 
repeated  by  most  writers  on  diseases  of  children — that  there  is  no  sign  or 
symptom  which  affords  positive  proof  of  the  presence  of  intestinal  worms 
except  the  expulsion  of  one  or  more.  In  recent  years,  however,  microscopic 
investigations  have  revealed  a  pathognomonic  sign — namely,  the  presence  of 
ova  in  the  feces,  which  indicates  not  only  the  nature  of  the  disease,  but  the 
species  of  the  worm. 

The  symptoms  and  disorders  produced  by  lumbrici  may  all  occur  from 
other  causes.  Still,  if  several  of  them  be  present  and  a  careful  examina- 
tion disclose  no  other  cause,  the  pres-ence  of  worms  should  be  suspected, 
provided  that  the  child  be  over  the  age  of  two  years.  The  microscope  may 
then  be  used  for  diagnosis.  A  little  tentative  treatment,  entirely  safe  to  the 
child,  will  also  determine  whether  the  suspicion  be  correct.  One  or  two 
doses  of  medicine,  administered  under  such  circumstances,  like  the  surgeon's 
exploring  needle  may  reveal  the  nature  of  the  disease  and  indicate  the  means 
of  cure. 

In  the  case  of  the  oxyuris  vermicularis  the  itching  directs  attention  to 
the  anus  as  the  place  of  the  disease,  and  here  the  offending  entozoa  may 
often  be  discovered  by  the  eye. 

Prognosis. — Intestinal  worms  produce  a  fatal  result  in  only  a  small  pro- 
portion of  cases.  Oxyurides  never  prove  fatal,  unless  in  rare  instances  through 
convulsions.  The  manner  in  which  death  may  be  produced  by  lumbrici  has 
already  been  pointed  out. 

In  general,  when  the  nature  of  the  disease  is  ascertained  the  worms  are 
'  Medico-Chir.  Rev.,  January,  1868. 


INTESTINAL   WORMS.  775 

readily  expelled  by  treatment  and  the  patient  restored  to  health.  Therefore, 
if  there  be  no  complicating  disease,  the  prognosis  is  good. 

Treatment. — Much  injury  has  been  done  to  children  by  the  use  of 
anthelmintics  occasionally  employed  by  physicians,  but  oftener  by  parents 
before  the  physician  is  called.  Medicines  of  this  kind  are  usually  irritants, 
and,  in  many  of  those  diseases  which  simulate  the  verminous  affection,  but 
are  distinct  from  it,  there  is  already  an  irritated  if  not  an  inflamed  state  of 
the  intestinal  mucous  surface. 

Vermifuges  administered  under  such  circumstances  obviously  do  harm, 
and  in  all  acute  diseases  in  which  they  are  not  required,  even  if  their  action 
be  harmless,  their  employment  is  to  be  regretted,  since  it  consumes  time, 
which  is  very  precious.  It  is  thus  that  many  lives  are  lost  by  the  use  of 
anthelmintic  nostrums  which  are  extensively  advertised  and  which  command 
a  ready  sale,  inasmuch  as  the  belief  in  the  presence  of  worms  as  a  frequent 
cause  of  disease  pervades  all  classes. 

A  safe  rule,  followed  by  many  physicians — and  it  would  be  much  better 
if  it  were  general — is  not  to  give  anthelmintics  unless  the  child  have  passed 
one  or  more  worms  or  their  ova  be  found  in  the  feces,  and  not  then  if  the 
symptoms  seem  to  be  referable  to  a  coexisting  disease.  In  doubtful  cases  in 
which  the  symptoms  resemble  those  of  worms  a  purgative  dose  of  calomel 
or  calomel  and  rhubarb  may  be  employed.  It  will  generally  bring  away  one 
or  more  lumbrici  or  a  mass  of  ascaris  vermicularis  if  either  species  of  entozoa 
be  present.  This  purgative  may  be  safely  employed  if  there  be  no  previous 
diarrhcea  or  debility.  If  after  one  or  two  doses  and  a  free  purgation  no 
worms  be  passed,  anthelmintic  remedies  should  not  be  given,  for  it  is  almost 
certain  that  none  exist. 

A  large  number  of  medicines  have  been  employed  for  the  purpose  of 
expelling  lumbrici.  Santonin,  the  active  principle  of  the  European  worm  seed, 
is  one  of  the  best,  and  is  much  employed  in  this  country  and  in  Europe.  It 
is  nearly  tasteless  ;  it  may  be  given  in  powder  spread  on  bread  with  butter.  It 
is  kept  in  shops  in  one  or  two-grain  lozenges,  with  and  without  calomel.  It 
has  the  advantage  of  easy  administration,  and  is  destructive  to  both  the 
round-  and  thread-worm.  M.  Bouchut  considers  it  preferable  to  all  other 
remedies  in  the  treatment  of  the  round-worm.  "  To  children  two  years  of 
age  he  administers  it  in  doses  of  ten  centigrammes  (1.54  grains),  and  in 
patients  above  this  age  the  quantity  is  increased  by  five  centigrammes  (0.75 
grain)  for  every  additional  year."  He  gives  in  addition  occasional  doses  of 
calomel  or  castor  oil.  In  this  country  santonin  is  usually  administered  in 
one-  to  three-grain  doses  once  or  twice  each  day,  with  an  occasional  purga- 
tive. The  purgative  is  required  to  aid  not  only  in  the  expulsion  of  the  worm, 
but  also  of  the  ova.  In  over-doses  santonin  causes  vomiting,  diarrhcea,  and 
altered  vision,  so  that  objects  appear  yellow,  but  in  medicinal  doses  it  pro- 
duces no  unpleasant  consequences.  Other  medicines  are  preferable  if  there 
be  symptoms  of  enteritis.  Treatment  by  santonin  from  two  to  three  days 
suffices.  For  many  years  the  anthelmintic  most  employed  in  this  country 
was  the  pinkroot,  the  root  of  the  Spigelia  marUandica^  an  indigenous  plant. 
It  was  not  only  prescribed  by  physicians,  but  employed  by  families  as  a 
domestic  remedy.  It  is  liable  to  cause,  if  the  dose  be  large,  cerebral  symp- 
toms, as  vertigo,  dimness  of  sight,  spasm  of  the  facial  muscles,  stupor,  and 
even  convulsions.  These  effects  less  frequently  occur  if  the  pinkroot  be 
given  with  a  purgative,  and  it  has  been  customary  to  administer  it  in  com- 
bination with  senna  in  an  infusion.  A  half  ounce  of  spigelia  with  an  equal 
quantity  of  senna  is  macerated  for  two  hours  in  a  point  of  boiling  water  and 
then  strained.  For  a  child  two  or  three  years  old  the  dose  is  half  an 
ounce  to  one  ounce.     So  popular  has  this  vermifuge  been  in  this  country  that 


776  LOCAL  DISEASES. 

probably  a  majority  of  the  native-born  old  people  in  the  States  recollect  the 
nauseating  doses  of  pinkroot  administered  by  anxious  parents.  Pharmacy 
now  provtdes  us  with  the  same  medicine  in  a  more  convenient  and  acceptable 
form,  that  of  the  fluid  extract: 

R.   Fluid  ext.  spigel.,  f^j  ; 

Fkiid  ext.  sennae,  f^ss. — Misce. 

One  teaspoonful  to  a  child  from  three  to  five  years. 

The  officinal  fluid  extract  of  spigelia  and  senna  may  be  given  in  the  same 
dose  as  the  above.  Professor  Proctor  recommends  the  addition  of  santonin 
to  this  extract : 

R.  Fluid  ext.  spigl.  et  sennae,  f5J  ; 

Santonin,  gr.  viij.— Misce. 

This  is  probably  the  best  anthelmintic  that  can  be  employed  for  the  destruc- 
tion of  the  round-worm  in  uncomplicated  cases,  and  it  is  also  very  useful  in 
treating  the  ascaris  vermicularis.  Chenopodium  is  also  a  good  anthelmintic. 
It  is  efficient,  and  at  the  same  time  one  of  the  safest  in  case  the  mucous 
membrane  be  inflamed.  If  there  be  abdominal  tenderness,  with  stools  too 
frequent  and  thin  or  mucous  and  tinged  with  blood,  I  should  prefer  the 
chenopodium  to  most  of  the  other  vermifuges.  To  a  child  of  three  years 
five  drops  of  the  oil  may  be  given  three  times  daily.  It  may  be  continued 
for  a  longer  period  than  would  be  safe  for  most  of  the  other  vermifuges. 
Twice  a  week,  during  its  use;  a  mild  purgative  should  be  given,  as  castor  oil, 
rhubarb,  or  magnesia,  unless  the  bowels  are  open.  It  may  be  given  dropped 
on  sugar  or  in  a  mucilaginous  mixture. 

Dr.  J.  F.  Meigs  says  :  "  I  myself  rarely  give  any  other  remedy  than 
tvormseed  oil  in  slight  and  especially  in  doubtful  cases,  unless  this  has  already 
been  tried  and  failed.  From  my  own  experience  I  believe  that  this  remedy 
is  all-sufficient  in  a  large  majority  of  the  cases  that  occur  in  this  city,  as  these 
are  almost  always  of  a  mild  character,  and  as  it  not  only  produces  the  expul- 
sion of  the  parasites  when  they  exist,  but  also  acts  beneficially  upon  the 
forms  of  digestive  irritation  which  simulate  so  closely  the  symptoms  pro- 
duced by  worms.  I  am  persuaded,  indeed,  that  of  all  the  cases  that  have 
come  under  my  notice  in  which  it  seemed  probable  that  worms  might  be 
present,  none  were  expelled  in  nearly  half,  and  yet  the  signs  of  disturbed 
health  have  passed  away  under  the  use  of  this  remedy."  ....  -'The  follow- 
ing is  a  very  good  formula  for  the  administration  of  this  remedy  : 

"  R.  01.  chenopodii,  gtt.  Ix  vel  f^j  ; 

P.  g.  acacise,  J^ij  ; 

Syrup  simplic,  ,5j  ; 

Aq.  cinnamom.,  5ij. — Misce. 

Give  a  dessertspoonful  three  times  a  dav  for  three  davs,  and  repeat  after  several 
days." 

In  cases  of  protracted  intestinal  disease  attended  by  an  increased  and 
vitiated  secretion  from  the  mucous  surface,  a  state  which  often  gives  rise  to 
worms,  turpentine  is  one  of  the  best  anthelmintics.  In  fact,  in  some  of  these 
cases  there  is  no  good  substitute  for  it.  For  example,  a  boy  of  about  ten 
years,  attended  by  myself.  October,  1864,  had  reached  or  nearly  reached  the 
fourth  week  of  typhoid  fever,  when  he  passed  from  his  bowels  a  large  quan- 
tity of  blood.  He  was  previously  emaciated  and  weak,  and  there  had  been, 
as    is    usual    in    such    cases,  considerable    diarrhoea.     The    hemorrhage  was 


INTESTINAL   WORMS.  777 

attended  with  great  prostration,  from  which,  however,  he  partially  rallied  by 
the  use  of  stimulants.  On  the  following  day  an  equally  severe  hemorrhage 
occurred,  attended  with  coldness  of  the  face  and  extremities  and  great  feeble- 
ness of  pulse,  so  that  death  appeared  imminent.  Turpentine  was  now  admin- 
istered every  six  hours,  a  few  lumbrici  were  passed,  and  the  case  thenceforth 
progressed  favorably.  The  mechanical  effect  of  the  lumbrici  on  the  ulcerated 
surface  of  intestine  had  probably  given  rise  to  the  hemorrhage.  Turpentine 
may  be  given  in  doses  of  from  five  to  ten  minims  three  times  daily  to  a  child 
five  years  old.  Sweetened  milk  or  sugar  in  powder  is  a  good  vehicle  for  it, 
or  it  may  be  given  in  a  mucilaginous  mixture : 

R.  Spts.  terebinth,  rect.,  ^ij  ; 

01.  limonis,  gtt.  v  ; 

Mucil.  gum.  acac, 

Syr.  simplic,  da.  ,^vj  ; 
Aq.  anisi,  ^ii-iij- — Misce. 

Dose  :  One  teaspoonful  every  six  hours. 

The  following  formula  for  the  employment  of  this  agent  is  recommended 
by  Dr.  Condie  : 

R.  Mucil.  gum  acac,  ^ij  ; 

Sacch.  alb.,  ^x  ; 

Spts.  fether.  nitr.,  ^iij  ; 

Spts.  terebinth,  rect.,  ^iij  ; 

Magnes.  calcinat.,  9j  ; 

Aquae  menthpe,  ^j. — Misce. 

It  is  useless  to  enumerate  the  many  anthelmintic  mixtures  which  have 
l)een  extolled  from  time  to  time.  Those  mentioned  above  are  the  least 
nauseous,  and  rarely  disappoint  the  practitioner.  One  other  antidote  for  the 
Tound-worm  should  be  mentioned,  as  it  has  been  much  used  and  is  efiicient 
— namely,  cowhage.  This  consists  of  the  bristles  which  cover  the  pods  of 
the  JIucuna  pruriens,  a  tropical  plant.  The  pods  are  dipped  in  plain  syrup 
of  the  ordinary  consistence,  and  the  bristles  are  scraped  off"  with  the  syrup. 
When  enough  of  the  medicine  is  added  to  render  the  syrup  of  the  consist- 
ence of  thick  honey,  it  is  ready  for  use.  The  dose  is  a  teaspoonful  every 
morning  for  three  days,  after  which  a  cathartic  should  be  administered.  I 
iave  never  prescribed  cowhage,  although  it  is  not  unfrequently  ordered  by 
physicians,  and  a  popular  nostrum  consists  chiefly  of  it. 

One  aff"ected  with  tape-worm  is  obviously  cured  only  when  the  head  of 
the  parasite  is  expelled ;  but  in  the  majority  of  cases  which  I  have  observed 
the  head  has  not  been  found  in  the  evacuations,  even  when  the  treatment 
had  eff"ected  a  complete  cure,  as  shown  by  the  subsequent  history.  The 
chain  of  expelled  segments  commonly  terminates  very  near  the  head.  This, 
I  believe,  is  the  common  experience  if  we  trust  the  friends  of  the  patient 
with  the  examination  of  the  stools.  The  physician  himself  should  search 
for  the  worm's  head,  the  evacuations  being  preserved.  The  nurse  should  be 
directed  to  add  a  little  carbolic  or  salicylic  acid,  and  a  sufficient  quantity  of 
■water  to  nearly  fill  the  vessel.  The  liquid  should  not  be  roughly  stirred  with 
a  stick,  as  physicians  are  in  the  habit  of  doing,  since  this  breaks  the  worm 
into  small  portions  and  renders  the  inspection  more  difficult,  but  it  should  be 
shaken  frequently,  so  as  to  detach  the  segments  and  head,  if  it  be  present, 
from  the  fecal  matter.  After  it  has  stood  at  least  five  or  ten  minutes,  the 
worm,  which  has  greater  specific  gravity  than  water,  sinks  to  the  bottom, 
and  the  upper  part  should  be  poured  off.  This  process  must  be  repeated  till 
the  water  is  nearly  colorless,  after  which  search  should  be  made  for  the 
fragments,  and  the  head,  if  present,  will  be  found. 


778  LOCAL  DISEASES. 

Since  entire  expulsion  of  the  tape-worm  is  effected  with  difficulty,  pre- 
paratory treatment  for  about  forty-eight  hours  should  be  employed  before 
the  vermifuge  is  administered.  During  this  time  the  patient  should  take  a 
mild  purgative  once  or  twice,  and  such  food,  in  moderate  quantity,  should 
be  allowed  as  leaves  little  residuum,  as  beef  tea,  milk,  etc.,  with  some  stimu- 
lant if  the  patient  feel  exhausted.  There  are  three  articles  of  food  which 
experience  has  shown  to  be  especially  useful  in  this  preparatory  treatment, 
perhaps  from  a  sickening  effect  which  they  produce  upon  the  worm — namely, 
salt  herrings,  onions,  and  garlic.  They  may  therefore  be  taken  as  food  in  the 
twelve  or  eighteen  hours  preceding  the  employment  of  the  vermifuge,  which 
it  is  ordinarily  most  convenient  to  administer  in  the  morning. 

The  various  tfenicides  recommended  in  the  books  are  probably  all  more 
or  less  efficient,  but  the  one  which  has  given  most  satisfaction  in  the  Out- 
door Department  at  Bellevue,  where  probably  a  larger  number  of  these  cases 
are  treated  than  in  any  other  place  in  this  country,  is  the  oil  of  male  fern ; 
but  it  is  found  necessary  to  employ  a  larger  dose  than  is  recommended  in 
some  of  the  books.  For  a  child  of  six  years  the  dose  employed  is  one  drachm 
in  any  convenient  vehicle,  as  the  syrupus  aurantii  florum.  This  should  be 
followed  in  about  four  hours  by  a  dose  of  castor  oil,  which  completes  the 
treatment.  Heller,  a  high  German  authority,  recommends  koosso,  or  its 
active  principle  koossin,  in  the  use  of  which  I  have  had  no  personal  experi- 
ence. The  pumpkin-seed  has  also  been  employed  at  Bellevue  and  elsewhere 
under  my  direction,  but  it  seems  to  be  less  efficient  than  the  oil  of  male  fern. 
If  the  chain  of  segments  break  near  the  head  and  the  head  be  not  seen,  it 
will  be  necessary  to  wait  two  or  three  months  in  order  to  determine  whether 
the  cure  is  complete. 

The  medical  journals  during  the  past  year  have  published  and  extolled 
the  following  formula  for  the  treatment  of  the  tape-worm.  It  is  difficult  to 
expel  the  head,  and  taenicides  employed  singly  so  often  fail  in  accomplish- 
ing this  result  that  so  powerful  a  combination  of  taenicides  deserves  consid- 
eration, and  perhaps  trial.  The  dose  recommended  is  probably  for  the  adult^ 
but  a  proportionate  dose  could  be  given  to  a  child : 

R.  Granati  corticis  radicis,  ,^ss  ; 

Seminarum  peponis,  ^j  ; 

Pulveris  ergotae,  zj  ; 

Aquffi  bullient,  S^iij. — Misce. 
Fiat  infus. 

R.  Extracti  filicis  maris  setheris,     i'^] ; 
01.  tiglii,  xrii]  ■ 

Pulveris  acacise,  ^ij. — Misce. 

Fiat  emulsionem. 

Mix  the  emulsion  with  the  infusion  and  give  them  at  10  A.  M.  A  full  dose 
of  Rochelle  salts  should  be  given  the  previous  evening,  and  no  breakfast 
taken. 

AVe  should  hesitate  to  administer  so  powerful  a  remedy  to  a  child  under 
the  age  of  eight  years.  Perhaps  it  might  be  best  to  recommend  one-quarter 
or  one-third  of  the  above  dose  to  a  child  of  eight  years,  and  half  the  dose  ta 
one  of  twelve  or  fifteen  years. 

Since  the  symptoms  produced  by  the  oxyuris  vermicular  is  are  referable 
chiefly  to  the  rectum,  and  are  caused  by  the  active  movements  of  the  worm, 
the  prompt  and  thorough  use  of  enemata,  which  causes  their  expulsion,  is- 
evidently  required.  Enemata  are  more  effectual  if  used  cool  than  if  warm  ; 
and  since  this  worm  inhabits  the  caecum  as  well  as  rectum,  large  enemata 


INTUSSUSCEPTION.  779 

given  through  a  long  tube  or  a  large  catheter  are  more  eiFectual,  causing  the 
expulsion  of  a  larger  number  of  worms  than  are  expelled  by  small  enemata 
employed  in  the  usual  manner.  Various  substances  have  been  used  for  this 
purpose,  as  lime-water,  table  salt  in  water,  turpentine  in  milk,  decoction  of 
aloe,  decoction  of  garlic,  etc.  Heller  says :  "  Simple  water  would  do  well 
for  this  purpose,  for  in  a  short  time  it  causes  the  worm  to  swell  up  and  burst ; 
but  it  is  not  altogether  without  an  injurious  eifect  on  the  intestinal  mucous 
membrane.  Hence,  Vix  recommends  a  solution  of  castile  soap  in  distilled 
water  or  rain-water  of  the  strength  of  one  to  two  and  a  half  grains  to  the 
ounce.  This  has  no  unpleasant  action  on  the  intestinal  mucous  membrane, 
while  at  the  same  time  it  quickly  destroys  both  the  worms  and  their  eggs. 
....  Vix  has  tested  all  the  medicine  in  general  use  in  enemata,  and  has 
found  the  above  solution  of  castile  soap  to  be  the  most  effectual."  The  use 
of  the  enema  in  the  evening,  although  only  a  small  quantity  of  liquid  be 
employed,  so  as  to  wash  out  the  rectum,  ensures  relief  from  the  itching  and 
sleeplessness  during  the  night. 

But  it  is  undeniable  that  enemata  alone  do  not  effect  a  complete  and  per- 
manent cure  in  a  large  proportion  of  cases,  and  hence  those  affected  with 
this  worm  remain  sufferers  for  years,  having  only  a  temporary  respite,  unless 
medicines  be  administered  by  the  mouth.  Those  medicines  which  produce 
free  watery  evacuations  appear  to  be  the  most  effectual  in  dislodging  and 
expelling  oxyurides,  whose  attachment  to  the  intestinal  surface  is  not  strong  ; 
therefore  Heller  recommends  the  saline  purgatives  "joined  with  copious 
draughts  of  water."  The  solution  of  magnesium  citrate  found  in  the  shops 
is  useful  for  this  purpose. 


CHAPTER    XII. 

INTUSSUSCEPTION. 

Intussusception,  or  the  passage  of  one  portion  of  intestine  into  another, 
has  long  been  known  as  an  occasional  accident.  Hippocrates,  though  debarred 
from  the  study  of  morbid  anatomy,  appears  to  have  had  a  pretty  clear  idea 
of  this  displacement,  and  he  suggested  a  mode  of  treatment  which  has  been 
employed  till  the  present  time. 

Intussusception  without  Symptoms. 

This  is  not  properly  a  disease.  It  consists  in  a  displacement  without  any 
other  anatomical  change.  There  is,  therefore,  no  obstruction,  inflammation, 
or  even  congestion  present,  and  no  symptoms.  This  form  of  invagination 
might  ordinarily  be  reduced  by  the  normal  peristaltic  and  vermicular  move- 
ments of  the  intestine. 

Invagination  of  a  portion  of  the  small  intestine  into  the  part  immediately 
below  it  is  often  observed  at  the  post-mortem  examination  of  young  infants 
who  had  presented  no  symptoms  due  to  the  displacement.  The  invaginated 
mass  is  usually  from  half  an  inch  to  two  inches  in  length,  and  as  a  rule  this 
accident  is  multiple.  There  may  be  ten  or  more  distinct  intussusceptions  at 
distances  of  a  few  inches  from  each  other.  The  simple  displacement  is 
believed  to  occur  ordinarily  at  or  a  short  time  pi'ior  to  the  moment  of  disso- 
lution.    It  has  been  supposed  to  be  most  frequent  in  those  who  have  died  of 


780  LOCAL  DISEASES. 

cerebral  or  spasmodic  diseases,  but  its  occurrence  is  not  unusual  in  otter 
pathological  states.  I  have  often  found  it  at  the  post-mortem  examination 
of  infants  who  have  had  subacute  or  chronic  entero-colitis.  Heven  states 
that  he  has  seen  it  at  the  Salpetriere  more  than  three  hundred  times.  Billard 
has  seen  it  especially  in  infants  who  have  been  subject  to  constipation.  Any 
irritant,  mechanical  or  other,  which  disturbs  the  regular  movements  of  the 
intestines  doubtless  may  produce  it.  It  has  been  caused  in  the  rabbit  by 
irritating  the  anus. 

It  is"  not  improbable  that  simple  intussusception  occasionally  occurs  tem- 
porarily in  children  whose  health  remains  good  when  the  regular  movements 
of  their  intestines  are  disturbed  by  irritating  ingesta  or  other  causes.  This 
form  of  displacement  never  takes  place  in  the  large  intestine.  Its  usual  seat 
is  the  lower  part  of  the  jejunum  and  upper  part  of  the  ileum.  Since  it  pos- 
sesses little  interest  as  regards  pathology,  and  none  whatever  as  regards 
symptomatology  and  therapeutics,  it  may  be  ignored  in  our  description  of 
intussusception. 

Intussusception  with  Symptoms. 

Intussusception,  or  invagination,  is  one  of  the  most  painful  and  danger- 
ous of  human  maladies,  but  fortunately  it  is  not  very  frequent.  I  have  the 
records  of  52  cases  occurring  in  children  in  addition  to  the  records  of  sev- 
eral cases  more  recently  observed.  From  these  the  facts  contained  in  this 
chapter  are  chiefly  derived.    The  patients  were  under  the  age  of  twelve  years. 

Previous  Health. — In  34  of  the  52  cases  the  state  of  the  health  pre- 
viously to  the  invagination  was  recorded.  From  the  following  table  it  is  seen 
that  one-half,  or  17,  were  previously  well,  the  remaining  half  suffering  from 
some  disease  or  derangement : 

Previous  Health. 


Age.  Good.      Disease  or  Derangement. 

One  year  or  under 15  8 

Over  one  year _2  9 

17  17 

MM.  Rilliet  and  Barthez,  whose  views  in  reference  to  intussusception  are 
derived  from  the  examination  of  the  records  of  25  cases,  state  that  the  pre- 
vious health  is  ordinarily  good,  and  the  intussusception  is  therefore  primary. 
Their  reiuark,  according  to  the  above  statistics,  is  seen  to  be  correct  as  regards 
patients  under  the  age  of  one  year,  but  incorrect  for  those  over  that  age. 

Most  of  the  17  who  had  previous  ill-health  had  diarrhoea,  dysentery,  or 
constipation,  or  diarrhoea  alternating  with  constipation.  Of  those  otherwise 
affected,  1  had  thread-worms,  2  obscure  abdominal  pains,  1  nausea  and  vomit- 
ing, and  1,  whose  age  was  four  months,  had  had  symptoms  of  invagination 
when  ten  weeks  old,  which  soon  passed  off.  It  is  seen  that  the  pre-existing 
affections  were  ordinarily  such  as  would  be  likely  to  accelerate  the  movements 
of  the  intestines  and  at  the  same  time  render  them  irregular. 

Causes. — The  above  statistics,  therefore,  show  that  intussusception  is 
often  preceded  by  disease  or  functional  derangement  of  the  intestines.  The 
two  opposite  conditions — namely,  constipation  and  the  diarrhoeal  maladies — 
so  often  precede  the  displacement  that  they  must  be  regarded  as  common 
causes.  Another  probable  cause  is  intestinal  worms,  which  by  their  mechani- 
cal action  stimulate  the  intestines.  They  were  present  in  3  of  the  52  patients, 
though  2  of  the  3  seemed  well  till  the  occurrence  of  the  intussusception,  but 
the  other  patient  had  complained  of  irritation  at  the  anus,  and  ascarides  had 
been  found  on  examination. 


3  were  3  months  old. 

12     "     4 

3     "     5 

5     "     6 

1  was  7 

1     "     8 

3  were  9 

INTUSSUSCEPTION.  781 

The  use  of  irritating  and  indigestible  food  is  an  occasional  cause.  Thus, 
some  who  have  had  intussusception  have  been  in  the  habit  of  eating  fruits, 
candies,  and  pastries  freely.  Such  ingesta  may  be  an  immediate  cause  by 
their  irritating  eifect,  or  a  remote  cause  giving  rise  to  diarrhoea,  which  in  turn 
produces  intussusception. 

Sex  is  a  predisposing  cause,  since  male  patients  are  largely  in  excess. 
Of  the  25  cases  collated  by  Rilliet  and  Barthez,  all  but  3  were  boys.  In 
our  own  collection  the  sex  of  34  of  the  patients  was  recorded,  and  of  these 
23  were  boys. 

In  rare  instances  external  violence  is  the  apparent  exciting  cause.  One 
patient  received  a  severe  contusion  of  the  abdomen  two  years  before  death, 
and  from  this  time  continued  to  complain  at  intervals  of  pain  in  the  bowels. 
One  writer  also  mentions  the  case  of  a  child  nine  years  old  who  received  a 
blow  from  a  comrade  at  school,  and  from  this  time  had  alternately  diarrhoea 
and  constipation  till  the  invagination  commenced.  Rilliet  and  Barthez  also 
relate  the  cases  of  two  children  who  were  taken  suddenly  with  invagination 
when  their  parents  were  tossing  them  in  their  arms. 

Age. — Of  the  52  cases  embraced  in  our  statistics,  the  ages  were  as 
follows : 

1  was  10  montlis  old. 
1     "    11 

1  "    12       " 

2  were  from  1  to    2  years  old. 

8     "       "      2  "    5      "       " 
8     "       "      5  "12      "       " 

3  not  given. 

Therefore,  no  cases  occurred  under  the  age  of  three  months ;  23  cases  were 
between  the  ages  of  three  and  six  months,  or  nearly  one-half  of  the  entire 
number  ;  8  between  the  ages  of  six  months  and  one  year  ;  and  only  18  between 
the  ages  of  one  year  and  twelve.  These  statistics  correspond,  in  the  main, 
with  those  of  Rilliet  and  Barthez,  in  whose  collection  of  25  cases  no  one  was 
under  the  age  of  four  months.  Leichtenstern ^  says:  "  Half  of  all  invagina- 
tions, according  to  my  statistics  of  473  cases,  occur  during  the  first  ten  years. 
The  first  year  after  the  third  month  is  remarkable  for  a  special  frequency — 
one-fourth  of  all  intussusceptions." 

The  great  liability  to  intussusception  in  infancy  is  due  partly  to  the  ana- 
tomical character  of  the  intestine  in  this  period  of  life,  and  partly,  doubtless, 
to  the  fact  that  there  are  more  frequent  irregularities  in  the  intestinal  move- 
ments than  in  older  children.  In  the  infant  the  walls  of  the  intestines  are 
thin,  the  mucous  and  muscular  coats  and  the  connective  tissue  being  much 
less  developed  than  in  those  that  are  older ;  the  mesentery  and  mesocolon 
have  also  greater  depth  as  compared  with  the  same  in  other  periods  of  life, 
except  the  mesocolon  at  the  points  where  it  passes  over  the  kidneys,  in  which 
places  it  is  very  short  or  even  in  some  cases  nearly  absent.  Moreover,  the 
space  occupied  by  the  large  intestine,  in  which  part  of  the  digestive  tube 
intussusception  commonly  occurs,  is  much  shorter  relatively  to  the  length  of 
the  intestine  than  in  those  that  are  older.  In  about  thirty  measurements 
which  I  have  made  of  the  length  of  the  large  intestine  and  the  space  occupied 
by  it  the  latter  was  found,  on  the  average,  about  one-third  that  of  the  former, 
which  of  course  necessitates  doubling  of  the  intestine  on  itself.  These  pecu- 
liarities of  structure  in  the  infant  obviously  favor  the  occurrence  of  intus- 
susception. 

Seat  and  Pathological  Anatomy. — While  intussusception  occurring 
^  Ziemssen's  Encydop. 


782  LOCAL  DISEASES. 

without  symptoms  is  usually  multiple,  that  form  which  occurs  with  symp- 
toms is  ordinarily  single.  Two  exceptional  cases  which  I  observed  will  be 
presently  related.  In  one  of  the  cases  embraced  in  the  statistics  an  invag- 
ination occurred  with  symptoms,  and  coexisting  with  it  was  another  in 
the  small  intestines  apparently  without  symptoms  and  quickly  reduced  by 
handling. 

While  intussusception  without  symptoms  occurs  in  the  small  intestine, 
the  seat  of  intussusception  with  symptoms  is,  with  occasional  exceptions,  the 
colon.  The  colon  constitutes  the  entire  invaginated  mass,  or  else  and  more 
frequently  it  forms  the  exterior,  while  the  incarcerated  portion  consists  wholly 
or  in  part  of  the  ileum. 

Intussusception  in  the  Small  Intestines. 

Bouehut  says :  "  M.  Rilliet  states  in  a  recent  treatise  that  in  infancy  the 
intestinal  invagination  is  always  accomplished  at  the  expense  of  the  la^ge 
intestine,  and  that  there  is  never  invagination  of  the  small  intestine.  This 
is  incorrect.  I  have  observed  the  small  intestine  invaginated  in  the  adjacent 
inferior  part.  Taylor  has  reported  a  case  of  this  kind  in  a  child  twenty 
months  old  who  died  after  an  attack  of  acute  peritonitis.  M.  Marage  has 
seen  another  case  in  a  child  thirteen  months  old,  who  recovered  after  having 
voided  the  invaginated  portion  furnished  with  two  of  those  diverticula  so 
frequent  in  the  small  intestine  of  the  foetus." 

But,  from  all  that  appears,  the  case  reported  by  M.  Marage  may  have 
been,  and  probably  was,  an  example  of  the  common  form  of  intussusception — 
to  wit,  the  prolapse  of  the  ileum  into  the  colon.  In  Mr.  Taylor's  case  the 
invagination  was  really  of  the  ileum  into  the  colon,  although  a  small  por- 
tion of  the  ileum  next  to  the  valve  had  not  been  inverted,  so  that  it  con- 
stituted a  little  of  the  exterior  of  the  mass. 

Nevertheless,  Bouehut  is  correct  in  stating  that  irreducible  and  fatal 
intussusception  may  occur  in  the  small  intestines.  Probably  the  displace- 
ment is  at  first  of  the  simple  variety,  but,  continuing  and  increasing  in 
extent,  its  return  becomes  impossible.  The  positive  statement  of  so  great 
an  authority  as  M.  Rilliet,  that  intussusception  with  symptoms  does  not 
occur  in  the  small  intestines,  justifies  the  publication  of  the  following  cases, 
which  establish  the  fact  that  there  are  instances,  though  not  frequent,  in 
which  the  displacement  does  have  this  location : 

Case  1. — This  patient's  health  had  been  uniformly  good,  and  nothing  unusual 
was  observed  in  his  condition  till  the  age  of  four  and  a  half  months,  when  he 
became  restless,  as  if  in  almost  constant  pain,  with  occasional  exacerbations. 
Castor  oil  was  prescribed,  which  operated  freely,  and  then  the  following  mixture : 

R.  Magnes.  calcinat.,  J)  j  ; 

Tinct.  opii  camphorat.,  ^ij  ; 

Tinct.  asafoet. ,  _:^ss  ; 

Aq.  anisi,  5J.— Misce. 

Dose  :  Ten  to  twenty  drops,  repeated  according  to  the  pain. 

These  remedies  failed  to  give  relief,  as  did  also  chloroform  given  in  doses  of 
two  drops.  After  two  or  three  days  another  set  of  symptoms  arose,  those  cha- 
racteristic of  pneumonia — to  wit,  hurried  respiration,  accelerated  pulse,  short, 
suppressed  cough,  and  expiratory  moan.  He  was  treated  with  the  oiled-silk 
jacket  and  mild  counter-irritation,  and  took  an  expectorant  mixture  containing 
ammonium  carbonate.  In  a  few  days  the  pulmonary  disease  was  evidently  sub- 
siding, but  the  pain  in  the  abdomen,  with  occasional  exacerbations,  continued. 
His  countenance  was  pallid  and  bore  an  expression  of  suffering.  There  was  no 
distention  or  tenderness  of  abdomen  and  no  abdominal  tumor.  He  took  little 
nutriment  and  seldom  vomited.     In  the  last  part  of  his  sickness  the  dejections 


IXTUSS  USCEPTION. 


783 


were  scanty,  and  the  last  three  days  his  stools  consisted  mainly  of  mucus  and  a 
little  blood.  The  pain  seemed  to  be  growing  less  when  he  was  seized  with  con- 
vulsions, and  died  the  same  day,  precisely  two  weeks  from  the  commencement 
of  his  sickness. 

Sectio  Cadaver. — Head  not  examined  :  body  slightly  emaciated  :  mucous  mem- 
brane of  trachea  and  bronchial  tubes  vascular  :  posterior  portion  of  the  lower  lobe 
of  each  lung  solid,  of  greater  specific  gravity  than  water,  and  alloAving  only  partial 
inflation  ;  it  was  in  the  second  stage  of  pneumonia.  Stomach,  duodenum,  jejunum, 
healthy.  In  the  upper  part  of  the  ileum  was  an  intussusception  two-thirds  of  an 
inch  long,  presenting  no  trace  of  inflammation  either  within  or  around  it,  and  its 
vascularity,  Avhen  it  was  examined  externally,  did  not  seem  notably  increased. 
Above  the  intussusception  the  intestine  was  empty :  below  it,  and  chiefly  in  the 
small  intestine,  was  a  dark-colored  substance,  evidently  blood,  and  giving  in  a  few 
hours  the  offensive  odor  of  decaying  animal  matter.  There  was  a  passage  through 
the  intussusception  at  least  two  or  three  lines  in  diameter,  as  shown  by  a  probe. 
The  intussusception  sustained  the  weight  of  sixteen  inches  of  the  intestine,  and  it 
would  have  apparently  sustained  considerably  more.  The  remaining  organs  were 
healthy. 

Case  2. — F.  S ,  a  female  infant  four  months  old,  was  treated  at  the  New 

York  Infant  Asylum  in  June  and  July,  1865,  for  entero-colitis,  the  usual  epidemic 
of  the  summer  season.  The  following  records  show  the  state  of  the  bowels  imme- 
diately before  her  death : 

June  29th  :  Has  five  or  six  stools  daily.  30th  :  Two  stools  in  twenty-four  hours. 
July  1st :  Had  two  stools  since  the  last  record  ;  no  vomiting.     3d  :  Four  stools  in 

Fig.  212. 


last  twenty-four  hours.  4th  :  The  diarrhoea  continues,  as  before ;  the  stools  about 
four  daily'     On  the  6th  of  July  she  died. 

Her  pulse  durinii:  the  time  in  which  these  records  were  taken  generally  num- 
bered about  128  per'minute.  She  was  much  emaciated,  and  the  day  before  death 
she  frequently  struck  her  head  with  her  hand.  The  medicines  employed  were 
mainly  alkalies  and  astringents. 

Sectio  Cadaver. — Parietal  bones  united ;  serous  effusion  over  the  convolutions 
of  the  brain,  under  the  arachnoid  :  occipital  bone  depressed  :  commencing  at  a  point 
about  two  feet  below  the  stomach  were  four  intussusceptions  t^vo  or  three  inches 
from  each  other.  The  invaginated  masses  were  from  one  to  one  and  half  inches  in 
length,  and  three  of  them  were  found  to  be  very  vascular  in  their  interior.  Above, 
between,  and  immediately  below  the  intussusceptions  the  intestine  was  healthy. 
One  of  the  invaginations  was  tested  bv  weight,  and  was  found  to  sustain  a  foot 


784  LOCAL  DISEASES. 

and  a  half  of  intestine,  and  would  have  sustained  more.  Water  poured  above 
these  intussusceptions  escaped  through  them  very  slowly  ;  no  fibrous  exudation ; 
descending  colon  vascular  and  thickened  and  solitary  glands  enlarged. 

The  irreducible  character  of  the  intussusceptions  in  the  above  cases  was 
shown  by  the  fact  that  they  sustained  weights  which  doubtless  produced 
greater  traction  than  that  exerted  by  the  intestine  in  its  normal  action. 
That  the  displacement  existed  prior  to  the  moment  of  death  was  shown  by 
the  symptoms  in  one  of  the  cases  and  by  the  anatomical  changes  in  both. 
In  one  the  capillaries  of  the  incarcerated  mass  were  ruptured  during  the 
last  days  of  life,  so  as  to  produce  sanguineous  stools,  while  in  the  other 
there  was  intense  congestion  of  the  invaginated  mucous  membrane,  and 
that  portion  of  this  membrane  which  was  adjacent,  but  not  engaged,  was 
healthy. 

In  both  patients  the  symptoms  were  less  severe  than  in  ordinary  cases, 
and  they  came  on  more  gradually,  for  the  invaginated  intestine  was  not  com- 
pletely closed,  so  that  it  allowed  the  passage  of  fecal  matter  in  one  till  the 
close  of  life,  and  in  the  other  till  near  its  close.  At  both  of  the  autopsies 
water  poured  into  the  intestines  above  the  invaginations  passed  slowly  through 
them. 

Intussusception  in  the  small  intestines  in  the  infant,  commencing  as  the 
simple  form,  may  become  irreducible,  and  yet.  remaining  pervious,  may  con- 
tinue for  weeks  without  giving  rise  to  severe  or  dangerous  symptoms.  The 
following  ease  was  an  example  of  this : 

Case  3. — Male  child,  died  at  the  age  of  nineteen  months,  the  last  eleven  of  which 
he  was  under  observation.  The  mother  states  that  he  had  never  been  well  since  the 
age  of  one  month,  and  that  there  had  been  little  variation  in  the  symptoms  of  his 
disease.  During  the  period  in  which  he  was  under  observation  he  was  ordinarily 
fretful,  and  frequently  seemed  to  be  in  considerable  pain.  His  stomach  during  this 
whole  time  was  so  irritable  that  he  rarely  took  more  than  three  or  four  spoonfuls 
of  nutriment  without  vomiting.  There  was  usually  more  or  less  diarrhoea,  but  no 
tenderness  or  distention  of  abdomen.  He  became  slowly  but  gradually  more  ema- 
ciated, and  finally  died  in  a  state  of  extreme  emaciation  and  exhaustion.  He  had 
no  convulsions,  and  was  conscious  to  the  last. 

Sectio  Cadaver. — Brain  not  examined ;  lungs  healthy,  except  a  circumscribed 
portion  which  was  inflamed  at  the  summit  of  the  right  lung  :  liver  small  and  almost 
destitute  of  oily  matter,  as  shown  by  the  microscope.  In  the  jejunum,  about  two 
feet  below  the  stomach,  was  an  intussusception  two  inches  long,  the  intestine  form- 
ing which  seemed  to  have  undergone  no  structural  change.  Above  the  intussuscep- 
tion the  intestine  was  of  small  calibre,  and  entirely  empty  and  pale :  below  the 
intussusception  the  intestine  was  somewhat  larger  than  above,  but  it  seemed  quite 
healthy.  The  invagination  was  sufiiciently  pervious  to  allow  water  to  pass  through 
it,  and  it  readily  sustained  the  weight  of  two  feet  of  intestine.  From  eight  to  ten 
inches  below  this  intussusception  there  was  another,  which  was  immediately  drawn 
out  the  moment  the  intestine  was  disturbed.  The  other  abdominal  viscera  were 
healthy. 

There  is  uncertainty  as  to  the  duration  of  the  intussusception  in  the 
above  case,  but  the  symptoms  indicated  that  it  existed  a  considerable  time 
prior  to  death.  There  was  no  strangulation,  nor  indeed  any  appreciable 
anatomical  alteration  in  the  coats  of  the  intestine,  but  the  fact  that  the 
invaginated  mass  sustained  two  feet  of  intestine  and  required  considerable 
traction  for  its  reduction  shows  that  it  was  not  a  case  of  simple  displace- 
ment occurring  at  the  moment  of  death  and  without  symptoms,  but  was  an 
example  of  the  variety  with  symptoms. 

Intussusception  in  the  Large  Intestines. 

In  most  cases  of  intussusception  occurring  in  infancy  and  childhood  the 
ileum  is  invaginated  in  the  colon  or  the  first  part  of  the  colon  is  invaginated 


INTUSSUSCEPTION.  785 

in  the  part  succeeding  it.  Intussusception  not  infrequently  begins  in  the 
prolapse  of  the  ileum  through  the  ileo-Ccecal  valve,  in  the  same  way  that  pro- 
lapse of  the  rectum  occurs  through  the  sphincter  ani.  If  death  take  place 
early,  only  a  small  portion  of  the  ileum  may  have  passed  the  valve.  If  the 
case  be  protracted,  the  tenesmus  brings  down  more  and  more  of  the  ileum, 
with  its  accompanying  mesentery.  The  constriction  of  the  valve,  which  acts 
as  a  ligature,  soon  prevents  the  further  descent  of  the  ileum  ;  and,  the  tenes- 
mus continuing,  the  next  step  in  the  displacement  is  the  inversion  of  the 
caput  coli.  which  is  drawn  into  the  colon  by  the  descending  mass,  and  unless 
the  case  terminate  by  sloughing  or  death,  the  ascending  and  transverse 
portions  of  the  colon  are  successively  invaginated.  The  records  show  that 
intussusception  occurs  as  above  stated  in  a  large  proportion  of  cases.  In 
one  case  among  those  which  I  have  collated  the  invagination  began  a  few 
inches  above  the  valve,  so  that  the  ileum  constituted  a  small  portion  of  the 
exterior  of  the  mass.  Occasionally  the  csecum  is  the  part  primarily  inverted 
and  invaginated,  and,  descending  along  the  colon,  it  draws  after  it  the  ileum, 
which  sustains  its  natural  relation  to  the  ileo-caecal  valve.  When  this  occurs 
the  cgecum  is  found  at  the  lower  end  of  the  mass,  and  two  orifices  are 
observed,  one  leading  through  the  valve  and  the  other  into  the  appendix 
vermiformis.  These  two  forms  of  invagination — that  in  which  the  ileum, 
passing  through  the  ileo-c^ecal  valve,  successively  inverts  and  draws  after  it 
the  caput  coli  and  the  divisions  of  the  colon,  and  that  in  which  the  caput 
coli  is  primarily  invaginated,  and,  descending  along  the  large  intestine,  in- 
verts the  latter  and  draws  after  it  the  ileum — constitute  the  vast  majority 
of  cases  of  this  disease  in  the  first  years  of  life. 

I  have  notes  of  45  fatal  cases  occurring  under  the  age  of  twelve  years 
in  which  the  portion  of  intestine  first  displaced  is  recorded.  In  4  of  these 
the  displacement  was  entirely  in  the  small  intestine,  involving  in  no  way  the 
colon ;  in  38  cases  it  commenced  either  by  prolapse  of  the  ileum  through  the 
ileo-caecal  valve  or  by  the  inversion  of  the  c^cum  into  the  ascending  colon, 
there  being  perhaps  not  much  difi'erenee  in  the  relative  frequency  of  these 
two  modes ;  in  one  case  the  invagination  was  confined  to  a  segment  of  the 
transverse  colon,  in  another  to  a  segment  of  the  descending  colon,  and  in  the 
remaining  case  to  the  lower  part  of  the  descending  colon  and  the  upper  part 
of  the  rectum.  In  three  instances  the  invaginated  mass  itself  became  invag- 
inated, producing  an  intussusception  of  great  thickness,  and  necessarily 
fatal. 

Intussusception  is  sometimes  attended  by  so  little  constriction  of  the 
incarcerated  portion  that  it  remains  pervious.  In  such  a  case  life  may  be 
protracted  for  weeks  or  even  months  without  reduction  of  the  displacement 
or  any  material  change  in  it,  the  passage  of  fecal  matter  being  sufficiently 
free  for  the  maintenance  of  life.  Death  finally  occurs  in  a  state  of  exhaus- 
tion. Thus  in  one  instance  a  child  four  months  old  lived  six  weeks  after  the 
symptoms  of  invagination  commenced,  and  seventeen  days  "  with  a  portion 
of  the  bowel  protruding  from  the  anus."  It  was  found  at  the  post-mortem 
examination  that  part  of  the  ileum  had  descended  through  the  entire  colon, 
and  had  remained  pervious.  In  a  case  related  by  Dr.  Worthington^  symp- 
toms of  intussusception  were  present  for  seven  months  before  death,  and 
during  the  last  six  weeks  of  life  the  invaginated  intestine  protruded  fre- 
quently from  the  anus,  and  was  replaced  by  the  mother.  In  this  case  "  the 
caecum  was  inverted,  and,  descending  through  the  colon  to  the  lower  portion 
of  the  rectum,  carried  with  it  the  ileum  and  the  entire  colon  except  the  last 
ten  or  twelve  inches."  In  another  case  the  symptoms  indicated  a  continu- 
ance of  the  disease  for  three,  if  not  eight,  months.  But  such  cases  are  ex- 
^  Amer.  Journ.  of  Med.  Sci.,  for  January,  1849. 
50 


786  LOCAL  DISEASES. 

ceptional.  Ordinarily,  as  the  intestine  becomes  invaginated  its  mesentery 
or  mesocolon  is  also  invaginated  and  its  veins  compressed.  The  pathological 
state  of  the  incarcerated  mass  soon  becomes  that  of  intense  congestion.  In 
infants,  usually  in  a  few  hours,  so  great  is  the  distention  of  the  capillaries 
that  they  give  way,  blood  escapes  into  the  intestine,  and  passes  from  the 
bowels  in  scanty  Diotions.  On  examining  the  invaginated  intestine  after 
death,  if  gangrene  have  not  occurred,  it  is  found  of  a  uniformly  intense  red 
color,  sometimes  resembling  to  the  naked  eye  a  long  and  firm  clot  of  blood. 
In  those  who  die  early  no  traces  of  inflammation  are  seen,  but  in  more  pro- 
tracted cases  the  attrition  between  the  serous  surfaces  excites  local  peritonitis. 
In  none  of  the  fifty-two  cases  which  I  have  collated,  in  which  post-mortem 
examinations  were  made,  did  the  inflammation  extend  more  than  a  few  lines 
beyond  the  invagination.  Usually  the  intestine  forming  the  exterior  of  the 
invaginated  mass  is  much  drawn  together  or  puckered.  In  one  case  treated 
by  myself  the  entire  large  intestine  which  formed  the  exterior  of  the  mass 
was  compressed  within  a  space  of  six  inches  or  less,  since  about  twelve 
inches  of  the  ileum,  doubled  on  itself,  lay  within  the  entire  colon  and  pro- 
truded from  the  anus,  the  only  part  of  the  large  intestine  which  was  inverted 
being  the  caput  coli.  In  one  case  six  or  seven  inches  of  the  ileum,  which 
formed  a  portion  of  the  exterior  of  the  mass,  were  compressed  within  the 
space  of  one  inch. 

The  abdomen,  at  first  of  natural  fulness  and  soft,  usually  becomes  more 
and  more  distended  till  the  close  of  life ;  but  in  case  of  much  vomiting  the 
distention  is  modei'ate.  The  fulness  is  due  to  gas  and  fecal  accumulation 
above  the  invagination.  The  portion  of  the  intestine  below  the  displacement 
is  ordinarily  empty,  except  that  in  the  infant  it  commonly  contains  mucus, 
mixed  with  more  or  less  blood  which  has  escaped  from  the  capillaries  of  the 
strangulated  mass. 

There  are  few  anatomical  changes  in  this  disease  which  do  not  arise 
directly  from  the  intussusception,  and  are  therefore  located  either  within  the 
mass  or  in  its  immediate  vicinity.  In  those  who  recover  by  the  process  of 
sloughing  the  cicatricial  contraction  may  give  rise  to  symptoms  and  lesions 
of  greater  or  less  gravity.  Thus  the  late  Sir  James  Y.  Simpson  examined  a 
child  aged  nine  years  who  recovered  with  loss  of  ten  inches  of  intestine, 
and,  at  the  meeting  of  the  Medical  Society '  before  which  the  specimen  was 
presented,  he  remarked  that  there  was  unusual  distention  of  the  cutaneous 
veins  of  the  patient,  due  probably  to  such  compressions  of  the  ascending 
vena  cava  by  the  cicatrix  that  the  venous  circulation  was  obstructed.  Mr. 
Charles  King'''  relates  the  case  of  a  child  aged  six  years  who  on  the  eleventh 
day  of  the  disease  voided  the  caecum  and  a  part  of  the  colon.  Two  days 
subsequently  pulsation  ceased  in  the  left  leg,  and  all  that  part  below  the 
patella  became  gangrenous.  The  patient  gradually  recovered  with  loss  of 
the  leg.  The  cause  of  this  unfortunate  sequel  was  doubtless  compression 
from  the  cicatricial  contraction  around  the  artery  which  supplied  the  leg,  and 
probably  the  formation  of  a  thrombus.  Dr.  F.  Bush  ^  relates  a  case  in  which 
he  was  enabled  to  observe  the  extent  and  appearance  of  the  cicatrix.  The 
patient,  aged  twelve  years,  discharged  from  the  bowels  fifteen  to  eighteen 
inches  of  the  ileum  on  the  eighth  day  of  the  intussusception,  after  which 
convalescence  was  rapid.  Fourteen  weeks  later  the  child  died  from  typhus 
fever,  and  at  the  autopsy  "  traces  of  the  diseased  bowels  were  visible  by  a 
contraction  and  puckering  where  the  slough  had  taken  place  and  the  parts 
united."  But,  fortunately,  in  most  instances  when  the  intestine  sloughs  and 
the  child  survives  no  serious  or  permanent  injury  results  from  the  cicatriza- 

1  Trans.  Medico-Chir.  Soc.  Edin.  2  J^ondon  Lancet,  for  1854. 

^  Load.  Med.  and  Phys.  Journ.,  for  December  18,  1823. 


INTUSSUSCEPTION.  787 

tion.  The  cicatrix  stretches  little  by  little  and  accommodates  itself  to  the 
surrounding  parts. 

Symptoms. — The  symptoms  vary  according  to  the  age  of  the  patient 
and  the  degree  of  strangulation.  Pain  in  the  abdomen,  usually  paroxysmal, 
is  among  the  first  and  is  one  of  the  most  conspicuous  symptoms.  It  is  often 
severe,  resembling  the  pain  of  hernia,  and  abating  only  with  the  failing 
strength  of  the  child.  After  the  first  few  days,  if  infiammation  arise,  the 
pain  is  continuous,  though  more  severe  in  paroxysms.  At  first  pressure  upon 
the  abdomen  is  tolerated,  but  afterward  there  is  tenderness.  This  is  due  to 
the  inflammation  which  occurs  in  and  around  the  invaginated  mass,  and  it  is 
therefore  confined  to  the  part  of  the  abdomen  in  which  the  tumor  lies.  At 
this  point  also  the  abdomen  is  more  full  than  elsewhere,  and  not  infrequently 
the  physician  can  feel  the  invaginated  mass  and  detect  its  exact  location  and 
approximately  its  extent.  Sometimes,  at  an  early  period  as  well  as  late, 
cerebral  symptoms  occur,  as  in  a  case  related  by  Dr.  CogswelP  which  ter- 
minated in  convulsions  and  death  on  the  second  day.  Convulsions  are,  how- 
ever, comparatively  rare,  and  the  mind  is  generally  clear  till  the  last  moment. 
In  infants  the  countenance  in  the  intervals  without  pain,  in  the  first  stages  of 
the  complaint,  is  often  placid  and  not  indicative  of  any  serious  disease,  but  in 
older  patients  constant  and  severe  local  symptoms,  referable  to  the  intus- 
susception, commence  early.  At  an  advanced  period,  whatever  the  age,  the 
countenance  becomes  anxious  and  haggard,  the  eyes  hollow  or  sunken,  the 
body  loses  its  plumpness,  and,  if  the  case  be  protracted,  becomes  emaciated. 

Vomiting  is  rarely  absent ;  in  39  out  of  47  cases  it  is  stated  to  have  been 
present;  in  7  cases  there  is  no  record  of  this  symptom,  while  it  is  recorded 
absent  in  only  1  case  ;  but  in  this  case,  the  records  of  which  are  very  meagre, 
<ieath  occurred  on  the  second  day.  The  vomiting  becomes  stercoraceous  in  a 
few  days,  and  it  ordinarily  continues  with  greater  or  less  frequency  till  the 
period  of  collapse.     It  relieves  partially  the  distention. 

The  appetite  is  impaired  and  often  entirely  lost.  Infants  at  the  breast 
commonly  nurse,  however,  for  several  days,  probably  from  thirst  rather  than 
hunger. 

In  most  patients  one  natural  evacuation  occurs  from  the  bowels  after  the 
intussusception  commences,  and  then  obstinate  constipation  succeeds.  This 
evacuation  consists  of  the  excrementitious  matter  below  the  invagination. 
In  children  under  the  age  of  one  year  scanty  motions  of  blood  mixed  with 
mucus  begin  to  occur  in  a  few  hours.  Of  27  children  under  this  age,  I  find 
that  24  had  such  evacuations,  occurring  in  most  of  them  several  times  in  the 
course  of  the  day  ;  in  2  of  the  27  there  is  no  record  of  this  symptom,  but  in 
the  remaining  case  it  is  stated  to  have  been  absent.  Scanty  evacuations  of 
blood  unmixed  with  fecal  matter  have  been  considered  pathognomonic  of 
intussusception  in  the  infant,  and  we  see  the  ground  for  such  belief;  but  in 
exceptional  instances  the  invaginated  mass  is  partly  pervious,  and  although 
the  dejections  may  contain  blood,  they  are  also  excrementitious.  In  our  col- 
lection of  cases  are  3  examples  of  this  in  infants  under  the  age  of  one  year. 
One  has  already  been  referred  to.  In  this  case  there  was  the  rare  anomaly  of 
so  large  an  opening  through  the  ileo-cfecal  valve  as  to  allow  not  only  prolapse 
and  descent  of  the  ileum  through  the  entire  colon,  so  as  to  protrude  six  inches 
from  the  anus,  but  also  fecal  passage  through  it  daily. 

In  children  above  the  age  of  one  year  the  capillaries  of  the  invaginated 
intestines  are  not  so  frequently  ruptured  as  under  this  age,  and  sanguineous 
evacuations  are  therefore  less  common.  I  have  records  of  19  cases  between 
the  age  of  one  year  and  twelve,  in  only  6  of  which  it  is  stated  that  there  were 
bloody  motions,  and  in  these  the  blood  was  not  passed  frequently,  nor  even 
^  London  Lancet,  for  July,  1853. 


788  LOCAL  DISEASES. 

in  some  cases  daily,  as  in  infants,  nor  in  so  pure  a  state,  unless  in  2  cases, 
the  records  of  which  are  not  explicit  on  this  point.  Two  of  these  6  patients 
passed  moderate  bloody  evacuations  after  protracted  periods  of  constipation, 
1  had  fecal  discharges  with  the  blood  through  the  entire  sickness,  and  in 
1  blood  was  passed  at  first,  but  finally  the  stools  were  entirely  fecal. 

In  those  above  the  age  of  one  year  obstinate  constipation  was  ordinarily 
present,  no  dejections,  either  bloody  or  fecal,  occurring  for  several  days  ;  but 
there  were  a  few  exceptions.  In  3  cases  the  bowels  were  relaxed.  The 
ileum  in  these  3  had  descended  through  the  entire  colon  or  the  larger  part 
of  the  colon,  and,  being  pervious,  the  feces  escaped  from  the  anus  without 
detention  in  the  large  intestine  or  with  detention  only  in  its  lower  portion, 
and  were  therefore  liquid. 

Tenesmus  is  another  symptom.  It  is  not  always  present,  but  in  a  large 
proportion  of  cases,  even  when  the  invagination  is  in  the  upper  part  of  the 
large  intestine,  it  is  a  frequent  and  distressing  symptom.  It  often  does  not 
commence  till  there  is  a  considerable  amount  of  displacement,  and  it  ceases 
when  the  strength  is  much  reduced. 

The  temperature  of  the  surface  is  normal  in  the  commencement  of  intus- 
susception ;  but  finally,  as  febrile  reaction  symptomatic  of  the  inflammation 
comes  on,  it  rises  and  continues  above  the  healthy  standard  till  the  intestine- 
sloughs  or  till  the  stage  of  collapse  occurs  which  ushers  in  death.  The  pulse, 
especially  in  the  infant,  is  tranquil  at  first,  but,  whatever  the  age,  it  soon 
becomes  accelerated  from  the  paroxysms  of  pain,  and  subsequently  from  the 
inflammation  which  occurs  in  the  invaginated  mass.  There  is  no  disturbance 
of  respiration,  except  that  it  is  somewhat  hurried  from  the  fever  and  from 
the  pain  felt  in  advanced  cases  on  full  respiration. 

It  will  be  seen  that  the  symptoms  vary  in  certain  particulars  under  the 
age  of  one  year  from  those  occurring  over  that  age,  but  difi'erences  in  the 
symptoms  depend  more  on  the  degree  of  invagination  and  constriction  than 
on   the  age  and  exact  location  of  the  disease. 

Diagnosis. — The  diagnosis  of  intussusception  is  not,  in  general,  difficult, 
except  at  its  commencement.  When  the  inversion  has  reached  that  degree 
at  which  obstruction  occurs,  the  symptoms  are,  in  most  cases,  such  that  the 
disease  can  be  readily  diagnosticated.  In  the  cases  whose  records  I  have  col- 
lated a  correct  diagnosis  was  made  with  few  exceptions,  and  at  an  early  period. 
In  the  infant  the  disease  for  which  intussusception  is  most  frequently  mis- 
taken is  dysentery,  on  account  of  the  tenesmus  and  the  muco-sanguineous 
stools.  In  certain  of  the  reported  cases  this  mistake  was  not  rectified  until 
it  was  ascertained  that  purgatives  produced  no  fecal  evacuations. 

The  symptoms  which  are  commonly  present,  and  which  indicate  the 
nature  of  the  disease,  are  obstinate  constipation,  vomiting,  paroxysmal  pain 
referred  to  the  seat  of  the  disease,  and  tenesmus.  In  the  infant  also  scanty 
evacuations  from  the  bowels  of  mucus  and  blood  or  of  pure  blood  are,  as  we 
have  seen,  an  important  diagnostic  sign.  It  should  be  borne  in  mind,  how- 
ever, that  in  exceptional  cases  the  displaced  bowel  may  remain  pervious,  and 
the  usual  symptoms  which  possess  diagnostic  value  therefore  be  absent. 
There  may  be  no  vomiting  or  tenesmus,  and  diarrhoea  may  even  occur  in  place 
of  constipation,  as  in  the  cases  related  above.  As  an  aid  to  diagnosis  it 
should  be  stated  that,  whatever  the  age  of  the  child  affected  with  intussus- 
ception, clysters  are  often  administered  with  difiiculty,  and  are  quickly  and 
forcibly  returned,  on  account  of  the  resistance  opposed  by  the  invaginated 
mass.  We  have  stated  above  that  the  seat  and  even  extent  of  displacement 
can  be  ascertained  in  a  large  proportion  of  eases  by  digital  examination  of 
the  abdominal  walls.  The  tumor  can  be  felt  hard,  elongated,  and  tender  on 
pressure,  so  that  the  diagnosis  is  clear.     If  the  invagination  have  extended 


INTUSSUSCEPTION.  789 

to  the  lower  part  of  the  large  intestine,  it  can  usually  be  discovered  by  an 
examination  per  rectum. 

Duration. — In  the  following  table  the  duration  of  the  intussusception 
in  49  cases  is  given  as  nearly  as  it  can  be  ascertained  from  the  records : 


2  died  the  1st  day. 


6 

2d 

4 

3d 

2 

4th 

o 

5th 

2 

6th 

2 

7th 

1  lived  over  a  week. 


1  died  the    8th  day. 

1     "      "    10th    " 

1     "      "    14th    " 

1  lived  nearly   a   week,  the  exact 

time  not  being  given. 
1  lived  six  weeks. 
3,  time  of  death  not  given. 
7  recovered. 


In  2  of  the  3  cases  in  which  the  duration  is  not  stated  the  patient  lived  much 
longer  than  the  usual  period.  One  of  these  2,  a  girl  of  six  years,  having 
eaten  raw  carrots,  was  seized  with  pain  in  the  abdomen,  which  lasted  eight 
months,  when  she  died.  During  the  last  three  months  she  passed  mucus 
and  blood.  In  this  case  the  csecum  had  descended  to  the  anus,  drawing  with 
it  the  ileum,  which  remained  pervious.  The  symptoms  indicated  the  con- 
tinuance of  the  invagination  for  three  months,  if  not  eight.  The  other 
patient  was  a  boy  aged  three  years  and  four  months,  who  complained  of  pain 
in  the  abdomen  for  many  months,  and  occasionally  vomited.  During  the  last 
six  weeks  of  his  life  all  the  phenomena  of  invagination  were  present.  In 
this  case  also  the  inverted  caput  coli  had  descended  the  entire  length  of  the 
colon,  and  at  the  autopsy  it  lay  in  the  rectum. 

In  West's  Treatise  on  Diseases  of  Children  (5th  ed.,  1866,  p.  504)  it  is 
stated  that  death  in  this  complaint  always  occurs  within  a  week.  The  above 
statistics,  however,  show  that  there  are  exceptions  to  this  statement,  although 
a  large  majority  do  die  within  the  first  seven  days.  In  33  of  the  cases 
embraced  in  my  statistics  death  occurred  within  the  first  week,  and  in  no 
fatal  case  in  which  strangulation  was  complete  was  life  prolonged  beyond  the 
eighth  day.  In  these  cases  of  complete  strangulation  the  average  duration 
was  3.7  days,  and  the  largest  number  of  deaths  occurred  on  the  third  day. 
Death  on  the  first  day  is  rare,  but  it  occurred  in  two  of  the  cases  embraced 
in  my  statistics.  Death  at  so  early  a  period  usually  takes  place  in  convul- 
sions and  coma. 

Prognosis. — Intussusception  is  in  its  nature  so  grave  an  accident  that  the 
physician  called  to  a  ease  should  always  explain  its  gravity  to  the  friends. 
But,  while  death  is  the  common  result,  there  are  three  different  modes  of 
termination  in  which  life  is  preserved  :  First,  the  reduction  of  the  incarcerated 
intestine,  with  immediate  relief.  There  can  be  no  doubt  that  it  is  possible  for 
intussusception,  when  recent,  to  be  reduced  by  the  unaided  action  of  the 
bowels,  in  the  same  way  as  the  common,  simple  intussusception  in  the 
jejunum  and  ileum  or  as  hernia  is  reduced,  through  the  vermicular  action 
of  the  intestines;  for  sometimes,  as  in  Dr.  Coggswell's^  case,  the  patients  at 
some  previous  time  have  experienced  the  same  symptoms  as  those  which 
accompanied  the  attack,  and  which  subsiding  they  remained  for  a  time  in 
perfect  health.  This  termination  is  probably  rare  if  the  symptoms  be 
sufficiently  marked  to  necessitate  treatment.  Again,  the  intussusception  may 
be  cured  by  early  and  well-applied  treatment.  The  physician  often  succeeds 
in  reducing  the  displaced  intestine,  even  if  the  intussusception  be  in  the 
upper  part  of  the  colon,  if  he  be  called  sufficiently,  early  and  employ  the 
proper  measures. 

A  second  mode  of  favorable  termination  is  alluded  to  by  certain  foreign 
^  London  Lancet,  July,  1853. 


790  LOCAL  DISEASES. 

writers.  The  intussusception  continues  for  a  considerable  period  with  the  cha- 
racteristic symptoms,  and  then,  as  Bouchut  expresses  it,  "  the  vomitings  grad- 
ually cease,  the  intestinal  hemorrhage  disappears,  the  strength  returns,  and 
the  health  becomes  restored  without  the  expulsion  of  fragments  of  the  intes- 
tine.' What  changes  the  displaced  intestine  undergoes  in  these  protracted 
cases,  which  gradually  recover  without  sloughing,  have  not  been  clearly  ascer- 
tained, although  they  have  been  the  subject  of  conjecture.  According  to 
Rilliet,  a  large  proportion  of  favorable  cases  terminate  in  this  manner.  It 
does  not  appear,  however,  from  the  statistics  which  I  have  collected  that  this 
is  a  common  mode  of  recovery.  The  clinical  history  of  intussusception  estab- 
lishes the  fact  that  in  a  large  majority  of  protracted  cases  there  is  either  death 
or  the  third  mode  of  favorable  termination — namely,  by  sloughing. 

But  we  cannot  reasonably  expect  recovery  in  young  children  through 
sloughing  and  the  expulsion  of  the  intestine,  since  few  have  the  requisite 
strength  for  so  tedious  and  exhaustive  a  process.  The  youngest  child  that 
recovered  in  this  way,  so  far  as  I  have  been  able  to  ascertain,  was  an  infant 
thirteen  months  old,  whose  case  was  reported  by  M.  Marage.  With  the 
exception  of  this  case  the  youngest  was  a  boy  aged  five  years.  The  older 
the  child  the  greater,  of  course,  the  power  of  endurance  and  the  better  the 
prospect  of  recovery.  Of  the  52  cases  whose  records  I  have  collated,  7 
recovered  by  the  sloughing  and  expulsion  of  the  mass.  These  children  were 
of  the  ages  of  five,  six,  six,  nine,  eleven,  twelve,  and  twelve  years.  The  sep- 
aration of  the  invaginated  mass  occurred  in  six  of  these  between  the  sixth 
and  twelfth  days,  with  an  average  of  nine  and  a  half  days.  In  the  remain- 
ing case  the  time  is  not  given.  If,  then,  the  patient  can  be  carried  through 
the  first  week  without  too  much  exhaustion,  discharge  of  the  slough,  reopen- 
ing of  the  bowels,  and  ultimate  recovery  may  possibly  be  the  result. 

But  in  those  cases  in  which  the  intussusception  remains  open,  so  as  to 
allow  the  passage  of  fecal  matter,  recovery  is  improbable  unless  the  displace- 
ment be  diagnosticated  early  and  properly  treated.  If  the  intussusception 
continue,  it  becomes  greater  and  greater  from  the  absence  of  strangulation. 
Without  inflammation  and  with  little  or  no  congestion  of  the  displaced  por- 
tion, and  without  the  severe  symptoms  which  occur  in  ordinary  cases,  the 
patient  wastes  away,  having  irregular  evacuations  and  more  or  less  abdominal 
pain,  and  finally  dies  in  a  state  of  emaciation  and  weakness.  In  the  early 
stage  of  this  form  of  displacement  it  is  not  improbable  that  injections  or 
inflation,  employed  with  sufficient  force,  will  give  relief,  but  if  the  early 
period  pass  without  such  treatment,  cure  is  impossible  by  the  ordinary 
methods.  It  is  in  such  instances  especially — to  wit,  those  in  which  the  dis- 
placement occurs  without  strangulation  or  inflammation,  and  in  which  fecal 
matter  passes  through  the  displaced  mass  more  or  less  freely— that  laparotomy 
is  justifiable,  and  is  likely  to  give  relief  when  injections  and  inflation  have 
been  employed  in  vain.  Jonathan  Hutchinson's  successful  performance  of 
this  operation  in  a  child  of  two  years  who  had  this  kind  of  displacement  is 
known  to  most  readers.^ 

The  prognosis  is  most  favorable  when  the  displacement  occurs  in  the 
lower  part  of  the  large  intestine,  for  its  reduction  is  then  comparatively  easy. 
An  interesting  case  of  this  kind  was  observed  and  treated  by  Drs.  O'JDwyer, 
Beid,  and  myself  in  the  New  York  Foundling  Asylum  in  1875.  The  child 
was  a  female  aged  two  years,  and  had  had  previous  good  health.  The 
invaginated  mass  protruded  like  a  prolapse  about  four  inches  outside  of  the 
anus.  It  was  cold,  considerable  hemorrhage  had  occurred  from  it,  and  the 
infant  seemed  in  collapse.  When  the  mass  was  returned  so  far  as  it  could 
be  carried  within  the  pelvis  by  the  index  finger,  the  lower  end  of  it  could 
'  London  Lancet,  November  22,  1873. 


INTUSSUSCEPTION.  791 

still  be  felt  like  an  os  uteri.  It  protruded  four  or  five  times  within  twenty- 
four  hours,  but  by  replacement  so  far  as  possible  with  the  fingers  and  the  use 
of  simple  water  injections,  with  the  hips  elevated,  it  was  finally  permanently 
reduced,  and,  with  the  use  of  stimulants,  she  soon  fully  recovered. 

Mode  of  Death. — This  is  difi"erent  in  difi"erent  cases.  It  sometimes 
occurs  from  collapse.  At  a  meeting  of  the  New  York  Pathological  Society, 
held  December  10,  1873,  I  presented  a  specimen  showing  intussusception 
occurring  about  one  foot  above  the  ileo-caecal  valve  in  an  infant  aged  thirteen 
months.  On  the  day  before  its  death,  its  previous  health  having  been  good, 
it  seemed  ill,  and  vomited  once  or  twice,  but  did  not  appear  to  be  in  pain.  It 
had  two  evacuations  from  the  bowels,  of  the  usual  appearance,  in  the  latter 
part  of  the  day.  On  the  following  morning  it  was  unexpectedly  in  collapse, 
and  died  within  about  twenty -four  hours  from  the  commencement  of  the  sick- 
ness. At  the  post-mortem  examination  the  cranium  was  not  opened,  but  all 
the  organs  of  the  trunk  were  found  normal  except  the  intussusception.  The 
mass  involved  in  the  displacement  measured  two  and  a  half  inches  in  length 
and  was  slightly  crescentic.  The  mucous  membrane  above  and  below  it  had 
the  normal  appearance,  as  had  that  of  the  external  or  incarcerating  portion  of 
the  mass,  while  that  of  the  incarcerated  part  was  deeply  injected.  Water 
poured  into  the  intestine  above  the  invagination  was  wholly  arrested  by  it.^ 
But  in  the  majority  of  instances  death  occurs  from  asthenia,  which  comes  on 
gradually,  but  increases  rapidly  in  consequence  of  the  pain,  vomiting,  and 
imperfect  nutrition.  Children  dying  in  this  way  may  have  convulsive 
movements  more  or  less  marked,  but  the  prevailing  characteristic  as  death 
approaches  is  extreme  exhaustion.  In  exceptional  instances  the  life  of  the 
suff"erer  is  cut  short  by  convulsions  before  the  stage  of  exhaustion  is  reached. 
Thus  a  child  aged  three  years,  whose  ease  was  reported  by  Dr.  Isaac  Thomas,^ 
and  another,  aged  two  years,  whose  case  was  reported  by  Dr.  Coggswell,^  died 
in  convulsions  on  the  second  day. 

Treatment. — It  is  unfortunate  in  cases  of  intussusception  that  the  time 
in  which  treatment  can  be  of  most  service  is  likely  to  pass  by  before  the  true 
condition  of  the  intestine  is  detected.  Invagination  being  comparatively  I'are, 
the  patient  is  generally  on  the  first  day  treated  for  colic  or  dysentery  or  some 
other  common  afi"ection  of  the  bowels,  and  it  is  often  not  till  the  second  day, 
when  the  intestine  has  become  incarcerated,  that  the  physician  accurately 
diagnosticates  the  disease.  The  purgative  medicines  often  given  in  the 
commencement  injure  the  patient.  In  fact,  both  reason  and  experience 
teach  us  the  impropriety  of  using  purgatives  in  this  complaint.  Cathartic 
remedies  act  as  a  vis  a  tergo^  and  may  cause  still  further  descent  of  the  in- 
verted intestine.  Yet  such  powerful  agents  of  this  class  as  quicksilver  have 
been  employed.  It  was  administered  in  two  doses  of  one  ounce  each  in  one 
of  the  cases  embraced  in  my  statistics,  but  none  of  the  mineral  passed  the 
bowels.  At  the  post-mortem  examination  a  considerable  part  of  it  was  found 
in  small  globules,  coated  with  a  black  layer  consisting  of  the  sulphuret  or 
black  oxide  of  mercury,  in  the  intestine  above  the  intussusception.  It  need 
not  be  added  that  the  case  was  speedily  fatal. 

The  proper  treatment  of  intussusception  consists  in  attempts  to  reduce 
the  displacement  by  pressure  from  below.  The  pressure  may  be  applied 
either  by  liquid  injections  into  the  rectum  or  by  inflation  of  the  lower  intes- 
tine by  air  or  gas. 

Injections  should  be  made  with  lukewarm  water,  for  cold  or  hot  water 
may  cause  contraction  of  the  muscular  fibres  of  the  intestine  and  increase 
the  constriction.     The  child  should  be  placed  in  bed  or  in  the  nurse's  lap, 

1  New  York  Medical  Record,  April  1,  1874,  ^  Amer.  Med.  Recorder,  1823. 

*  London  Lancet,  July,  1853. 


792  LOCAL  DISEASES. 

with  the  nates  elevated  45°.  With  the  common  India-rubber — or,  better, 
the  fountain  syringe — and  the  aid  of  an  assistant  the  liquid  should  be  gently 
thrown  into  the  rectum  until  the  abdomen  is  fully  distended.  By  carry- 
ing the  fingers,  firmly  but  gently  applied  upon  the  abdominal  walls,  along  the 
direction  of  the  colon,  the  liquid  is  made  to  press  against  the  lower  end  of 
the  intussusception.  The  same  gentleness  and  perseverance  are  required  in 
kneading  and  pressing  the  abdominal  walls  as  in  the  treatment  of  hernia  by 
taxis.  If  the  invagination  be  in  the  descending  colon,  probably  only  a  small 
quantity  of  the  liquid  can  be  injected,  and  it  may  be  forcibly  returned,  but 
by  repeating  the  injections  a  sufficient  quantity  can  ordinarily  be  introduced 
to  obtain  the  full  eifect  of  the  mode  of  treatment.  There  is  also  sometimes 
an  increased  irritability  of  the  rectum,  even  when  the  intussusception  is  at 
the  upper  extremity  of  the  large  intestine,  so  that  tenesmus  and  expulsive 
efforts  follow  the  introduction  of  the  instrument.  The  assistant  can  aid  in 
overcoming  this  and  in  retaining  the  water  by  pressing  the  soft  parts  of  the 
nates  around  the  instrument. 

If  the  injection  fail  to  reduce  the  displacement,  it  may  be  repeated  after 
allowing  the  patient  to  rest  for  a  while.  In  the  J)lew  York  Medical  Journal 
for  May,  1875,  is  the  history  of  an  interesting  case  which  was  treated 
by  Drs.  Church  and  Warren,  and  is  reported  by  the  latter.  The  infant 
was  seven  months  old  and  had  the  usual  symptoms,  such  as  frequent  parox- 
ysmal pain  in  the  abdomen,  vomiting,  tenesmus,  and  scanty  muco-sanguineous 
stools.  On  the  third  day  injections  were  twice  employed  without  result,  but 
on  the  fourth  day  an  injection  of  ten  or  twelve  ounces  reduced  the  displace- 
ment and  the  infant  recovered.  In  a  second  case  treated  by  Dr.  Warren  the 
age  was  nine  months,  and  a  tumor  appeared  a  little  above  the  umbilicus  a  few 
hours  after  the  commencement  of  the  symptoms.  The  following  is  Dr.  War- 
ren's account  of  this  interesting  case,  which  will  give  a  clear  idea  of  the  proper 
mode  of  treatment : 

"  The  patient  was  looking  very  pale  and  prostrated,  the  pulse  was  quick 
and  feeble,  and  the  skin  cold.  I  at  once  determined  to  use  fluid  injections, 
and,  with  the  little  patient  placed  in  a  semi-prone  position  in  his  mother's  lap, 
with  an  ordinary  Davidson's  syringe  I  commenced  injecting  tepid  soap-and- 
water,  but  after  perhaps  a  gill  had  been  thrown  into  the  rectum  it  was  almost 
immediately  rejected,  very  highly  colored  with  blood,  and  mixed  with  it  a 
very  small  quantity  of  mucus  and  fecal  matter ;  the  latter,  by  the  way.  not 
hardened,  but  of  the  consistency  of  soft  putty.  In  a  second  attempt  the 
fluid  was  retained  longer,  but  was  after  a  little  while  discharged,  with  more 
blood  and  mucus,  but  with  much  less  tenesmus  and  pain. 

"  When,  soon  after,  I  made  my  third  attempt,  the  child's  chest  was  rested 
upon  the  side  of  its  mother's  lap,  with  the  lower  extremities  elevated  by  an 
assistant,  so  that  the  po.sition  was  at  an  angle  of  about  45°,  anus  upward. 
This  time  I  injected  the  fluid  very  slowly,  in  order  to  avoid,  if  possible,  the 
irritation  caused  generally  by  the  frequent  emptying  and  refilling  of  the 
syringe  (which,  by  the  way,  is  a  very  serious  hindrance  to  the  successful  use 
of  this  syringe,  and  which  renders  it  much  inferior  to  the  fountain  or  hydro- 
static). In  this  manner  I  succeeded  in  injecting,  as  I  estimated  at  the  time, 
perhaps  ten  or  twelve  ounces,  and  during  the  operation  the  child  gradually 
became  more  quiet,  and  had,  when  I  ceased,  fallen  asleep.  Then,  with  the 
direction  that  occasional  doses  of  tinct.  opii  camph.  should  be  administered 
during  the  night,  to  control,  if  possible,  the  peristaltic  action  of  the  intes- 
tines, I  left  him. 

"  On  the  following  morning,  to  my  surprise,  I  found  the  child  sleeping 
quietly  and  naturally,  and  I  was  informed  that  at  about  5  a.  m.  (six  hours 
after  my  visit)  he  had  a  movement  of  the  bowels,  which  was  saved  for  my 


INTUSSUSCEPTION.  793 

inspection,  and  consisted  simply  of  the  enema,  slightly  colored  with  fecal 
matter.  From  that  time  he  seemed  to  be  entirely  free  from  pain,  and  six  or 
seven  hours  later  had  a  natural  passage,  after  which  recovery  progressed 
rapidly,  and  in  a  few  days  he  was  discharged  well." 

The  following  case  is  interesting  as  showing  success  from  the  use  of 
injections  after  the  lapse  of  two  days  in  a  severe  case  which  had  resisted 
treatment  on  the  first  day.  The  good  result  was  apparently  in  great  part  due 
to  the  manipulation,  which  was  made  so  as  to  press  the  water  against  the 
course,  which  intussusceptions  are  known  to  take. 

On  September  10,  1876,  I  visited,  with  Dr.  Gillette,  a  nursing  infant  aged 
nine  months  whose  history  was  as  follows :  It  was  habitually  constipated,  but 
it  continued  in  its  usual  health  till  September  8th,  on  which  day  it  was  carried 
by  its  nurse  to  one  of  the  city  parks.  After  its  return  it  began  to  be  fretful ; 
it  vomited  and  seemed  to  be  in  pain.  It  continued  to  vomit  frequently,  espe- 
cially after  nursing  or  taking  drinks,  and  in  the  ensuing  night  passed  two 
scanty  stools  of  mucus  and  blood  without  fecal  matter.  In  the  morning  of 
September  9th,  Dr.  G.  was  summoned,  who  found  the  pulse  180  and  tem- 
perature 102°,  and  the  matter  vomited  greenish  like  bile.  In  the  evening  the 
temperature  was  102J°.  Dr.  G.  diagnosticated  intussusception,  and  employed 
injections  of  water,  but  they  were  returned  without  bringing  fecal  matter  and 
without  apparent  result.     He  also  administered  opiates  by  the  mouth. 

September  10th  :  Temperature  102f°  ;  features  pallid,  beginning  to  have  a 
pinched  or  sunken  appearance,  and  indicative  of  much  suiFering ;  no  nutri- 
ment is  apparently  retained  on  account  of  the  frequent  vomiting,  and  the 
bowels  are  obstinately  constipated.  As  the  symptoms  indicated  rapid  sink- 
ing and  collapse,  consultation  was  called  at  4  p.  M.  It  was  impossible  to 
determine  certainly,  through  the  abdominal  walls,  on  account  of  the  disten- 
tion, whether  there  was  any  tumor,  but  it  was  my  opinion  and  the  opinion  of 
one  of  the  other  physicians  that  a  tumor,  hard  and  inelastic,  could  be  felt 
nearly  in  the  median  line  between  the  umbilicus  and  the  symphysis  pubis. 
At  about  5  P.  M.  the  shoulders  of  the  little  patient  were  lowered  and  the 
nates  elevated,  so  that  the  trunk  formed  an  angle  of  perhaps  45°  with  the 
horizontal,  and  a  large  quantity  of  tepid  water  was  gently  passed  into  the 
intestine  through  Davidson's  syringe,  with  the  vaginal  nozzle  attached.  It 
was  impossible  to  estimate  the  quantity  retained,  since  a  considerable  part  of 
it  escaped,  although  the  anus  was  firmly  pressed  around  the  instrument. 

When  the  abdomen  was  distended  as  fully  as  seemed  justifiable,  the  nates 
being  still  elevated,  and  the  liquid  retained,  so  far  as  possible,  by  firm  pres- 
sure upon  the  anus,  the  abdomen  was  firmly  and  deeply  kneaded  by  the 
hand,  the  movements  being  made  chiefly  from  the  right  lumbar  toward  the 
right  inguinal,  and  from  the  right  inguinal  toward  the  hypogastric  region. 
The  kneading  was  continued  perhaps  eight  or  ten  minutes,  and  the  water, 
which  contained  no  perceptible  amount  of  fecal  matter,  blood,  or  mucus,  was 
allowed  to  escape. 

After  this  operation  the  child  became  quiet,  slept,  and  the  vomiting 
ceased.  At  our  next  visit,  at  7  P.  M.,  although  the  severe  symptoms  had 
in  a  great  part  abated  and  the  countenance  had  lost  that  pinched  and  suffer- 
ing aspect  which  was  so  prominent  before,  it  was  deemed  best,  in  consulta- 
tion, to  repeat  the  injection,  and  this  time  through  a  rectal  tube,  which  was 
introduced  farther  than  the  nozzle  employed  at  the  preceding  visit.  The 
body  was  placed  in  the  same  position  as  before  and  the  abdomen  kneaded  in 
the  same  manner.  The  water,  when  allowed  to  return,  brought  no  fecal  mat- 
ter, but  the  last  that  flowed  contained  two  shreds,  the  largest  about  one  inch 
in  length  by  two  lines  in  width,  resembling  matted  and  nucleated  epithelial 
cells.     It  was  believed  that  they  were  composed  of  such  cells,  with  perhaps 


794  LOCAL  DISEASES. 

some  of  the  mucous  membrane  to  which  they  were  attached,  and  that  they 
were  detached  from  the  invaginated  portion.  An  opiate  mixture  was  now 
prescribed,  to  be  given  sufficiently  often  to  relieve  any  restlessness  and  keep 
the  patient  quiet,  and  a  flaxseed  poultice  was  applied  over  the  abdomen. 
On  the  following  day  the  temperature  was  103^°,  pulse  158,  and  the  abdo- 
men somewhat  distended ;  but  the  vomiting  had  ceased,  and  there  had  been 
two  fecal  evacuations  since  our  last  visit.  The  intussusception  had  been 
relieved,  the  inflammatory  symptoms  soon  abated,  and  the  infants  health  was 
fully  restored. 

Groodhart  reports  a  case  of  cure  by  injecting  a  boracic-acid  solution  after 
the  symptoms  had  continued  seventy-six  hours.  The  patient's  age  was  eight 
months,  and  the  tumor  could  be  felt  per  rectum.^  Humphreys  relates  two 
cases  of  recovery  by  injection  of  water  thirteen  and  forty  hours  after  the 
commencement  of  symptoms  in  infants  of  eight  months  and  two  years. '^ 
Butler  also  succeeded  by  water  injections  in  reducing  intussusception  of 
thirty-six  hours'  continuance  in  a  child  of  three  years.^  But  injections  of 
water  have  not  always  been  successful.  Chafiey  failed  to  reduce  invagination 
of  the  caecum  and  appendix  in  a  "  somewhat  chronic  "  case,  but  inflammatory 
bands  were  found  in  their  vicinity,*  and  Cripps  ruptured  the  intestine  by 
injecting  water  in  a  girl  of  eighteen  months.  The  symptoms  had  continued 
four  or  five  days  and  the  tumor  projected  from  the  anus. 

Injections,  in  order  to  be  eff"ectual  and  give  promise  of  success,  should  be 
aided  by  gravitation.  The  physician  should  remember  to  elevate  the  nates 
higher  than  the  shoulders,  as  in  the  case  related  above.  Treatment  by  infla- 
tion—which indeed  ought  to  occur  to  any  intelligent  physician  appreciating 
the  anatomical  condition  of  the  parts  as  deserving  of  trial — was  prominently 
brought  to  the  notice  of  the  profession  in  modern  times  by  Mr.  Samuel 
Mitchell.^  "  I  take  the  liberty,"  he  writes,  "  of  suggesting  to  the  pi'ofession, 
through  the  medium  of  your  valuable  periodical,  the  trial  of  inflating  the 
bowels  by  means  of  a  glyster-pipe  attached  to  a  common  pair  of  bellows ;  it 
has  fallen  to  my  lot  to  witness  several  of  these  most  distressing  eases  in  chil- 
dren ;  the  natui'e  of  the  obstruction  was  foretold  during  life,  and  unfortu- 
nately verified  by  post-mortem  examination.  The  last  case  of  the  kind  which 
came  under  my  care,  about  two  years  since,  presented  all  the  usual  symp- 
toms— intolerable  restlessness,  the  most  obstinate  sickness,  the  singulai'ly  dis- 
tressed state  of  countenance,  and  shrunken  features.  The  usual  remedies 
were  had  recourse  to — viz.  warm  baths,  glysters,  anodyne  frictions  over  the 
abdomen,  etc. — but  without  avail.  As  a  forlorn  hope  I  made  trial  of  infla- 
tion by  the  above  means,  with  the  most  happy  result.  The  sickness  imme- 
diately ceased ;  the  child  within  an  hour  passed  a  natural  stool,  and  in  the 
morning  was  almost  without  ailment." 

This  mode  of  treatment  is  termed  novel  in  the  Lancet,  but  it  is  really  as 
old  as  the  time  of  Hippocrates,  who  speaks  of  throwing  air  into  the  bowels, 
by  which  flatulence  is  imitated  (flatus  immitatur).®  Haller''  also  recom- 
mended the  same  treatment :  "  Flatus  etiam  immissus  celerrime  susceptionem 
dispellet."  Dr.  David  Greig*  relates  five  cases  of  successful  treatment  of 
intussusception  by  inflation.  The  first,  an  infant  six  months  old,  previously 
in  good  health,  suddenly  became  very  fretful,  apparently  having  severe 
paroxysmal  pain  in  the  abdomen.     She  had  vomiting,  and  finally  tenesmus^ 

1  London  Lancet,  Feb.  25,  1888.  '^  Ibid.,  Oct.  27,  1888. 

2  Brooklyn  Med.  Journ.,  Feb.,  1888.  *  London  Lancet,  July  7,  1888. 
5  Ibid.,  for  March  17,  1838. 

^  Hippocrates'   Works,  translated  from  the  Greek  by  Grimm,  4  Bd.  p.  198. 
'  Physiologia  Corporis  Humani,  torn.  vii.  p.  95. 
^  Edinburgh  Medical  Journal,  October,  1864. 


INTUSSUSCEPTION.  795 

with  bloody  evacuations.  Warm-water  enemata  could  not  be  employed,  on 
account,  the  writer  thinks,  of  the  spasmodic  action  of  the  intestines,  and  an 
abdominal  tumor  could  be  felt  near  the  umbilicus.  Castor  oil  and  a  purga- 
tive powder  and  enemata  of  water  having  been  employed  in  vain,  and  the 
case  becoming  really  critical  on  the  second  day,  inflation  was  resorted  to. 
The  writer  says :  "  The  nozzle  of  a  small  pair  of  bellows  was  introduced  into 
the  anus,  and  air  injected  to  a  considerable  extent.  Contrary  to  our  expecta- 
tion, the  air  passed  readily  into  the  bowel,  and  seemed  to  give  the  child  great 
relief.  After  the  injection  it  lay  very  quiet,  as  if  asleep,  and  evidently  quite 
free  from  pain.  In  about  twenty  minutes  from  the  time  the  air  injection  was 
administered  a  slight  rumbling  noise  was  heard  in  the  child's  abdomen,  fol- 
lowed by  a  crack  so  loud  and  distinct  as  to  alarm  the  attendants  in  the  room, 
who  thought  something  had  burst  in  the  child's  bowels.  The  child,  however, 
continued  as  if  asleep  and  free  from  pain,  and  in  about  half  an  hour  a  large 
feculent  stool,  slightly  mixed  with  blood  and  mucus,  was  passed  without  pain. 
During  the  night  the  child  rested  pretty  well,  had  no  return  of  vomiting,  took 
the  breast  as  usual,  and  in  two  days  was  quite  well." 

Another  child,  nine  months  old,  treated  by  Dr.  Greig,  presenting  nearly 
the  same  symptoms  and  the  abdominal  tumor,  also  obtained  relief  by  inflation 
after  castor  oil  and  enemata  had  failed  to  produce  any  benefit. 

An  apparatus  for  the  production  and  injection  of  carbonic-acid  gas 
has  been  invented  by  Schultz  &  Warker,  and  is  manufactured  by  them. 
It  consists  essentially  of  two  glass  chambers,  one  over  the  other.  In 
the  lower  one  a  bicarbonate  is  placed,  and  in  the  upper  an  acid  in  a  liquid 
state.  By  the  gradual  admixture  of  the  two  carbonic  acid  is  set  free.  An 
elastic  tube  conveys  the  gas  from  the  lower  chamber.  This  apparatus  has 
been  used  by  physicians  of  this  city  for  the  reduction  of  intussusception  and 
other  purposes,  and  is  a  useful  invention. 

Syphons  of  highly- charged  carbonic-acid  water,  from  which,  when  in- 
verted, a  powerful  current  of  the  gas  is  evolved,  may  also  be  used  for  the 
purpose  of  reducing  the  displacement.  Two  or  three  of  these  bottles,  with 
a  portion  of  the  tube  from  Davidson's  syringe,  which  can  be  readily  at- 
tached to  the  stem  from  which  the  gas  escapes,  constitute  all  that  is  required 
for  an  ordinary  case. 

The  following  eases,  which  I  have  treated  with  Dr.  Btichler  in  1871, 
show  what  may  be  achieved  by  inflation,  and  also  the  unfavorable  result 
which  must  inevitably  occur  in  certain  cases.  A  German  infant  five 
months  old,  nursing,  began  to  be  fretful,  crying  often,  on  March  7th,  and 
before  night  passed  a  scanty  motion  of  blood.  The  symptoms  continuing,  I 
was  asked  to  examine  the  infant  on  the  10th,  and  learned  the  following  facts  : 
It  had  vomited  daily,  had  had  daily  scanty  but  infrequent  stools,  consisting 
chiefly  of  blood,  accompanied  at  first  by  tenesmus,  but  not  within  the  last 
day ;  it  continued  to  nurse,  but  was  becoming  thinner  and  weaker,  and  was 
evidently  in  pain.  The  symptoms  indicating  the  nature  of  the  disease,  the 
abdomen,  which  was  not  distended,  was  examined  for  the  tumor,  which  was 
found  on  the  right  side  in  the  site  of  the  ascending  colon,  apparently  about 
one  and  half  to  two  inches  in  length ;  pulse  124  in  sleep ;  no  cough.  An 
ineflFectual  attempt  was  made  to  reduce  the  intussusception  by  a  very  rude 
and  imperfectly  constructed  apparatus  (the  bellows),  when  from  the  lateness 
of  the  hour  further  treatment  was  postponed  till  early  the  following  morning. 
11th.  Tumor  still  detected  in  the  right  lumbar  region  ;  pulse  120  asleep, 
150  awake.  By  means  of  Schultz  &  Warker's  apparatus  the  intestines  were 
inflated  so  as  to  produce  very  decided  prominence  of  the  abdomen,  and  the 
abdomen  was  gently  kneaded.  After  some  minutes  the  gas  was  allowed  to 
escape,  when  it  was  seen  that  the  tumor  had  disappeared.     In  a  few  hours 


796  LOCAL  DISEASES. 

a  natural  evacuation  occurred  from  the  bowels,  and  the  infant  has  remained 
well  since. 

The  second  case  ended  unfavorably,  although  the  symptoms  were  appar- 
ently no  more  grave  than  in  the  ease  just  related  and  had  continued  a  shorter 
time.  This  infant  was  also  of  German  parentage.  The  tumor,  firm  and 
elongated,  could  be  distinctly  felt  in  the  left  lumbar  region.  In  this  case 
the  inverted  bottles  of  carbonic-acid  water  were  employed,  and  when,  after 
considerable  delay  and  kneading  of  the  abdomen,  the  gas  was  allowed  to 
escape  from  the  intestine,  the  tumor  had  disappeared.  A  few  hours  after- 
ward convulsions  occurred,  ending  fatally.  At  the  autopsy  the  invaginated 
mass,  which  was  too  firmly  strangulated  to  admit  of  reduction  by  inflation, 
was  found  in  the  epigastric  region,  having  been  carried  up  from  its  former 
position  by  the  inflation  of  the  intestine  below.  It  consisted  of  the  terminal 
part  of  the  ileum,  which  had  passed  through  the  ileo-caecal  orifice,  and  had 
become  incarcerated  in  the  ascending  colon,  and,  as  is  not  unusual  in  these 
cases,  the  movements  of  the  intestines  had  changed  the  location  of  the  tumor 
in  the  abdomen  from  the  right  to  the  left  side.  In  the  London  Lancet  for 
Feb.  18,  1888,  Cheadle  reports  a  case  of  successful  inflation  in  an  infant  of 
fifteen  months,  whose  symptoms  indicated  intussusception  of  fifteen  hours' 
duration,  and  the  tumor  could  be  felt  per  rectum.  Higginson  also  reduced 
an  intussusception  by  inflation.  The  patient,  an  infant  of  seven  months,  had 
symptoms  of  intussusception  three  days,  and  the  tumor  could  also  be  felt 
per  rectum.^ 

Whether  air  or  carbonic  acid  be  employed,  it  is  necessary  to  produce 
distention  of  the  intestine  to  its  fullest  extent  below  the  seat  of  the  com- 
plaint without  endangering  rupture,  and  of  course  the  sooner  it  is  used  the 
better  the  chance  of  success.  In  a  few  days  the  displaced  intestine  has,  in  a 
large  proportion  of  cases,  become  so  firmly  incarcerated,  and  has  descended 
so  far,  that  attempts  to  replace  it,  either  by  injections  or  inflation,  are  unsuc- 
cessful ;  still,  even  at  a  late  period,  a  persevering  attempt  should  be  made  if  it 
have  not  previously  been  tried.  During  the  four  years  which  have  elapsed 
since  the  publication  of  the  sixth  edition  of  this  treatise  in  1886,  I  have 
treated  successfully  three — I  think  I  may  say  four — cases  of  intussusception 
in  infants  by  frequent  rectal  injections  of  warm  water  as  large  as  could  be 
given,  and  followed  by  kneading  of  the  abdomen.     The  youngest  of  these 

infants  was  Greo.  H.  Mc ,  male,  aged  four  months,  nursing,  to  whom  I 

was  called  on  Dec.  24,  1886.  He  had  been  very  fretful  since  Dec.  22d,  had 
the  last  fecal  evacuation  on  the  morning  of  Dec.  23d,  and  had  since  passed 
stools  of  mucus  and  blood  without  the  least  fecal  matter.  Enemata  of  warm 
water  as  large  as  possible  were  given  every  hour  to  two  hours  with  the  nates 
raised,  and  were  followed  by  kneading  the  abdomen.  The  fretfulness  was 
always  less  after  these  enemata.  On  Dec.  26th  the  temperature  fell  from 
101  j°  to  normal,  and  a  fecal  evacuation,  the  first  in  three  days,  occurred. 
From  this  time  the  infant  was  well.  The  vomiting,  which  had  been  frequent 
since  the  22d,  ceased  on  the  26th.  The  mother  stated  that  the  tenesmus, 
which  had  been  a  distressing  symptom,  was  uniformly  less  after  the  injec- 
tions. My  experience  during  the  last  ten  years  with  cases  of  intussusception 
incline  me  more  and  more  to  the  belief  that  copious  and  frequent  warm-water 
injections,  employed  in  the  manner  described  above,  are  more  likely  to  give 
relief  than  any  other  mode  of  treatment.  But  it  is  proper  that  I  should 
state  that  during  this  time  I  have  seen  cases  that  were  fatal  in  which  this 
and  other  modes  of  treatment,  including  laparotomy,  were  employed. 

If  the  modes  of  treatment  which  I  have  recommended  above  fail  to  give 
relief  when  perseveringly  and  sufficiently  employed  in  a  case  of  acute  intus- 
^  London  Lancet,  May  19,  1888. 


INTUSSUSCEPTION.  797 

suseeption,  the  patient's  state  is  one  of  extreme  peril  and  the  prognosis  is 
unfavorable.  Yet  recovery  is  possible  in  one  of  two  ways — namely,  first, 
by  incision  through  the  abdominal  walls  (laparotomy),  and  reduction  of  the 
displacement  by  the  fingers  within  the  abdominal  cavity ;  and  secondly,  by 
sloughing  of  the  invaginated  mass  and  union  by  adhesive  inflammation  of 
the  ends  of  the  intestine  which  have  preserved  their  vitality.  Cripps  relates 
a  remarkable  case  of  spontaneous  cure  in  an  infant  of  seven  months.  It  had 
been  two  weeks  sick,  with  vomiting  and  alvine  discharges  of  blood  and  mucus, 
when  presented  for  examination.  A  portion  of  the  large  intestine,  gangrenous, 
protruded  from  the  rectum.  This  was  cut  ofi",  and  portions  of  sloughy  sub- 
stance were  removed  daily  for  a  month  afterward,  when  the  child  recovered. 
It  died  of  scarlet  fever  eight  months  subsequently,  and  the  autopsy  revealed 
the  entire  loss  of  the  large  intestine,  the  small  intestine  being  united  to  the 
anus.^  Atrophy  of  the  imprisoned  part  so  seldom  occurs  in  a  case  which  has 
resisted  injections  and  inflation  that  it  need  not  be  considered  in  this  connection 
as  a  mode  of  recovery. 

Laparotomy  has  been  successfully  performed  in  a  child  aged  two  years, 
as  I  have  stated  above,  by  Dr.  Jonathan  Hutchinson  of  London.  The  case 
was  one  of  those  exceptional  ones  in  which  great  displacement  had  occurred 
without  strangulation.  It  had  continued,  as  indicated  by  the  symptoms, 
about  one  month,  and  a  portion  of  the  intestine  terminating  in  the  ileo-caecal 
valve  had  protruded  several  inches  from  the  anus.  "  The  patient  was  anaes- 
thetized by  chloroform,  and  the  abdomen  was  opened  in  the  middle  line  below 
the  umbilicus.  The  intussusception  was  then  easily  found  and  as  easily  re- 
duced. The  after-treatment  consisted  only  in  the  administration  of  a  few  mild 
opiates,  and  the  child  made  rapid  recovery."  ^  In  a  case  of  this  kind  there 
can  be  no  doubt  of  the  propriety  and  necessity  of  laparotomy  as  the  last 
resort,  for,  there  being  no  strangulation,  sloughing  could  not  occur,  and  death 
sooner  or  later  from  exhaustion  must  be  the  result.  Cases  of  this  sort  have 
usually  been  left  to  perish  after  the  ordinary  modes  of  relief  have  failed. 
Thus  as  far  back  as  1784,  M.  Eobin  published^  the  case  of  a  child  aged 
three  and  a  half  years  who  died  after  the  lapse  of  three  months  with  a 
c^cum  protruding  from  the  anus  ;  and  in  the  American  Journal  of  Medical 
Science  for  1849,  Dr.  Worthington  published  a  similar  case,  in  which  a  child 
aged  three  years  and  four  months  lived  a  longer  time.  In  these  days  of 
anesthetics,  and  with  the  brilliant  success  of  Hutchinson,  a  phj'sician  would, 
in  my  opinion,  be  reprehensible  if  he  allowed  a  child  aged  two  years  or  over 
with  this  form  of  displacement  to  perish  without  strongly  advising  laparotomy 
when  injections  with  water  have  failed. 

But  the  question  'arises  whether  in  those  more  frequent  cases  of  intussus- 
ception in  young  children  in  which,  after  displacement  has  continued  a  few 
hours,  there  is  such  flrm  constriction  of  the  invaginated  mass  that  the  patient 
sufi"ers  much  pain  and  constitutional  disturbance,  and  passes  blood  and  mucus 
without  fecal  matter,  laparotomy  is  justifiable.  This  operation  in  the  case  of 
infants  has  heretofore  been  regarded  as  so  dangerous  and  so  likely  in  itself 
to  prove  fatal  that  the  profession  have  generally  considered  it  unjustifiable, 
believing  that,  although  death  was  nearly  certain  without  it,  the  perform- 
ance of  it  did  not  increase  the  chances  of  a  favorable  result.  Dr.  J.  B.  Sands 
of  Xew  York  has  recently  shown  that  laparotomy  is  justifiable  as  a  last  resort 
for  the  relief  of  this  form  of  intussusception,  even  in  the  youngest  infants, 
and  in  the  following  case,  recorded  in  the  Xen-  York  Medical  Journal,  June, 
1877,  saved  the  patient,  who  doubtless  would  otherwise  have  perished : 

On  March  11,  1877,  an  infant  of  six  months  suddenly  presented  the  cha- 

^  Brit.  Med.  Journ.,  June  2,  1888.  '^London  Lancet,  Xovember  22,  1873. 

^  Mem.  de  V  Acad,  de  Chirurg. 


798  LOCAL  DISEASES. 

racteristie  symptoms  of  intussusception,  such  as  tenesmus,  abdominal  pain, 
vomiting,  and  bloody  stools.  A  few  hours  later,  when  Dr.  Sands  was  called, 
the  pulse  was  rapid  and  feeble,  with  symptoms  of  collapse.  An  elongated 
tumor  could  be  felt  in  the  abdomen,  extending  from  the  left  iliac  region  to 
the  left  hypochondrium,  inelastic,  tender  on  pressure,  and  dull  on  percussion. 
The  lower  end  of  the  invaginated  mass  could  be  readily  touched  by  the  finger 
introduced  into  the  rectum.  The  usual  methods  to  effect  reduction  were  at  once 
employed  with  partial  success,  for  the  tumor  disappeared  from  the  site  where 
it  had  been  discovered,  and  was  reduced  to  a  small  and  firm  mass  on  a  level 
with  the  umbilicus,  but  it  resisted  any  further  attempts  to  effect  its  reduction. 

Dr.  Sands  then,  having  etherized  the  patient,  made  an  incision  in  the 
median  line  of  the  abdomen,  extending  downward  about  two  inches  from  a 
point  a  little  below  the  umbilicus.  Through  this  opening,  proceeding  cau- 
tiously and  using  as  little  violence  as  possible,  he  was  able,  after  some  delay, 
to  reduce  the  displacement.  The  invaginated  mass,  which  was  only  one  and 
a  half  inches  in  length,  consisted  of  the  terminal  portion  of  the  ileum  and 
ctecum,  which  had  entered  the  ascending  colon.  The  wound  was  closed  by 
five  silver  sutures,  which  embraced  the  peritoneum,  and  the  patient  made  a 
good  recovery.  The  operation  was  performed  eighteen  hours  after  the  com- 
mencement of  symptoms. 

Dr.  Sands  has  collected  the  statistics  of  20  cases  of  laparotomy  for  intus- 
susception occurring  at  different  ages  in  which  the  result  was  stated.  Of 
these,  7  recovered,  or  1  in  3 ;  but  he  judiciously  remarks,  considering  the 
gravity  of  the  operation,  that  it  is  doubtful  whether  future  statistics  will 
show  so  favorable  a  result  of  laparotomy  for  this  displacement  as  to  justify 
the  frequent  use  of  the  knife.  For  facts  and  statistics  relating  to  this  sub- 
ject the  reader  is  referred  to  an  able  and  elaborate  paper  by  Dr.  Ashhurst.^ 

It  is  obvious  that  the  earlier  the  displacement  is  recognized,  the  greater 
the  probability  of  the  reduction  by  the  judicious  use  of  injections  or  infla- 
tion, and  it  is  seen  from  cases  related  above  that  this  treatment  may  be  suc- 
cessful as  late  as  the  second  or  third  day,  after  previous  attempts  to  reduce 
the  intussusception  by  the  same  means  have  failed,  and  when  there  is  that 
degree  of  strangulation  that  bloody  stools  occur.  But,  as  my  own  experi- 
ence has  shown  me,  there  is  also  inevitably  a  large  proportion  of  cases  in 
which  the  use  of  injections  and  inflation,  however  judiciously  and  persever- 
ingly  made,  totally  fails,  and  it  seems  to  me,  in  the  light  of  present  expe- 
rience, that  when  pressure  from  below  by  water,  air,  or  gas,  which  is  the  only 
efiicient  mode  of  treatment  short  of  the  knife,  has  been  tried  sufl&ciently  long 
and  sufficiently  often  without  result,  it  is  the  duty  of  the  physician  to  seek  sur- 
gical advice  in  reference  to  laparotomy,  as  he  would  in  a  case  of  hernia,  espe- 
cially since,  under  Lister's  antiseptic  method,  the  danger  from  severe  operations 
appears  to  be  considerably  diminished.  It  may  be  added  that  laparotomy 
performed  on  the  first  or  second  day  will  be  much  more  likely  to  save  life  in 
ordinary  cases  than  if  performed  later,  since  the  strangulated  intestine  is 
soon  badly  damaged,  and  a  local  peritonitis  is  likely  to  be  developed  any 
time  after  the  first  forty-eight  hours. 

When  an  intussusception  has  reached  that  stage  in  which  active  inter- 
ference by  injections,  inflation,  or  laparotomy  is  no  longer  proper,  the  physician 
can  only  prescribe  opiates  with  sustaining  measures  and  an  emollient  poultice 
over  the  abdomen,  and  must  await  the  result.  The  diet  should  consist  of 
beef  juice  and  other  concentrated  nutriment  which  leaves  little  residuum. 
Vomiting,  which  is  so  common,  is  best  controlled  by  bismuth  and  opiates ; 
convulsions  require  the  bromide  of  potassium  and  an  enema  of  three  to  five 
grains  of  chloral  hydrate  dissolved  in  a  little  water. 

^  American  Journal  of  the  Medieal  Sciences,  for  July,  1874. 


APPENDICITIS.  799 

CHAPTEE    XIII. 

APPENDICITIS  AND  PERITONITIS. 

Appendicitis. 

Etiology. — The  most  common  cause  of  this  inflammation  is  the  lodge- 
ment and  impaction  in  the  appendix  of  fecal  matter  or  hard,  indigestible 
foreign  bodies  which  produce  inflammation,  and  sometimes  perforation,  by 
their  pressure.  In  146  cases  of  perforation  of  the  appendix  collated  by  Mat- 
terstock,  fecal  concretions  were  present  in  63 ;  foreign  bodies  difi"erent  from 
concretions  in  9  ;  neither  fecal  masses  nor  hard  bodies  in  8 ;  and  in  the 
remaining  cases  the  records  do  not  mention  the  presence  of  any  substance 
likely  to  cause  inflammation.  In  49  cases  of  fatal  appendicitis  in  children, 
perforations  had  occurred  in  37.  The  analysis  of  152  cases  collated  by  Fitz 
gives  a  very  similar  result  to  that  obtained  from  the  examination  of  Matter- 
stock's  records ;  but  Hagen  ascertained  the  presence  of  fecal  concretions  in 
69?  per  cent.,  and  hard  bodies  not  concretions  in  30?  per  cent.,  of  the  cases 
of  perforation  of  the  appendix.  We  must  therefore  regard  foreign  sub- 
stances, either  concretions  or  other  hard  bodies  which  act  mechanically  by 
pressure,  as  the  common  cause  of  appendicitis,  perforation  of  the  appendix, 
and  consecutive  inflammations  extending  from  the  appendix. 

The  fecal  concretions  found  in  the  appendix  are  single  or  multiple,  and 
of  difi"erent  degrees  of  hardness.  The  hardest  masses  sometimes  exhibit  con- 
centric layers  and  contain  phosphate  of  calcium.  Exceptionally,  the  concre- 
tion has  a  nucleus  of  some  solid  substance  in  the  interior.  The  foreign  bodies 
which  lodge  in  the  appendix  and  cause  ulceration  are  numerous.  In  a  case 
in  my  practice  an  over-baked  bean,  hard  and  black,  perforated  the  appendix 
and  caused  an  abscess,  which  by  rupturing  produced  fatal  peritonitis.  Among 
the  substances  which  have  caused  perforation  and  been  recovered  we  may 
mention  hard  fecal  matter,  small  buttons,  beads,  grape-seeds,  cherry-stones, 
orange-seeds,  raisin-seeds,  apple-seeds,  and  seeds  of  other  fruits. 

X  perforation  occurring  in  this  manner  allows  fecal,  purulent,  or  gan- 
grenous matter  to  escape  into  the  abdominal  cavity,  causing  peritonitis.  A 
perforation  occurring  in  this  way  is  indeed  the  most  common  cause  of 
peritonitis  in  children. 

Anatomical  Characters. — The  initial  lesions  take  place  in  most 
instances  in  the  appendix.  Ulceration  or  necrosis  of  its  epithelium  occurs 
from  pressure  of  the  foreign  substance ;  then  the  intestinal  microbes  invade 
the  exposed  subepithelial  tissue,  causing  septic  inflammation.  This  inflam- 
mation extends  through  the  muscular  coat  to  the  subperitoneal  connective 
tissue  and  peritoneum,  causing  peritonitis. 

The  extension  of  the  disease  and  adhesive  peritonitis  around  the  ulcerated 
appendix  is  common.  The  extent  and  gravity  of  the  peritonitis  depend  on 
the  size  of  the  perforation  and  the  quantity  of  pus  or  feculent  matter  that 
escapes.  If  the  substance  which  escapes  from  the  perforation  be  considerable 
and  highly  irritating,  the  inflammation  is  of  course  severe  and  suppuration 
results.  Its  location  depends  upon  the  place  of  perforation.  It  is  stated  that 
in  most  instances  the  centre  of  the  abscess  is  behind  or  alongside  the  caecum, 
and  if  it  extend  upward  its  walls  consist  of  intestine  and  the  posterior  and 
lateral  parietes  of  the  abdomen.  If  the  appendix  be  long  and  extend  to  the 
brim  of  the  pelvis  minor,  and  the  perforation  be  near  its  distal  end,  a  some- 
what rare  occurrence,  the  abscess  may  press  upon  the  rectum  or  uterus. 


800  LOCAL  DISEASES. 

The  abscess,  left  to  itself,  may  open  in  any  direction.  It  sometimes  dis- 
charges into  the  intestine,  either  into  the  lower  end  of  the  ileum,  the  ca3cum, 
ascending  colon,  or  rectum,  through  an  opening  that  is  quite  small  in  the 
mucous  membrane,  but  larger  in  the  other  intestinal  coats.  Evacuation  of 
the  pus  per  rectum,  sometimes  tinged  with  blood,  has  been  regarded  as  favor- 
able from  the  time  of  Dupuytren.  It  occurred  in  18  per  cent,  of  the  cases 
collated  by  Fitz,  the  pus  breaking  into  the  intestine  at  some  point  above,  and 
escaping  by  the  rectum.  But  the  result  is  not  always  favorable  when  the 
abscess  breaks  into  the  intestine,  for  after  the  pus  has  been  evacuated  fecal 
matter  may  escape  from  the  intestine  through  the  opening,  carrying  with  it 
microbes  which  may  poison  the  system  and  set  up  septic  fever.  Of  6  eases 
related  by  Demme  in  which  the  abscess  broke  into  the  intestine,  3  subse- 
quently died.  In  a  case  treated  by  the  late  Dr.  F.  M.  Warner  and  myself  a 
boy  of  about  eight  years  recovered  in  this  manner.  Henoch  states  that 
abdominal  abscesses  are  very  prone  to  escape  at  the  umbilicus,  since  this  is 
the  weakest  part  of  the  abdominal  wall.  Rarely  the  pus  makes  a  passage 
into  the  bladder,  and  if  this  occur  cystitis,  due  to  the  presence  of  purulent 
and  fecal  matter,  may  result.  The  inflammation  has  also,  in  a  case  mentioned 
by  Eisenchtitz,  extended  from  the  perforated  appendix  to  the  right  ovary, 
producing  purulent  inflammation  in  this  organ.  Extension  of  the  inflamma- 
tion from  the  perforated  appendix  to  and  around  the  contiguous  blood-vessels 
may  produce  disastrous  results.  The  superior  mesenteric  vein,  which  con- 
veys blood  from  the  caecum  and  appendix  to  the  portal  vein,  sometimes 
becomes  the  seat  of  thi'ombosis,  the  circulation  in  its  branches  being  inter- 
rupted by  the  presence  and  pressure  of  inflammatory  products.  Detached 
particles  of  the  thrombi,  conveyed  through  the  portal  vein  to  the  liver,  pro- 
duce septic  inflammation  and  abscesses  in  this  organ.  Matterstock  has  the 
records  of  eleven  cases  in  which  the  liver  became  involved  in  this  manner. 
Occasionally  the  abscess  ascends  along  the  colon  and  behind  the  liver,  becom- 
ing subdiaphragmatic,  and  cases  have  been  reported  in  which  it  entered  the 
right  pleural  cavity.  Tillmann  states  that  in  22  cases  of  fecal  fistula  extend- 
ing into  the  pleural  cavity  6  originated  from  perforations  in  the  appendix. 
The  abscess  penetrating  the  retro-peritoneal  tissue  may  extend  to  the  kidney, 
so  as  to  become  perinephritic,  or  it  may  descend  along  the  psoas  and  iliac 
muscles,  even  under  or  below  Poupart's  ligament.  Cases  are  reported  in 
which  it  burrowed  under  the  gluteus  maximus  muscle  or  in  the  perirectal 
tissue,  occupying  the  sacral  or  coccygeal  region. 

Evidently,  inasmuch  as  the  appendix  is  invested  by  peritoneum,  its  per- 
foration and  the  escape  of  fecal  substance  or  a  foreign  body,  which  produces 
the  abscess  described  above,  cannot  occur  without  a  localized  peritonitis  behind 
and  below  the  caecum,  where  the  appendix  lies.  But  a  more  serious  and 
ordinarily  fatal  result  sometimes  follows— to  wit,  the  occurrence  of  acute  dif- 
fuse peritonitis.  This  may  take  place  immediately  after  the  perforation,  but 
frequently  an  abscess  forms,  perhaps  of  little  extent,  around  the  appendix,  and 
it  may  continue  for  weeks  or  months  without  producing  any  dangerous  symp- 
toms. Finally  it  bursts,  and  its  contents  escape  into  the  general  peritoneal 
cavity,  producing  an  acute  peritonitis,  which  rapidly  extends  over  the  perito- 
neal surface.  A  large  proportion  of  the  cases  of  perforation  of  the  appendix 
if  left  to  themselves  terminate,  after  a  time,  in  this  manner,  in  peritonitis, 
which  from  its  extent  and  severity  is  usually  fatal.  This  was  the  result,  ac- 
cording to  Volz,  in  31  of  39  cases,  and,  according  to  Cless,  in  7  out  of  8  cases. 

Symptoms. — The  initial  symptom  of  this  form  of  inflammation  is  pain, 
more  or  less  severe,  in  the  region  of  the  appendix,  perhaps  at  first  paroxysmal, 
with  intervals  of  comparative  ease,  but  accompanied  by  tenderness.  The 
patient  is  apt  to  have  nausea  and  even  vomiting,  constipation  or  diarrhoea,, 


APPENDICITIS.  '        801 

flatulence,  and  tenesmus,  so  that  experienced  physicians  sometimes  err  in 
diagnosticating  a  milder  disease,  not  aware  of  the  serious  malady  which  is 
impending.  These  symptoms  in  the  initial  period  frequently  abate  for  a  day 
or  two,  and  the  patient  is  able  to  be  about,  but  they  return  with  equal  or 
greater  severity. 

When  the  disease  continues,  the  pain  in  the  csecal  region  is  so  constant 
that  the  patient  takes  to  bed,  unable  to  stand  upright  or  to  walk.  He  inclines 
forward  and  to  the  right,  and  his  right  thigh  is  flexed  to  relieve  the  tension. 
Sometimes  he  refers  the  pain  to  the  epigastrium  or  the  abdomen,  and  it  is 
increased  by  coughing,  by  full  inspiration,  and  by  extension  of  the  right 
thigh  when  the  peritonitis  begins.  Vomiting  of  the  ingesta  mixed  with 
mucus  and  bile  is  common,  and  eructations  of  gas  may  occur.  Occasionally 
these  symptoms  are  preceded  by  a  chill,  but  less  frequently  in  children  than 
in  adults.  The  following  are  the  symptoms  commonly  present :  anorexia, 
thirst,  fever  with  morning  remissions  (101°  to  103°  F.),  accelerated  pulse, 
features  indicative  of  severe  sickness,  sometimes  icteric  hue  of  skin  and  con- 
junctiva, perhaps  dysuria,  scanty  urination  or  retention  of  urine,  diarrhoea 
or  constipation ;  abdomen  ^at  and  muscles  tense  at  first,  but  subsequently 
abdomen  tympanitic ;  tenderness  on  pressure  at  first  in  the  right  iliac  region, 
but  subsequently  more  general ;  prominence  of  the  ileo'-caecal  region,  at  first 
from  gas,  subsequently  from  exudates  ;  a  caecal  tumor,  tender  and  immovable  ; 
adjacent  loops  of  intestine  distended.  Such  are  the  symptoms  and  phenomena 
that  attend  this  disease.  Pressure  of  the  crural  plexus  may  cause  numb- 
ness, pain,  or  other  abnormal  sensation  in  the  right  leg  and  the  external 
genital  organs.  Pressure  on  the  iliac  vein  may  retard  the  return  circulation 
from  the  leg  and  cause  oedema  of  the  limb. 

The  progress  of  this  disease  and  its  gravity  vary  greatly  in  different  cases. 
In  the  mildest  forms  of  the  inflammation,  the  pain,  nausea,  fever,  ileo-csecal 
tenderness,  and  fulness  gradually  abate,  and  in  two  or  three  weeks  the  health 
is  restored ;  or  the  symptoms  may  continue  longer,  but  finally  yield  after  the 
discharge  per  rectum  of  gas  and  ofi"ensive  feces.  A  deep-seated  induration  and 
soreness,  gradually  abating,  may  remain  at  the  seat  of  the  disease  for  months, 
and  the  patient  may  complain  of  aching  or  pain  after  a  full  meal  or  active 
exercise.  When  the  abscess  opens  into  the  intestine  the  dangerous  symp- 
toms abate  rapidly,  and  the  patient,  as  a  rule,  quickly  begins  to  convalesce. 

In  other  cases  the  symptoms  continue,  but  with  some  remission  due  to 
the  fact  that  the  abscess,  which  does  not  discharge,  becomes  surrounded  by 
condensed  connective  tissues  which  limit  its  extension.  Then,  perhaps  after 
some  unusual  eff"ort  or  a  blow  or  pressure  upon  the  inflamed  part,  an  aggra- 
vation of  symptoms  occurs.  Purulent  or  septic  matter  has  probably  escaped 
at  some  point,  and  peritonitis  may  have  resulted,  or  burrowing  of  pus,  as  has 
been  described  above,  or  septic  inflammation  in  some  important  organ.  The 
sudden  advent  of  alarming  symptoms  when  the  patient  has  been  compara- 
tively comfortable,  severe  and  general  abdominal  pain,  prostration,  rapid 
pulse  (150  to  160),  a  high  temperature  (105°  or  106°),  or  abnormally  low 
for  the  other  symptoms,  painful  respiration,  tenseness  of  the  abdominal  mus- 
cles, followed  by  tympanites  and  distention,  indicate  rupture  of  the  abscess, 
general  peritonitis,  and  rapidly  approaching  death,  unless  early  and  imme- 
diate laparotomy  be  performed  and  the  peritoneal  cavity  be  irrigated  by  a 
warm  antiseptic  lotion.  In  this  alarming  state  vomiting,  gaseous  eructa- 
tions, constipation,  more  rarely  diarrhoea,  retention  of  urine,  clammy  perspi- 
rations, hiccough,  flexed  thighs,  pallor,  and  finally  collapse,  indicate  the  fatal 
progress  of  the  disease. 

To  add  to  the  gravity  of  the  situation,  septic  inflammations  in  other  parts 
sometimes  start  up,  as  empyema  or  pericarditis,  cystitis,  perhaps  with  per- 
51 


802  LOCAL  DISEASES. 

foration  of  the  bladder,  inflammation  around  or  within  the  female  genital 
organs  or  in  the  retro-peritoneal  connective  tissue. 

On  the  other  hand,  it  must  be  remembered  that  in  a  considerable  propor- 
tion of  cases  the  abscess  is  so  encapsulated  that  septic  poisoning  and  diffuse 
peritonitis  are  prevented,  at  least  for  a  time. 

Of  the  symptoms  enumerated  above,  pain  is  one  of  the  most  constant, 
and  was  present  in  84  per  cent,  of  the  cases  collated  by  Fitz.  It  is  of  course 
less  severe  if  the  inflammation  is  localized  in  the  ileo-caecal  region  and  of 
little  extent  than  when  it  occupies  a  wider  area  from  the  extension  of  peri- 
tonitis. 

Vomiting  is  one  of  the  most  common  symptoms.  It  was  absent  in  only 
2  of  the  72  cases  collated  by  Matterstock,  and  was  present  in  Pepper's  13 
cases.  It  appears  to  be  more  common  in  children  than  in  adults.  Diarrhoea 
was  present  in  33.3  per  cent,  of  Matterstock's  cases,  and  constipation  in  46.6 
per  cent.,  alternating  constipation  and  diarrhoea  in  15.5  per  cent.,  and  normal 
stools  in  4.5  per  cent,  of  the  cases.  According  to  Pott,  diarrhoea  is  more 
common  than  constipation  in  children,'  and  in  fatal  cases  approaching  termi- 
nation severe  colliquative  diarrhoea  sometimes  occurs. 

More  or  less  fulness  and  induration  can  usually  be  detected  in  the  ileo- 
caecal  region  at  an  early  as  well  as  late  stage  of  the  disease,  but  a  distinct 
tumor  is  only  occasionally  perceptible.  According  to  Pepper,  in  19  children 
with  this  disease  a  tumor  could  be  detected  in  only  3  instances.  A  dull  per- 
cussion sound  in  the  right  ileo-cascal  region  is  common,  but  occasionally, 
even  when  there  is  considerable  inflammatory  induration,  loops  of  intestine 
distended  with  gas  lie  over  the  seat  of  inflammation,  so  that  the  percussion 
sound  is  resonant.  The  temperature  usually  ranges  from  100°  to  103°  or 
104°.  It  is  sometimes  remittent.  In  a  ease  treated  by  the  late  Dr.  H.  B. 
Sands  the  temperature  fell  from  101.6°  before  laparotomy  to  98.5°  imme- 
diately after  the  operation,  and  it  remained  below  100°  during  convalescence. 
A  sudden  rise  in  temperature  indicates  extension  of  inflammation  or  perhaps 
the  occurrence  of  septic  inflammation  in  organs  not  previously  involved.  A 
sudden  fall  of  temperature  when  other  symptoms  are  grave,  like  cessation 
of  pain,  indicates  collapse. 

Diagnosis. — Recurring  pain  or  tenderness  in  the  caecal  region  at  intervals 
of  a  few  weeks  should  excite  suspicion  of  the  presence  of  a  foreign  sub- 
stance in  the  appendix.  Dr.  C.  E.  With  ^  found  that  such  recurring  attacks 
preceded  the  severe  disease  for  weeks,  months,  or  even  years  in  certain  cases, 
and  in  the  large  number  of  cases  which  he  collated,  Matterstock  ascertained 
that  these  occasional  attacks  of  pain  and  tenderness  preceded  the  disease  in 
8  per  cent,  of  the  children  affected.  Sometimes  the  accumulation  of  fecal 
matter  in  the  caecum  can  be  determined  by  palpation,  since  it  produces  a 
"  doughy  "  feel.  The  diagnosis  of  this  inflammation  from  invagination  is  not 
difficult,  since  the  latter  occurs  chiefly  in  infancy,  is  attended  by  a  tumor 
more  centrally  located  in  the  abdomen  than  the  ileo-caecal  induration  which 
we  are  considering,  and  is  attended  often  by  bloody  stools  and  fecal  vomiting. 
Dr.  V.  P.  Gibney^  states  that  four  children  with  perityphlitis  had  been 
brought  to  his  orthopaedic  hospital  in  the  belief  that  they  had  hip  disease, 
and  had  been  treated  for  it ;  but  a  more  careful  examination  of  such  cases, 
especially  under  ether,  shows  that  the  hip-joint  is  not  affected.  The  swelling 
in  hip-joint  disease  is  lower  down  than  the  perityphlitic  induration.  Besides, 
perityphlitis  does  not  produce  the  change  in  the  appearance  of  the  hip  when 
examined  from  behind,  or  in  the  position  of  the  foot,  which  we  observe  in 

1  Jahrbuch  fur  Kinderheilk. ,  N.  F.  xiv. 

^  Peritonitis  Appendicularis,  etc.,  Kjobenliavn,  1879. 

^  ATuer.  Journ.  of  Med.  ScL,  1881. 


APPENDICITIS.  803 

hip  disease.  N.  Senn  ^  recommends  rectal  injection  of  hydrogen  gas  as  a 
means  of  determining  the  presence  of  perforation  of  the  caecum  or  appendix, 
since  in  case  of  perforation  the  gas  enters  the  peritoneal  cavity,  and  lapa- 
rotomy without  delay  is  indicated.  The  diagnosis  from  a  psoas  abscess  may 
be  made  by  attention  to  the  following  facts :  This  abscess  occurs  gradually, 
without  symptoms  referable  to  the  intestines  or  peritoneum,  and  without  the 
ileo-c£ecal  induration  of  perityphlitis.  Moreover,  the  abscess  usually  descends 
along  the  psoas  muscle  and  forms  a  swelling  under  Poupart's  ligament,  or  it 
extends  along  the  thigh  under  the  fascia. 

Prognosis. — This  varies  greatly  in  different  cases.  If  the  inflammation 
be  of  little  extent  and  encapsulated,  and  sepsis  do  not  occur,  the  prognosis  is 
good.  On  the  other  hand,  if  the  perforation  of  the  caecum  or  appendix  be 
of  considerable  size,  with  considerable  escape  of  feculent  matter,  loaded  as  it 
is  with  microbes,  the  severe  inflammation  which  results  in  the  peritoneum  or 
retro-peritoneal  tissue,  with  perhaps  consecutive  septic  inflammation  in  adja- 
cent organs  or  tissues,  to  which  septic  matter  has  been  conveyed  by  the 
lymphatics  or  blood-vessels,  a  fatal  termination  is  almost  certain.  It  is  evi- 
dent that  the  statistics  relating  to  the  result,  as  ascertained  by  different 
writers,  vary  according  to  the  average  severity  of  the  cases  whose  records 
they  consult.  The  following  statistics  have  been  published,  showing  the 
mode  of  termination  of  appendicitis,  extending  in  many  of  the  cases  which 
ended  fatally  so  as  to  cause  more  or  less  typhlitis,  perityphlitis,  and  perito- 
nitis : 

Authors.  Deaths.  Recoveries. 

Volz 39 10 

Bamberger 18 -55 

W.  T.  Bull 33 34 

Matterstock 49 21 

With 12 18 

Demme 27 9 

According  to  Matterstock,  age  influences  the  result  in  a  measure,  since 
of  12  patients  under  the  age  of  six  years,  11  died;  of  24  patients  between 
the  ages  of  six  and  ten  years,  15  died ;  and  of  34  patients  between  the  ages 
of  ten  and  fifteen  years,  23  died.  A  diff"use  peritonitis,  whether  resulting 
immediately  from  the  perforation  or  from  rupture  of  an  abscess  which  has 
been  previously  encapsulated  and  indolent,  is  usually  fatal.  Evacuation  of 
the  abscess  into  the  caecum  or  rectum  justifies  a  favorable  prognosis,  though 
some  die  in  which  this  occurs.  Evacuation  of  pus  through  the  abdominal 
walls,  if  it  takes  place  at  an  early  date,  is  also  regarded  as  favorable.  Lapa- 
rotomy, as  this  operation  is  designated,  if  performed  at  the  proper  time  and 
with  antiseptic  precautions,  greatly  increases  the  chances  of  recovery. 
According  to  Noyes.'  in  100  such  operations  the  mortality  was  only  15.  But 
according  to  Bull,  the  result  is  not  so  favorable  if  the  abscesses  burrow  their 
way  to  the  surface  and  open  without  surgical  assistance,  for  of  28  such 
abscesses,  11  were  fatal. 

How  long  patients  may  live  in  fatal  cases  after  the  occurrence  of  severe 
symptoms  has  been  investigated  by  Fitz,  who  found  that  in  176  cases  34  per 
cent,  died  in  the  first  five  days,  more  than  half  in  the  first  week,  31  per  cent, 
in  the  second  week,  and  4  per  cent,  in  the  third  week.  In  those  mild  cases 
in  which  the  inflammation  in  the  caecal  region  is  of  slight  extent  and  the 
patient  is  soon  convalescent,  a  sudden  aggravation  of  symptoms  sometimes 
occurs  from  breaking  loose  of  the  inflammatory  products  of  septic  absorp- 
tion, and  the  case  ends  fatally. 

^  Journ.  of  the  Amer.  Med.  Assoc,  June  23,  1888. 
2  Tram.  Rhode  Island  Med.  Soc,  1882. 


804  LOCAL  DISEASES. 

Treatment. — Prophylactic. — Children  should  have  plain  and  easily- 
digested  diet,  from  which  seeds  or  other  indigestible  substances  are  removed 
as  much  as  possible.  They  should  be  instructed  to  reject  the  seeds  of  the 
ordinary  fruits  which  they  are  allowed  to  eat,  since  seeds  are  the  offending 
substances  which  cause  appendicitis  and  perforation  in  so  large  a  proportion 
of  cases.  Daily  fecal  evacuations  should  be  procured,  so  as  to  prevent  fecal 
accumulation  in  the  caecum.  If  there  be  complaint  of  colicky  pain  in  the 
abdomen  while  the  bowels  move  regularly,  or  if  there  be  occasional  pain  or 
aching  in  the  cgecal  region,  a  careful  examination  should  be  made  in  order  to 
ascertain  if  there  be  tenderness  or  induration  at  the  point  complained  of,  and 
if  so,  a  quiet  life  with  open  bowels  should  be  enjoined.  By  such  measures 
the  threatening  symptoms  may  pass  off. 

Curatioe. — The  late  Prof.  Henoch  of  the  University  of  Berlin,  whose 
opinions  relating  to  the  diseases  of  children  always  claim  attention,  if  not 
acceptance,  on  account  of  his  large  experience,  says  that  whether  the  inflam- 
mation occurs  from  over-distention  of  the  caecum  by  fecal  masses  or  from 
concretions  in  the  appendix,  the  symptoms  are  the  same  as  in  later  life — to 
wit,  pain  in  the  caecal  region,  which  is  likely  to  extend  over  "  a  large  part  of 
the  peritoneum  ;  the  frequent  formation  of  a  tumor  by  the  exudation,  which 
not  infrequently  terminates  in  suppuration ;  the  repeated  relapses,  etc." 
Henoch  states  that  he  keeps  the  intestines  perfectly  quiet  by  opium,  and  only 
gives  castor  oil  or  calomel  when  prolonged  constipation  and  palpation  indicate 
the  presence  of  a  large  fecal  accumulation  in  the  caecum ;  otherwise,  he  ab- 
stains from  purgatives,  applies  a  few  leeches,  without  after-bleeding  if  there 
be  much  tenderness,  gives  an  emulsion  of  oil  (emulsio  oleosa),  with  the 
aqueous  extract  of  opium  every  two  hours,  and  uses  constantly  the  ice-bag 
over  the  caecum.  When  with  this  treatment  the  pain  and  tenderness  cease, 
he  states  that  defecation  usually  occurs  spontaneously  or  is  produced  by  a 
simple  enema  or  a  dose  of  oil.  The  following  remark  might  be  thought  to 
be  an  exaggeration  were  it  not  for  the  well-known  accuracy  and  high  profes- 
sional standing  of  Prof.  Henoch :  "  When  this  treatment  was  begun  early 
enough,  recovery  ensued  in  almost  all  cases,  and  if  a  swelling  had  been  formed 
by  the  exudation,  its  transition  into  suppuration  was  prevented  even  in  chil- 
dren who  in  the  course  of  a  few  years  had  been  repeatedly  admitted  to  the 
hospital  on  account  of  relapses."  The  treatment  detailed  above,  employed 
and  recommended  by  Prof.  Henoch,  is  in  my  opinion  the  best  that  can  be 
prescribed  for  typhlitis,  appendicitis,  and  perityphlitis  before  suppuration  has 
occurred.  The  use  of  laxatives,  unless  sometimes  laxative  enemata,  should 
be  postponed  until  the.  tenderness  and  other  inflammatory  symptoms  have  to 
a  considerable  extent  abated  by  the  use  of  a  warm  flaxseed  poultice,  or,  if  the 
temperature  be  above  103°,  the  ice-bag,  and  opium  in  sufficient  doses  to  allay 
restlessness  and  procure  sleep  should  be  employed.  If,  when  the  inflammation 
has  been  subdued,  we  ascertain  by  palpation  the  presence  of  fecal  masses  in 
the  caecum,  a  large  clyster  of  warm  water,  containing  one  ounce  of  glycerin 
and  one  of  sweet  oil,  may  be  prescribed,  or  perhaps,  as  recommended  by 
Henoch,  a  dose  per  orem  of  castor  oil  or  calomel  may  be  given.  Even  in 
the  commencement  of  the  treatment,  if  there  be  the  history  of  constipation, 
and  on  palpation  the  caecum  appears  to  be  distended  with  fecal  matter,  it  is 
proper  to  employ  a  large  clyster  of  warm  water,  containing  one  ounce  of 
glycerin  and  one  of  sweet  oil,  in  order  to  remove  a  chief  cause  of  irrita- 
tion. ■  The  diet  should  consist  of  liquids  that  leave  little  residuum,  as  the 
beef  peptones  and  peptonized  milk.  Carbonized  water  may  be  allowed  to 
relieve  the  thirst  or  nausea.  If  the  case  result  favorably,  the  child  should 
lead  a  quiet  life,  avoiding  violent  exercise  during  and  after  convalescence, 
for  relapse  is  not  infrequent. 


PERITONITIS.  805 

But  in  appendicitis,  with  the  contiguous  inflammations,  typhlitis  and  peri- 
typhlitis, or  without  them  when  the  inflammation  persists,  an  abscess  results ; 
and  in  recent  years  many  lives  have  been  saved  by  the  incision  and  drainage 
of  the  abscess. 

In  America  the  advantages  of  early  liberation  of  the  pus  in  ileo-caecal 
abscesses  was  brought  to  the  notice  of  the  profession  by  the  late  Prof.  Wil- 
lard  Parker,  whose  first  case  of  successful  operation  occurred  in  1843.  Since 
this  time  the  treatment  of  perityphilitic  abscesses  by  incision  has  been  prac- 
tised in  numerous  instances,  so  that  Dr.  R.  F.  Noyes  was  able  to  collate  the 
records  of  119  cases,  only  about  16  per  cent,  of  which  were  fatal. ^ 

Dr.  Sands  strongly  objected  to  the  use  of  the  exploring  needle  at  an  early 
stage  of  the  inflammation,  employed  for  the  purpose  of  determining  the 
presence  or  absence  of  pus,  since  it  might  penetrate  the  healthy  peritoneal 
cavity  and  pierce  the  intestine  or  pus-cavity,  and  when  withdrawn  the  foul 
substance  adherent  to  it  would  probably  infect  the  peritoneum  and  cause  a 
difi"use  peritonitis.  Gr.  Buck,  Wier,  and  Bull  advise,  if  the  presence  of  pus 
be  determined  by  the  needle,  to  leave  it  in  situ,  that  it  may  serve  as  a  guide 
in  making  the  incision.  Morton  states  that  the  aspirator  needle  should  never 
be  used,  and  Ransohofi"  also  objects  to  it.  Dr.  Lange^  in  making  the  incision 
and  entering  the  peritoneal  cavity,  finding  that  the  tumor  was  covered  by 
omentum,  closed  the  opening  and  made  the  cut  farther  to  the  right,  where 
the  peritoneum  was  adherent  to  the  tumor,  and  the  patient  recovered. 

Sands  recommends  making  a  vertical  incision  over  the  tumor,  as  aff"ording 
the  readiest  approach  to  the  diseased  parts.  Noyes,  Parker,  Hancock,  and 
others  make  the  incision,  four  inches  in  length  and  even  longer,  in  a  line 
parallel  with  the  outer  half  of  Poupart's  ligament.  Hadden  and  Bontecou 
make  a  curved  incision  along  the  crest  of  the  ileum,  and  others,  as  Gibney 
and  Parker,  make  the  incision  at  the  most  prominent  part  of  the  tumor  and 
nearer  the  median  line  than  most  other  operators. 

Laparotomy,  or  the  opening  of  the  abdominal  cavity  for  the  purpose  of 
evacuating  the  abscess,  has  been  performed  a  considerable  number  of  times 
during  the  last  ten  years,  and  cases  have  been  published  showing  very  favor- 
able results. 

Peritonitis. 

The  peritoneum  is  very  extensive.  It  is  a  serous  membrane  and  a  closed 
sac,  except  in  the  female  at  the  extremities  of  the  Fallopian  tubes.  It  covers 
all  the  viscera  in  the  abdominal  and  pelvic  cavities,  and  is  reflected  over  their 
parietal  surfaces,  forming  by  its  extension  the  greater  and  lesser  omentum. 
Its  free  surface  is  moist,  smooth,  and  covered  by  a  layer  of  thin  squamous 
epithelium,  while  its  under  surface  connects  with  the  underlying  viscera,  and 
fascia,  in  which  the  muscles,  blood-vessels,  lymphatics,  and  nerves  lie.  The 
great  extent  of  the  peritoneum  and  the  large  number  of  lymphatics  in  it 
render  its  inflammation  dangerous,  and,  if  it  be  general,  likely  to  be  fatal. 

Etiology. — The  earliest  form  of  peritonitis  occurs  in  the  foetus,  rendering 
it  non-viable.  This  form  ordinarily  originates  from  syphilis.  Septicaemia  is 
also  a  common  cause  of  peritonitis  in  the  newly-born  in  filthy  and  degraded 
families.  If  sanitary  precautions  are  neglected  and  the  habits  of  the  house- 
hold are  filthy  and  degraded,  germs  from  sources  of  uncleanliness  are  liable 
to  enter  the  umbilical  fossa.  We  have  shown  elsewhere  how  pathogenic  germs 
derived  from  the  decaying  cord  not  infrequently  enter  the  umbilical  vessels 
and  lymphatics,  and  are  conveyed  to  difi'erent  and  distant  parts,  setting  up 
inflammation  in  the  peritoneum  as  well  as  elsewhere. 

Prudden  and  Delafield  state  that  peritonitis  may  occur  without  apparent 

1  Trans,  of  Rhode  Island  Med.  Sac,  1882.         ^  jy;  y.  Med.  Journ.,  Mar.  3, 


806  LOCAL  DISEASES. 

cause,  but  it  is  more  frequently  produced  by  appreciable  agencies.  AVe  have 
mentioned  s\'pliilis  and  septicajmia  as  causes,  but  the  distinguished  pathol- 
ogists named  above  enumerate,  among  the  causes,  abdominal  wounds,  con- 
tusions, ulcers,  new  growths,  intussusceptions,  ruptures,  perforations,  inflam- 
mations of  the  stomach  and  intestines  and  of  the  vermiform  appendix.  If  the 
inflammation  of  any  organ  or  tissue  covered  by  peritoneum  reach  the  peri- 
toneum, peritonitis  occurs  by  extension  of  the  inflammation,  or  by  rupture 
of  the  peritoneum  and  the  escape  of  irritating  matter  into  the  peritoneal 
cavity,  which  produces  a  general  and  usually  fatal  peritonitis. 

If  we  exclude  peritonitis  due  to  tubercles  and  that  from  septicaemia  and 
syphilis,  it  may.  in  my  opinion,  be  truthfully  said  that  a  majority  of  the  cases 
of  peritonitis  in  the  young  originate  from  appendicitis.  From  an  anatomical 
point  of  view  we  recognize  two  forms  of  acute  peritonitis,  designated  the 
cellular  and  exudative.  As  described  by  Prudden  and  Delafield,  the  former 
is  produced  by  an  irritant  of  moderate  activity. 

After  death  in  this  form  of  peritonitis  the  entire  peritoneal  surface  is  of  a 
bright-red  color,  but  with  no  visible  fibrinous,  serous,  or  purulent  exudate. 
The  endothelial  cells  have  increased  in  number  and  size,  so  as  to  project 
outward  more  than  in  health.  The  second  form  of  peritonitis,  designated 
exudative,  was  studied  experimentally  by  Prudden  and  Delafield.  In  one 
to  two  hours  after  the  injection  of  an  active  irritant  into  the  peritoneal 
cavity  of  the  dog  they  found  a  little  serum  in  the  cavity,  congestion  of 
the  peritoneum,  and  points  of  exuded  serum  upon  the  inflamed  surface. 
No  marked  changes  occurred  in  the  connective  tissue  or  endothelial  cells, 
but  pus-cells  collected  in  the  stroma  under  the  endothelium,  and  white  blood- 
cells  increased  in  the  vessels.  Twenty-four  hours  later  the  peritoneal  con- 
gestion was  greater,  as  well  as  an  increase  of  serum,  fibrin,  and  pus.  and  an 
increase  and  swelling  of  the  endothelial  cells.  In  the  human  being,  if  death 
occurs  by  the  third  day,  which  is  the  common  result  in  experiments  on  dogs, 
the  same  anatomical  results  are  observed — to  wit,  general  congestion  in  the 
peritoneal  surface,  along  with  an  increase  in  pus,  fibrin,  serum,  in  the  number 
and  size  of  the  epithelial  cells.  Death  commonly  results  between  the  sixth 
and  fourteenth  days,  and  the  anatomical  changes  which  have  occurred  vary 
in  different  cases.  Congestion  of  blood-vessels  may  be  very  intense,  with 
extravasation  of  blood,  or  the  latter  may  be  absent.  Pus  and  fibrin  in  a 
thick  or  thin  layer  may  cover  the  adjacent  surfaces,  or  pus  may  infiltrate 
the  entire  thickness  of  the  peritoneum  and  subjacent  connective  tissue. 

Sometimes  the  pus  is  sacculated  by  adhesions,  so  as  to  appear  like  an 
abscess ;  it  may  have  a  dirty  color  from  the  presence  of  bacteria  ;  and  it  is 
thick  or  thin  according  to  the  relative  proportion  of  serum  and  pus-cells. 

Acute  peritonitis,  if  it  be  not  fatal  or  the  symptoms  are  not  aggravated 
by  the  close  of  the  second  week,  may  become  chronic.  Local  peritonitis 
often  results  from  an  underlying  inflammation  commencing  in  one  of  the 
viscera  and  extending  to  the  peritoneal  covering.  The  inflammation  may 
be  circumscribed  by  adhesions  or  may  extend  so  as  to  be  fatal.  The  most 
important  and  interesting  instances  of  this  kind  have  only  in  recent  years 
been  correctly  understood.  It  is  now  known  beyond  doubt,  from  surgical 
experience  and  observations  in  the  dead-house,  that  the  peritonitis  occurring 
in  children  previously  supposed  to  be  healthy,  and  ending  ordinarily  in  death, 
results  in  a  large  proportion  of  cases  from  appendicitis.  The  lodgement  of  a 
foreign  substance,  often  fetid  and  highly  irritating,  in  the  appendix  causes 
inflammation,  ulceration,  and  not  infrequently  perforation,  with  the  escape 
of  the  putrefying  matter,  which  causes  a  general  peritonitis. 

The  subject  of  appendicitis  as  a  cause  of  peritonitis  will  be  considered 
hereafter. 


PERITONITIS.  807 

Delafield  and  Prudden  describe  the  following  varieties  of  chronic  perito- 
nitis : 

1.  Cellular  peritonitis;  , 

2.  Peritonitis  with  adhesions  ; 

3.  Chronic  peritonitis  with  thickening  of  the  peritoneum  ; 

4.  Chronic  peritonitis  with  the  production  of  fibrin,  serum,  and  pus ; 

5.  Hemorrhagic  peritonitis ; 

6.  Tubercular  peritonitis : 

(a)  Tubercular  ascites  ; 

(b)  Tubercular  peritonitis  with  the  production  of  a  large  amount  of 

fibrin  ; 

(c)  Tubercular  peritonitis  with  adhesions. 

Symptoms. — Obviously,  since  peritonitis  in  many  instances  results  from 
some  anterior  disease,  the  symptoms  of  this  disease  precede  it.  Frequently, 
especially  during  childhood,  abdominal  pains,  often  intermittent  and  vague, 
precede  the  severe  symptoms  indicating  peritonitis.  An  appendicitis  has 
probably  pre-existed.  Sometimes  an  empyema  has  occurred,  more  or  less 
filling  the  affected  side  of  the  chest  with  pus,  and  pus-cells  traversing  the 
lymph-spaces  of  the  diaphragm  appear  on  its  under  surface  and  excite  a 
peritonitis,  which,  commencing  in  the  upper  part  of  the  abdominal  cavity, 
extends  downward.  A  suppurating  mesenteric  gland,  an  ulcerating  Peyerian 
patch,  scarlatinous  uraemia,  and  a  local  inflammation,  whatever  the  cause, 
extending  to  the  peritoneum,  inevitably  give  rise  to  inflammation  of  this 
membrane. 

Typical  peritonitis  begins  with  severe  pain,  vomiting,  and  tenderness,  in- 
creased by  pressure,  followed  by  distention  with  gas.  Sometimes  there  is 
initial  chilliness,  followed  by  a  quick  pulse  and  heat  of  surface  ;  constipation 
is  common  ;  the  countenance  is  anxious  and  expressive  of  sufi"ering ;  and  the 
legs  are  flexed.  As  the  disease  continues  the  intestines  become  distended  by 
gas,  which  increases  the  pain,  and  the  food  is  ejected.  The  loss  of  appetite 
and  loss  of  food  by  vomiting,  by  which,  after  a  time,  even  bile  is  ejected, 
cause  progressive  emaciation  and  weakness.  Hiccoughs,  sometimes  present, 
greatly  aggravate  the  pain.  The  eyes  become  sunken.  While  the  abdomen 
is  distended,  other  portions  of  the  system  emaciate. 

The  pulse  in  the  beginning  of  peritonitis  is  usually  accelerated,  being 
perhaps  from  110  to  150,  and  the  temperature  from  101°  to  104°  F.,  though 
these  symptoms  are  variable.  The  pain  is  usually  severe  or  griping,  and  is 
increased  by  pressure  or  motion,  as  by  a  deep  breath  or  a  cough.  The  pain 
is  also  increased  by  peristaltic  or  vermicular  movements  of  the  intestines. 
Exceptionally,  the  pain  may  be  slight.  It  is  usually  most  severe  in  perfora- 
tive or  traumatic  cases  before  adhesions  have  occurred.  As  peritonitis  is 
usually  local  at  first,  the  pain  is  at  first  localized,  and  it  extends  and  becomes 
more  severe  as  the  inflammation  increases  until  it  is  general.  Nausea  i^ 
likely  to  occur  when  there  is  no  vomiting,  accompanied  with  belching.  The 
distention  may  become  such  that  the  abdomen  is  not  only  markedly  dis- 
tended, so  that  the  skin  is  smooth  and  shining,  but  the  diaphragm  is  carried 
up — the  apex  of  the  heart  upward  and  backward ;  the  liver  is  carried 
upward  and  turned  on  its  axis  in  extreme  cases.  In  severe  peritonitis,  espe- 
cially from  perforation,  collapse  may  soon  follow.  The  pulse  is  rapid  and 
weak,  the  voice  feeble.  In  severe  cases,  approaching  a  fatal  termination,  the 
temperature  may  be  very  high- — as  high  as  108°  or  even  110°  F.  It  is  often 
higher  in  the  latter  part  of  the  day  than  at  other  times.  On  the  other  hand, 
it  may  be  subnormal.  The  tongue  at  first  is  moist,  but  afterward  it  becomes 
dry  and  furred ;  in  cases  of  septicaemia  or  other  grave  constitutional  diseases 
it  may  be  dry  and  covered  by  a  brown  fur  from  the  first. 


LOCAL  DISEASES. 

The  appetite  and  digestion  are  greatly  impaired,  and  the  food  is  regurgi- 
tated to  a  greater  or  less  degree  ;  constipation  is  also  common,  due  to  paraly- 
sis of  the  muscular  coat  of  the  intestines  and  fibrinous  adhesions.  Urination 
may  be  frequent  or  of  natural  frequency,  but  it  is  likely  to  be  painful  and 
scanty  when  the  inflammation  extends  to  the  bladder.  At  a  later  stage  the 
catheter  is  often  required  if,  as  is  usual,  the  inflammation  has  extended  over 
the  bladder  and  the  patient  is  fully  under  the  influence  of  opium.  In  certain 
grave  forms  of  peritonitis  a  trace  of  albumen  appears  in  the  urine. 

Diagnosis. — It  is  very  important  that  the  diagnosis  be  made  earl}',  for 
correct  treatment  and  the  life  of  the  child  depend  on  it.  On  palpation  in  the 
beginning  of  peritonitis  the  abdominal  walls  are  commonly  tense  and  resist- 
ing. Occasionally  the  friction  between  the  inflamed  surfaces  can  be  detected, 
and  the  fluctuation  is  noticed  if  there  be  considerable  increase  of  serous  exu- 
dation. A  clear  history  of  the  case,  a  careful  examination  of  the  abdomen 
by  palpation,  percussion,  and  change  of  position,  with  proper  appreciation  of 
the  history  and  symptoms,  generally  will  lead  to  a  correct  diagnosis. 

If  there  be  general  peritonitis,  there  is  general  tenderness,  fulness,  and 
hardness.  If  the  inflammation  be  limited  to  one  part,  that  part  exhibits 
hardness,  fulness,  and  tenderness,  or  tympanitic  resonance  may  occur,  due  to 
distended  intestine  underneath.  The  acuteness,  pain,  vomiting,  tympanism, 
fever,  and  the  continuance  of  these  symptoms,  with  the  aspect  of  severe 
sickness,  justify  or  render  probable  the  diagnosis  of  peritonitis.  If  by  de- 
cided measures  to  relieve  the  patient,  which  will  be  mentioned  hereafter,  he 
do  not  on  the  following  day  express  considerable  relief  from  the  suffering, 
the  case  is  probably  one  of  peritonitis. 

No  physician  summoned  to  a  case  of  abdominal  tenderness  or  pain  should 
neglect  to  examine  the  region  of  the  appendix  vermiformis,  located-  in  most 
cases  midway  between  the  umbilicus  and  the  anterior  superior  angle  of  the 
ileum.  From  the  fact  that  peritonitis,  occurring  in  those  who  have  previously 
been  free  from  ailment  and  robust,  ordinarily  begins  in  the  appendix,  this 
region  should  in  such  instances  be  carefully  examined  by  deep  pressure  with 
the  tips  of  the  fingers.  The  space  between  the  right  iliac  bone  and  the  um- 
bilicus should  be  thoroughly  explored  in  order  to  ascertain  if  there  is  any 
tenderness,  fulness,  or  hardness  in  the  site  of  the  appendix.  The  examina- 
tion can  be  facilitated  by  pressing  at  the  same  time  posteriorly  with  the 
thumb  of  the  same  hand  or  the  fingers  of  the  other  hand  applied  against  the 
right  lumbar  region.  By  this  manner  the  site  of  the  appendix  is  grasped 
anteriorly  and  posteriorly.  Prominent  surgeons  of  New  York  with  whom  I 
have  examined  cases  have  sometimes  been  able  by  rectal  examination  with 
the  finger  to  refer  the  localized  peritonitis  to  an  abscess  in  the  appendix. 

Prognosis. — In  acute  general  peritonitis  a  fatal  result  should  be  predicted 
if  the  diagnosis  is  clear.  I  have  not  yet  seen  a  patient  recover  who  had 
general  peritonitis,  manifested  by  intense  redness  of  the  entire  visceral  and 
parietal  surfaces,  with  purulent  and  commencing  fibrinous  exudation,  as 
shown  by  a  subsequent  autopsy.  Of  course  septic  or  tubercular  peritonitis 
is  fatal  from  the  primary  disease.  There  can  be  no  doubt  that  many  more 
children  with  local  peritonitis  are  now  cured  than  formerly,  and  this  improve- 
ment in  the  result  of  treatment  has  occurred  chiefly  from  the  surgical  meas- 
ures employed  in  the  treatment  of  the  peritonitis  caused  by  and  extending 
from  an  appendicitis.  This  is  treated  of  elsewhere.  The  most  favorable 
forms  of  peritonitis  are  evidently  the  local,  and  especially  those  occurring 
in  parts  which  are  susceptible  of  removal. 

Treatment. — Evidently  the  most  urgent  indication  is  to  relieve  pain, 
and  the  measures  employed  for  this  purpose  fortunately  have  a  tendency  to 
check  the  inflammation.     Many  remedies  will  relieve  pain,  but  an  opiate  is 


HERNIA   OF  THE  ABDOMEN.  809 

preferable,  because  it  is  best,  at  least  after  one  or  two  evacuations,  to  keep 
the  bowels  checked,  and  this  an  opiate  accomplishes.  A  child  of  eight  years 
may  take  one-fourth  of  a  grain  of  opium  or  5  drops  of  deodorized  tincture  of 
opium  every  two  hours  until  the  pain  ceases  or  the  physiological  effects  of  the 
drug  begin  to  be  manifested  by  contracted  pupil,  stupor,  and  slow  respiration. 
The  opiate  appears  to  be  absorbed  slowly,  and  it  is  the  common  belief  that  ab- 
sorption is  slower  in  a  case  of  peritonitis  than  in  one  not  affected  by  this  dis- 
ease. It  is  better,  as  a  rule,  to  avoid  subcutaneous  injections  of  an  opiate  in 
children,  since  a  dangerous  stupor  may  suddenly  occur  from  this  treatment. 
Given  by  the  mouth  and  its  effects  carefully  observed,  if  the  pain  becomes 
less  the  intervals  between  the  doses  should  be  lengthened. 

If  the  vomiting  be  persistent,  it  may  be  necessary  to  employ  rectal  sup- 
positories. In  all  cases  local  treatment  over  the  site  of  inflammation  is 
required.  A  light  poultice  of  one  part  of  ground  mustard  and  twenty  of  flax- 
seed, between  two  pieces  of  muslin  so  moist  as  to  wet  the  hand  in  holding  it, 
and  as  thin  as  the  pasteboard  covers  of  a  book,  may  be  employed,  or  a  flax- 
seed poultice  may  be  applied  with  the  following  on  its  under  surface : 

01.  caryopliylli,  gij  ; 

01.  camphoratse,  ^iij. — Misce. 

Or  hot  water  in  a  rubber  bag  may  be  used. 

Some  physicians  recommend  cold  applications  over  the  abdomen  in  cases 
of  acute  peritonitis.  Broken  ice  should  be  mixed  with  bran  in  about  equal 
quantity,  and  applied  over  the  abdomen  if  it  give  most  relief.  Generally, 
according  to  my  experience,  if  the  temperature  of  the  patient  reach  or  exceed 
103°  F.,  the  cool  applications  give  most  relief  and  should  be  preferred.  If  it 
be  below  103°,  the  warm  applications  best  satisfy  the  patient  and  should  be 
used. 

Vomiting,  flatulence,  and  eructations  of  gas  are  often  symptoms  which 
cause  considerable  distress.  In  such  cases  the  most  success  attends  the  fol- 
lowing mode  of  treatment :  A  flexible  No.  12  catheter  is  introduced  six,  per- 
haps eight;  inches  through  the  rectum,  and  half  a  pint  of  predigested  milk, 
with  half  a  pint  of  hot  water  to  which  two  teaspoonfuls  of  Rudisch's  predi- 
gested extract  of  beef  are  added,  should  be  cautiously  injected.  The  expul- 
sion of  gas  and  undigested  matter  will  be  useful  in  relieving  the  distention, 
and  what  remains  will  be  useful  in  sustaining  the  strength,  especially  if  one 
or  two  teaspoonfuls  of  brandy  be  added  to  it. 


CHAPTER    XIV. 
HEENIA  OF  THE  ABDOMEN. 

Inguinal  hernia  consists  in  the  protrusion  of  the  abdominal  viscera  cov- 
ered by  the  peritoneum  in  the  course  of  the  inguinal  canal,  the  channel 
by  which  the  spermatic  cord  passes  through  the  abdominal  muscles  to  the 
testis. 

Several  forms  are  recognized,  which  depend  chiefly  upon  the  varying  rela- 
tions of  the  peritoneum.     They  have  been  explained  as  follows  (T.  Holmes)  : 

{a)  In  congenital  inguinal  hernia  the  process  of  peritoneum  which  passes  down 
with  the  cord,  funicular  process,  remains  freely  open ;  the  general  cavity  of  the 


810 


LOCAL  DISEASES. 


peritoneum  is  therefore  identical  with  that  of  the  tunica  vaginalis  testis  forming  the 
hernial  sac,  the  bowel  contained  in  which  is  in  direct  contact  with  the  testicle  (Fig. 

(b)  The  condition  of  the  parts  in  an  infantile  hernia  are  as  follows :  The  tunica 
vaginalis,  1  (Fig.  214),  is  closed  above,  at  or  near  the  external  inguinal  ring,  but 


Fig.  213. 


Fig.  214. 


Congenital  inguinal  hernia. 


Infantile  hernia. 


its  funicular  portion  is  open  ;  the  bowel  in  the  hernial  sac  lies  behind  this  funicular 
portion,  and  is  represented  in  the  diagram  as  having  made  its  way  between  the 
funicular  process  and  the  cord  ;  the  relation  of  the  sac  to  the  cord  seems,  however, 
to  be  variable ;  the  bowel  is  covered  in  cutting  down  from  the  skin  by  three  layers 
of  peritoneum — viz.  1  and  2,  the  opposite  surfaces  of  the  funicular  process,  and  3, 
the  anterior  layer  of  the  peritoneal  hernial  sac. 

(c)  In  the  encysted  form  (Fig.  215)  of  infantile  hernia  the  bowel,  instead  of 
passing  behind  the  closed  funicular  process,  has  distended  the  membrane  which 
closes  its  upper  end,  and  has  pushed  itself  into  the  funicular  process,  the  upper  or 
back  wall  of  which  envelops  it ;  in  this  case,  therefore,  the  hernial  sac  is  furnished 
by  the  funicular  process  itself,  and  only  two  layers  of  peritoneum  cover  the  intes- 
tine. 

(d)  In  the  common  scrotal  hernia  (Fig.  216)  the  tunica  vaginalis  is  seen  behind 


Fig.  215. 


Fig.  216. 


Encysted  form  of  infantile  hernia. 


Common  scrotal  hernia. 


and  below,  and  is  represented  as  distended  with  a  certain  amount  of  hydrocele  fluid, 
but  quite  distinct  from  the  hernial  sac. 

(e)  Partial  obliteration  of  the  funicular  process  illustrates  the  formation  of  cysts 
in  the  pord,  encysted  hydrocele  of  the  cord  (Fig.  217);  the  cavity  of  the  tunica 
vaginalis  testis  is  closed  at  c  :  the  funicular  process  is  also  separated  from  the  peri- 
toneal cavity  at  a,  the  situation  of  the  abdominal  ring ;  there  is  also  another  septum 
at  b.  When  one  or  more  of  these  septa  are  absent  or  imperfect  various  conditions 
occur. 


HERNIA    OF  THE  ABDOMEN. 


811 


(/")  In  the  formation  of  the  hernia  into  the  funicular  process  of  the  peritoneum 
(Fig.  218)  the  septum  or  obliteration  at  c  is  absent,  so  that  the  tunica  vaginalis  is 


Fig.  217. 


Fig.  218. 


Cysts  of  the  cord ;  encysted  hydrocele. 


Hernia  into  the  funicular  process. 


open  as  high  as  the  septum,  6,  which  is  imperfect  or  has  given  way  from  some  acci- 
dental cause  ;  in  the  diagram  the  septum  at  the  external  abdominal  ring,  a,  is  drawn 
as  being  widely  open,  but  strangulation  may  occur  either  in  the  septum  at  &,  some- 
what lower  down,  or  at  both. 

The  SYMPTOMS  and  appearances  of  inguinal  hernia  are  generally  suflB.- 
ciently  characteristic,  but  even  in  the  most  marked  case  it  is  important, 
by  a  formal  inquiry  and  the  recognized  tests,  to  distinguish  it  from  differ- 
ent affections  which  occur  in  these  organs  and  tissues. 

The  more  noticeable  are  hydrocele ;  inflammatory  affections  and  other 
diseases  of  the  testis,  cord,  and  their  coverings ;  of  inguinal  and  lymphatic 
glands  ;   malpositions  of  the  testis. 

Femoral  hernia  is  so  rare  in  children  as  not  to  require  notice.  Femoral 
must  be  distinguished  from  inguinal  hernia  by  its  position  below  Poupart's 
ligament ;  from  abscess ;  from  an  enlarged  gland  and  an  enlargement  of  the 
femoi'al  vein ;   from  tumors  at  this  point. 

Umbilical  hernia  occurs  at  the  point  where  the  umbilical  vessels  pass 
through  the  abdominal  wall ;  it  exists  anterior  to  the  period  when  cicatrization 
is  complete,  which  varies  in  different  infants,  but  in  general  requires  several 
months.  When  the  parts  which  fill  the  aperture  are  firmly  cicatrized,  this 
point  of  the  wall  is  firmer  than  surrounding  parts, 
owing  to  the  condensation  of  the  cicatrix  and  the 
peculiar  arrangement  of  the  fibres  of  the  trans- 
versalis  fascia  (Fig.  219). 


Fig.  219. 


In  infants  the  protruding  viscus  pushes  before  it 
that  portion  of  the  parietal  peritoneum  lying  imme- 
diately behind  the  aperture  in  the  linea  alba,  through 
which  the  umbilical  vessels  enter  the  abdominal 
cavity ;  the  hernial  sac  thus  formed,  before  the 
closure  of  the  ring  is  effected,  may  pass  into  the 
connective  tissue  of  the  cord  itself  before  that  struc- 
ture has  separated  ;  after  the  separation  of  the  cord 
the  hernial  sac  may  be  protruded  in  consequence  of 
the  umbilical  aperture  remaining  imperfectly  closed, 
when  it  is  covered  only  by  the  integuments ;  in  the 
youth  the  hernia  may  escape  through  a  partially 
closed  ring,  which  it  dilates  by  continual  pressure ;  in  the  adult  the  fibres  of  the 
linea  alba  may  become  separated  by  stretching,  owing  to  the  pressure  within,  and 
the  hernia  escape  at  the  site  of  the  once-closed  ring  or  in  its  vicinity  (Fig.  219). 


.x^x^A-v^'^^x  \\\"^^~-*=«^^P 


7" 


Fascia  at  umbilicus. 


812  LOCAL  DISEASES. 

The  hernia  begins  by  forming  a  soft,  projecting  ovoid  tumor  at  the  navel ; 
at  first  it  may  be  reduced  by  pressure,  when  a  small  hole  is  felt  with  very 
sharp  and  rigid  edges  ;  if  the  finger  is  removed,  the  skin  either  remains  re- 
laxed in  the  fossa  of  the  navel  or  it  is  slowly  projected  forward ;  as  the  dis- 
ease progresses  the  protruding  viscus  descends  lower  and  lower,  so  that  the 
broadest" part  lies  below  the  mouth  of  the  sac;  the  tumor  varies  much  in 
form,  the  transverse  diameter  being  sometimes  greater  than  the  vertical ; 
occasionally  it  is  pyriform,  and  seems  suspended  or  spread  out  like  a  mush- 
room (Fig.  220)  ;  again,  its  base  is  nearly  as  large  as  its  body  ;  in  infants  the 

Fig.  220. 


^ ^.^s^^^^'^"''^         Point  of 
y^  attachment  of  cord. 

Congenital  umbilical  hernia. 

hernia  usually  contains  intestines,  but  in  the  adult  omentum  is  generally 
added,  and  sometimes  the  stomach ;  the  coverings,  usually  very  thin  and 
often  inseparably  united,  are  the  integument,  some  fat,  the  internal  abdominal 
fascia,  the  sac ;  the  body  of  the  sac  is  usually  very  delicate,  but  stronger 
near  and  at  its  orifice,  around  which  the  tissues  form  a  firm,  resisting,  unyield- 
ing band ;  the  mouth  of  the  sac  is  often  large  in  proportion  to  the  bulk  of 
the  protrusion.  This  hernia  has  been  overlooked  in  very  corpulent  persons, 
and  proved  fatal  by  strangulation. 

The  TREATMENT  of  hernia  should  first  be  palliative.  The  truss  is  the 
first  appliance  to  be  resorted  to' in  reducible  hernia;  it  should  be  applied 
immediately  that  the  disposition  to  the  formation  of  rupture  is  detected,  with 
a  view  to  procure  adhesions  of  the  serous  surfaces :  the  rule  applies  to  both 
sexes  and  all  ages,  the  only  exception  being  a  misplaced  testis.  The  efi"ect 
of  such  pressure  is  to  approximate  the  sides  of  the  mouth  of  the  sac,  prevent 
the  descent  of  the  bowel,  and  lead  to  contraction  and  final  obliteration  of  the 
hernial  sac.  As  the  commencement  of  a  radical  cure  by  truss-pressure  dates 
from  the  last  time  the  bowel  or  omentum  came  into  the  sac,  it  is  of  the  first 
importance  to  prevent  the  hernia  from  ever  coming  down.  About  15  to  20 
per  cent,  may  be  cured  by  judicious  and  persistent  truss-pressure. 

DeGarmo  reported  a  cure  of  one-fourth  of  his  cases  by  the  truss  in  a 
total  of  1000  treated ;  he  believes  a  large  percentage  of  cases  under  middle 
life  curable  by  mechanical  means. 

Inguinal  hernia  requires  a  truss-pad  that  does  not  press  upon  or  interfere 
with  the  circulation  or  other  functions  of  the  spermatic  cord.  Not  uncom- 
monly the  cord  becomes  jammed  by  the  downward  pressure  of  the  truss-pad 
upon  the  crest  of  the  pubic  bone  below,  causing  pain  and  uneasiness  along 
the  cord  and  in  the  testicle ;  the  latter  slowly  enlarges  if  the  pressure  be  con- 
tinued, effusion  takes  place  in  the  tunica  vaginalis,  and  a  hydrocele  or  a 


HERNIA   OF  THE  ABDOMEN.  813 

hydro-sarcocele  is  gradually  formed,  or  the  pressure  upon  the  spermatic 
origin  of  the  cord  gives  rise  to  varicocele.  It  is  of  great  importance  to  pro- 
tect those  who,  from  hereditary  tendency  or  weakness  of  the  abdominal  walls, 
are  predisposed  to  rupture. 

_  For  this  purpose  a  broad  band  with  a  suitable  pad  (Fig.  221)  may  be  worn 
(Fig.  222).     It  should  consist  of  stout  elastic  web,  which  passes  round  the  body, 

Fig.  221.  Fig.  222. 


Band  and  pad  applied. 

and  it  is  attached  to  the  pad  in  front  by  metallic  loops  engaging  studs  on  the  pad  ; 
elastic  bands  pass  from  the  body-band,  under  the  limbs,  to  studs  upon  the  rupture- 
pads. 

The  bearing  of  the  surface  of  the  pad  should  be  flat,  the  edge  rounded  off,  the 
shape  being  an  oblique  oval.  The  best  substance  for  the  pad  is  vulcanite,  and  it 
should  be  maintained  in  position  by  a  side-spring  which  encircles  the  body  midway 
between  the  trochanter  and  the  anterior  superior  iliac  spine ;  sometimes  it  is  neces- 
sary to  wear  a  perineal  band  which  buttons  in  front,  but  this  may  be  dispensed 
with  when  the  truss  has  accommodated  itself  to  the  shaj^e  of  the  body.  A  great 
variety  of  trusses  may  be  found,  but  unless  they  conform  in  construction  to  the 
principles  given  they  will  fail  to  meet  the  indications. 

Femoral  hernia  requires  that  the  truss-pad  protect  the  crural  ring  by 
pressure  over  Poupart's  ligament,  and  also  press  upon  and  fill  the  saphenous 
opening  without  pressing  downward  so  as  to  obstruct  the  saphenous  vein. 

Umbilical  hernia,  if  congenital,  should  at  first  be  treated  with  a  piece  of 
lint  wrapped  around  a  penny  piece  and  kept  on  with  a  light  flannel  bandage, 
lightly  swathing  the  infant's  body,  and  kept  from  chafing  by  powdered 
starch. 

This  form  of  hernia  in  the  infant  requires  persistent  eiforts  to  close  the  opening 
by  the  following  dressing :  Apply  a  flat  pad  of  any  soft  and  tolerably  firm  material, 
moulded  to  the  shape  of  the  parietes  and  extending  beyond  the 
margin  of  the  opening  (Fig.  223)  ;  maintain  it  in  position  by  Fig.  223. 

adhesive  strips   or  by  a  broad  elastic  band  properly  padded  ;      ^'°°™™°^^'^^*8wlii^ 
remove  the  apparatus    frequently  to   preserve  cleanliness  and     (     ^^^^^      fIjliP' 
prevent  chafing,  the  finger  being  applied  meantime  to  the  open-      ^'^BiF'-^^^^^^tn^ 
ing.     Radical  cures  have  been  effected  by  the  truss.     In  the        Umbilical  truss. 
adult  this  hernia   is  best  retained  by  a  truss  with  a  wooden 
block  slightly  convex  on  its  abdominal  surface  and  secured  to  an  elastic  spring 
encircling  the  body ;  if  the  hernia  has  become  irreducible,  apply  a  hollow,  cup- 
shaped,  well-padded  truss.     Obstruction  from  accumulation  of  stercoraceous  matters 
frequently  occurs  in  irreducible  umbilical  hernia,  with  severe  constitutional  dis- 
turbance, but  without  positive  strangulation  ;  this  condition  is  best  overcome  by  the 
free  administration  of  aperient  enemata. 

The  radical  treatment  of  hernia  should  be  undertaken  when  palliative 
treatment  has  failed.  Of  the  many  different  operations  devised,  few  are 
absolutely  free  from  danger,  and  none  are  always  ultimately  successful.  In 
determining  the  question  of  the  propriety  of  an  operation  every  case  must 
be  studied  by  itself,  and  the  decision  should  depend  upon  the  condition  of 
the  hernia,  the  health  of  the  patient,  and  the  risk  incurred. 


814 


LOCAL  DISEASES. 


The  following  metliod  of  operation  for  inguinal  hernia  is  advised :  The 
external  surfaces  having  been  made  aseptic-ally  clean,  make  an  incision  the 
centre  of  which  is  over  the  external  abdominal  ring ;  the  dissection  is  con- 
tinued until  the  sac  is  exposed.  While  it  is  important  to  be  careful,  owing 
to  the  peculiar  delicacy  of  the  structures  in  children,  the  operator  may  be  so 
cautious  as  to  tear  and  bruise  tissues  needlessly.  The  sac  must  now  be  care- 
fully separated  from  the  cord  and  freed  from  all  connections  to  a  point  within 
the  internal  ring,  this  latter  being  eifected  by  the  end  of  the  index  finger. 
The  sac,  being  empty,  is  drawn  down  so  as  to  be  quite  tense,  and  then  firmly 
tied  with  strong  carbolized  silk  as  high  up  as  possible  within  the  internal 
ring.  The  fundus  is  next  cut  off  about  half  an  inch  below  the  ligature,  and 
the  stump  is  pushed  into  the  abdomen.  Ball  twists  the  sac  with  strong  for- 
ceps, making  four  or  five  complete  revolutions,  then  ligates  the  highest  part 
of  the  twisted  pedicle  with  catgut  ligature  and  cuts  away  the  mass.  The 
next  step  in  the  operation  is  to  raise  the  cord,  and  close  by  firm  suture  the 
internal  ring  from  below  upward.  This  should  be  done  with  carbolized  silk 
and  in  such  manner  as  to  bring  the  conjoined  tendon  in  contact  with  Pou- 
part's  ligament.  In  order  to  bring  these  margins  in  firm  contact,  so  as  to 
secure  a  complete  closure  of  the  canal  and  internal  ring,  the  best  suture  is 
that  of  the  shoemaker,  which  gives  the  support  of  a  double  suture.  The 
old  canal  and  the  internal  ring  having  been  closed,  the  cord  is  placed  in  posi- 
tion and  the  external  wound  closed.  No  drainage  is  required,  and  the  exter- 
nal dressings  must  be  antiseptic.  Owing  to  the  difficulty  of  keeping  the 
wound  of  a  child  clean,  Gerster  of  Xew  York  closes  the  neck  of  the  sac  and 
packs  the  wound  with  iodoform  gauze,  and  thus  treats  it  as  an  open  wound. 
The  radical  operation  for  femoral  hernia  in  children  has  rarely  been 
required.  Umbilical  hernia  is  so  generally  relieved  by  a  very  simple  pad 
as  to  have  attracted  little  attention.  Nota  (Marcy)  reduces  the  hernia  and 
closes  the  ring  with  the  finger ;  while  the  sac  is  held  firmly  by  an  assistant, 
the  operator  winds  a  rubber  tubing,  one-eighth  of  an  inch  thick,  three  or 
four  times  around  the  neck  of  the  sac  tightly,  and  then  ties  the  ends  secure 
with  a  silk  ligature.  The  whole  is  covered  with  cotton.  In  ten  or  twelve 
days  the  mass  sloughs  off,  and  the  surface  is  dressed  with  iodoform  and  car- 
bolized cotton.  The  wound  closes  in  four  or  five  days.  Xota  has  operated 
successfully  on  18  cases. 

A  strangulated  hernia  in  a  child  does  not  differ  from  that  in  an  adult  in 
its  management.     The  practitioner  must  first  examine  to  determine  the  kind 

and  variety ;  its  duration ;  the  hour  at 
which  vomiting  commenced  ;  the  varia- 
tions in  the  composition  of  the  fluid 
ejected ;  the  usual  size  of  the  tumor ; 
its  bulk  before  vomiting ;  the  changes 
during  this  stage ;  the  pain,  whether 
local  or  extending  into  the  abdomen  with 
or  without  manipulation  ;  the  condition 
of  its  coverings ;  its  probable  contents ; 
the  treatment  already  pursued.  The 
first  step  in  the  treatment  is  to  endeavor 
to  displace  the  hernia  from  its  abnormal 
position  and  pass  it  through  the  orifice 
of  the  sac  into  the  peritoneal  cavity. 
Before  vomiting  occurs  abstain  from  manipulation  of  the  tumor  until  other 
remedial  measures  have  been  tried  ;  place  the  patient  on  the  back,  with 
knees  flexed  and  pelvis  raised,  and  apply  warm  fomentations  over  the  region 
of  the  mouth  and  neck  of  the  sac  ;  if  urgent  symptoms  do  not  arise,  a  few 


Fig.  224. 


Distended  and 

congested 
proximal  end. 


Neck  of  sa 


Collapsed  and 
bloodless 
lf,tal  end. 


A  strangulated  hernia. 


HERNIA   OF  THE  ABDOMEN. 


815 


hours  may  be  allowed  to  elapse  to  afford  time  for  this  treatment  to  take 
effect.  Other  measures  have  been  employed  to  assist  in  reduction,  with 
occasional  benefit,  as  cold  to  the  hernia  ;  reversing  the  trunk  by  keeping  the 
head  nearest  the  ground  and  the  pelvis  upward.  Anaesthetics  exert  a  power- 
ful influence  over  the  causes  preventing  reduction.  During  the  administra- 
tion of  the  anaesthetic  taxis  should  be  employed.  This  is  a  method  of  manip- 
ulation, and  must  be  practised  as  follows :  Place  the  patient  in  a  position  to 
relax  all  abdominal  muscles  which  contract  around  the  mouth  of  the  sac ; 
fix  as  far  as  it  is  possible  the  mouth  and  neck  of  the  sac  with  the  fingers  of 
one  hand,  whilst  the  fundus  of  the  tumor  is  held  in  the  palm  of  the  other, 
the  object  being  to  dilate  the  mouth  of  the  sac  and  diminish  the  bulk  of  the 
protrusion,  the  fact  being  borne  in  mind  that  irreparable  injury  is  frequently 
inflicted  upon  the  herniated  bowel  by  violence,  and  that  the  danger  of  mis- 
chief by  the  use  of  the  taxis  increases  in  proportion  to  the  length  of  time 
the  bowel  has  been  strangulated.  As  soon  as  the  voluntary  muscular  con- 
traction ceases,  make  gentle  and  well-preconcerted  pressure,  and,  if  the  taxis 
succeed,  the  tumor  will  gradually  become  softer  or  less  elastic,  smaller,  and 
of  different  shape,  until  it  escapes  from  the  embrace  of  the  mouth  of  the  sac; 
taxis,  if  not  already  abandoned,  must  always  be  discontinued  altogether  when 
it  is  certain  from  the  vomited  fluids  that  there  is  regurgitation  of  the  contents 
of  the  duodenum  and  jejunum. 

The  failure  of  the  taxis  necessitates  the  liberation  of  the  hernia  by  the 
operation  of  herniotomy. 

An  inguinal  hernia  which  has  resisted  well-directed  taxis  must  be  at  once 
liberated  by  division  of  the  stricture.     This  operation  should  be  performed 
with  careful  attention  to  all  of  the  details  rec^uired  in  the  use 
of  antiseptic   dressings.      Provide  an  ordinary  hernia-knife,  a        Fig.  225. 
common  scalpel,  probe-pointed  bistoury  (Fig.  225),  forceps,  di- 
rector, carbolized  sponges,  carbolic  water   1   to   20,  bichloride 
solution  for  irrigation,  and  carbolized  gauze.     Place  the  patient 
on  a  firm,  low  table ;  shave  the  parts  and  wash  them  with  bi- 
chloride solution ;  give  the  ansesthetic  fully. 

If  the  hernia  is  an  oblique  inguinal,  raise  the  shoulders  and 
slightly  flex  the  thigh  of  the  affected  side,  and  make  an  incision 
through  the  skin  over  the  neck  and  body  of  the  tumor,  its  upper  ex- 
tremity being  nearly  midway  between  the  anterier  superior  spinous 
process  of  the  ilium  and  the  tuberosity  of  the  pubes,  about  one  inch 
and  a  half  above  the  level  of  Poupart's  ligament,  and  its  lower  about 
the  middle  of  the  scrotum.  This  incision  exposes  the  intercolumnar 
fascia  which  forms  the  first  and  thickest  covering  of  the  sac  :  divide 
this  fascia  after  raising  with  forceps  or  on  a  director,  when  the  cre- 
master  muscle  will  be  exposed,  which  must  be  cut  in  a  similar  man- 
ner, and  this  incision  lays  bare  the  sac.  The  division  of  these  layers 
often  causes  great  embarrassment  and  delay,  for  the  operator,  expect- 
ing to  see  the  sac  itself  when  he  has  divided  the  integuments,  mis- 
takes the  thickened  covering  and  the  cremaster  muscle  for  the  hernial 
sac,  and  cuts  the  fascia  with  extreme  caution,  fibre  by  fibre.  Open 
the  sac  with  exceedingly  great  care  to  avoid  including  the  walls  of 
the  bowel,  either  seizing  the  sac  with  forceps  (Fig.  226)  or  raising  it 
between  the  thumb  and  fingers.  Make  an  opening  sufficiently  large 
to  admit  a  grooved  director  with  the  scalpel,  the  sharp  edge  of  which 
is  directed  laterally,  the  side  of  the  blade  being  placed  nearly  flat  on 
the  tumor :  divide  the  sac  on  the  director,  pressed  firmly  against  its  inside  (Fig. 
227).  Make  slight  pressure  upon  the  sac  to  return  its  contents  into  the  abdomen  ; 
if  reduction  be  impracticable,  open  the  sac  sufficiently  to  reach  its  orifice  easily : 
pass  the  index  finger  along  the  anterior  surface  of  the  protrusion  upward  toward 
the  mouth  of  the  sac,  when  the  stricture  will  be  encountered :  the  palm  being 
upward,  pass  the  hernia-knife  flatwise  along  the  finger  (Fig.  22S)  or  on  a  grooved 


Probe-pointed 
bistoury. 


816 


LOCAL  DISEASES. 


director  through  the  mouth  of  the  sac :  turn  the  knife  so  as  to  cut  parallel  with 
the  linea  alba,  and  divide  the  structures  in  contact  with  it  sufficiently  to  allow 

Fig.  226.  Fig.  227. 


Dissection  of  hernia. 


Introduction  of  director. 


Finger  as  director  in  operation  for  hernia. 


Fig 


the  ungual  phalanx  to  pass  freely  into  the  abdominal  cavity.  Carefully  examine 
the  protruded  intestine  to  determine  whether  the  brown  color  which  it  assumes 
under  strangulation  lessens  or  disappears,  the  proof  of  a  return  of  circulation ; 

the  intestine  should  also  be  pulled 
Fig.  228.  down  a  little  to  examine  the  part 

immediately  compressed  by  the 
stricture  ;  the  veins  on  the  surface 
may  be  emptied  by  pressure  and 
their  sudden  filling  noted :  if  the 
intestine  appears  to  have  free  cir- 
culation, relax  the  parts  by  posi- 
tion, and  directly  but  gradually 
return  it,  replacing  about  an  inch 
at  a  time,  and  securing  each  part 
with  the  fingers  until  the  Avhole  is 
returned  into  the  abdomen.  The 
contents  of  the  hernial  sac  should 
now  be  returned  :  all  violence  and 
improper  haste  should  be  guarded  against,  for  the  intestine  is  tender  and  will  easily 
tear  at  the  strictured  part.  Clear  the  parts  of  blood,  irrigate  with  bichloride  solu- 
tion 1  :  5000,  nicely  adjust  the  sac  and  its 
coverings,  introduce  a  drainage-tube  at  the 
upper  angle,  and  stitch  all  opposing  tissues 
together  with  a  continuous  suture,  in  such 
manner  as  to  firmly  close  the  would.  Bring 
the  edges  of  the  wound  together  with  in- 
terrupted sutures  (Fig.  229).  Dust  the  sur- 
face with  iodoform,  and  apply  iodoform 
dressings  with  the  spica  bandage  to  retain 
them  in  position. 

The  important  feature  of  the  after- 
treatment  is  the  diet,  which  should  be 
farinaceous,  with  milk ;  opium  should 
be  used  when  required ;  the  bowels  are 
often  relieved  spontaneously,  but  if  they 
remain  inactive  and  any  discomfort 
arises,  give  an  enema  of  warm  water 
or  gruel  with  common  salt  or  a  little 
castor  oil ;  if  thirst  is  distressing,  give 
ice ;  stimulants  are  often  required  soon 
after  the  operation,  but  should  be  given 
in  small  quantities,  and  the  addition  of 
opiates  is  frequently  very  useful. 


Incision  for  inguinal  hernia,  stitched,  show- 
ing the  position  of  the  drainage-tube  at 
the  outer  angle  of  the  wound. 


HERNIA    OF  THE  ABDOMEN. 


817 


Fig.  230. 


Umljilical  hernia,  strangulated,  differs  from  other  hernise  in  this,  that  too 
much  stress  cannot  be  laid  upon  the  protracted  and  judicious  employment  of 
taxis,  owing  to  the  great  fatality  of  operations  upon  this  hernia.  Place  the 
patient  on  the  back ;  give  an  anaesthetic :  as  the  tumor  has  descended,  if  at 
all  bulky,  draw  it  away  from  the  ring,  press  its  contents  directly  upward  and 
backward  in  a  direction  opposite  to  that  of  the  displacement.  Should  the 
taxis  fail  and  the  symptoms  not  be  urgent,  try  the  effects  of  a  full  anodyne 
and  cold  or  warm  applications.  These  efforts  having  failed,  proceed  to  ope- 
rate antiseptically  : 

Select  a  scalpel  and  director ;  bearing  in  mind  the  thinness  of  the  external 
coverings,  particularly  in  recent  cases,  make  a 
J_-shaped  incision  (Fig.  230),  the  vertical  limb 
being  carried  nearly  an  inch  above  the  upper 
extremity  of  the  tumor,  directly  in  the  line  of 
the  linea  alba ;  raise  successive  layers  on  the  director 
down  to  the  sac,  which  must,  if  possible,  be  left  intact, 
owing  to  the  great  danger  of  fatal  peritonitis  if  it  is 
divided.  Seek  the  seat  of  stricture,  which  is  generally 
found  at  the  upper  margin  of  the  ring  ;  carry  the  knife 
upward  upon  the  finger,  and  divide  the  stricture  to  the 
requisite  extent :  draw  the  protruded  parts  somewhat 
downward  to  liberate  them  from  their  confinement, 
and  gently  replace  them  in  the  abdomen — first  bowel 
and  then  omentum.  If  the  constriction  is  within  the 
sac,  the  latter  must  be  opened,  the  incision  being  as 

small  as  possible.     When  the  hernia  is  irreducible  leave  the  protruded  structures, 
after  the  division  of  the  stricture,  in  their  extra-abdominal  situation. 
52 


Incision  in  operation  for 
umbilical  hernia. 


SECTION  IV. 

DISEASES   OF   THE   RESPIRATORY   SYSTEM. 


CHAPTER    I. 

COEYZA. 

The  term  "  coryza  "  is  applied  to  inflammation  of  tlie  Sclineiderian  mem- 
brane. It  is  acute  or  chronic.  The  acute  form  is  primary  or  secondary.  Acute 
primary  coryza  is  common  in  infancy  and  childhood.  Its  usual  cause  is 
exposure  to  currents  of  air,  to  cold,  and  especially  to  sudden  changes  of  tem- 
perature, from  warm  to  cold.  The  cause  is  the  same  as  that  in  the  ordinary 
forms  of  bronchitis.  The  two  diseases  frequently  indeed  coexist,  occurring 
from  the  same  exposure.  The  inflammation  in  such  cases  commences  upon 
the  Schneiderian  membrane  immediately  upon  the  operation  of  the  cause, 
and  soon  after  extends  to  the  bronchial  tubes.  Acute  coryza  may  also  be 
produced  by  the  inhalation  of  irritating  vapors,  hot  air,  or  dust,  and  also  by 
the  presence  of  a  foreign  body,  as  a  button  or  bean,  in  the  nostril. 

Secondary  coryza  is  commonly  due  to  a  specific  cause.  The  diseases  in 
connection  with  which  it  occurs  are  influenza,  whooping  cough,  measles, 
scarlet  fever,  diphtheria,  and  constitutional  syphilis.  In  the  infant  coryza  is 
one  of  the  first  manifestations  of  inherited  syphilitic  taint. 

Acute  primary  coryza  ordinarily  abates  in  from  one  to  two  weeks.  The 
secondary  form  gradually  declines,  in  most  cases,  when  the  primary  afiection 
on  which  it  depends  is  cured.  Syphilitic  coryza  is  more  protracted  than  the 
primary  form  or  than  that  accompanying  the  eruptive  fevers.  Some  children 
are  so  liable  to  coryza  that  it  occurs  whenever  they  take  cold.  Occasionally 
it  is  so  frequently  renewed  in  the  winter  months  that  it  resembles  the  chronic 
form  of  the  disease. 

Acute  coryza  is  commonly  dependent  on  a  dyscrasia,  usually  the  syphilitic 
or  strumous.  The  dyscrasia  is  indicated  by  pallor,  flabbiness  of  the  flesh,  and 
liability  to  glandular  swellings.  Certain  cases  take  their  origin  in  the  nasal 
catarrh  of  the  exanthematic  fevers,  the  local  afiection  continuing  after  the 
constitutional  disease  has  declined.  Chronic  coryza  sometimes  occurs  in  chil- 
dren who  appear  otherwise  in  good  health.  It  is  probable  that  in  such  cases 
there  is  a  dyscrasia  of  which  the  coryza  happens  to  be  the  sole  manifestation. 
If  the  coryza  appear  on  one  side,  be  persistent,  and  the  discharge  be  muco- 
purulent and  offensive,  probably  a  foreign  substance,  as  a  button,  has  been 
pushed  into  the  nostril.  Obviously,  if  present,  the  coryza  will  continue  until 
the  substance  is  removed  by  the  forceps  or  otherwise. 

Anatomical  Characters.  —  The  alterations  which  the  nasal  mucous 
membrane  undergoes  when  inflamed  vary  considerably  in  different  cases.  In 
the  simplest  and  most  common  form  of  coryza  this  membrane  is  sometimes 
in  patches,  sometimes  generally  reddened,  thickened,  and  softened.  Its  papillae 
are  prominent,  producing  an  inequality  of  the  surface.  Ulcerations  are  not 
common  in  simple  acute  coryza,  but  they  sometimes  occur  in  the  chronic 
form. 

In  diphtheria,  and  sometimes  in  scarlet  fever  and  variola  of  severe  type, 
the  coryza  is  pseudo-membranous,  and  when  it  presents  this  form  it  is  com- 
818 


CORYZA.  819 

monly,  but  not  always,  associated  witli  pseudo-membranous  angina  or  laryn- 
gitis. It  is  commonly  diphtheritic  wherever  diphtheria  prevails,  and  is  very 
prone  to  end  in  systemic  infection  unless  promptly  and  properly  treated. 

Symptoms. — The  constitutional  symptoms  are  mild  or  severe  according 
to  the  gravity  of  the  inflammation.  If  the  coryza  be  acute  and  pretty  general, 
there  is  febrile  movement,  with  thirst  and  loss  of  appetite.  Frontal  headache 
is  common,  from  the  proximity  of  the  inflammation  to  the  head  or  its  exten- 
sion to  the  frontal  sinuses.  Sneezing  is  the  first  symptom  in  many  cases  of 
acute  coryza.  As  the  inflamed  membrane  swells  more  or  less  obstruction 
occurs  to  respiration.  The  breathing  is  noisy,  especially  during  sleep,  and 
in  severe  cases  the  patient  is  compelled  to  breathe  through  the  mouth.  If 
there  be  much  obstruction  to  respiration,  the  sufi'ering  of  the  patient  is  con- 
siderable, from  the  sensation  of  fulness  in  the  nostrils,  the  headache,  and  the 
muscular  efi"ort  required  in  each  respiratory  act. 

In  the  commencement  of  coryza  the  patient  experiences  a  sensation  of 
dryness  in  the  nostrils,  which  is  soon  succeeded  by  a  thin  discharge  of  a 
serous  appearance.  In  the  course  of  a  few  hours  the  secretion  becomes 
thicker.  It  is  muco-purulent,  and  remains  such  till  the  disease  begins  to 
decline.  Inspissated  mucus  and  crusts  are  liable  to  collect  within  the  nos- 
trils and  around  their  orifice  in  chronic  coryza,  and  sometimes  also  in  the 
acute  disease  if  the  discharge  be  not  abundant.  These  crusts  increase  the 
difficulty  of  breathing.  Often  the  acridity  of  the  discharge  is  such  that 
the  skin  of  the  upper  lip  and  around  the  nostrils  is  excoriated. 

Prognosis.  —  Uncomplicated  catarrhal  corj^za  rarely  terminates  fatally. 
It  is  only  dangerous  in  young  nursing  infants,  in  whom  it  may  prevent 
proper  traction  of  the  nipples.  Coryza  accompanying  the  eruptive  fevers, 
although  it  may  increase  the  sufi'ering,  does  not  materially  increase  the 
danger.  Syphilitic  coryza  subsides  when  the  system  is  sufiiciently  afi"ected 
by  antisyphilitic  remedies.  Chronic  coryza  is  sometimes  very  obstinate.  It 
may  continue  for  months  or  years,  giving  rise  to  a  constant  though  not 
abundant  discharge. 

Treatment. — Common  mild  attacks  of  coryza  require  little  treatment. 
The  bowels  should  be  kept  open  and  the  body  should  be  warmly  clothed. 
Inunction  of  the  nostrils  is  a  popular  remedy,  and  it  seems  to  give  some 
relief.  The  most  successful  mode  of  treating  simple  catarrhal  coryza,  as 
well  as  ulcerative  or  membranous,  is  by  nasal  irrigation  by  means  of  a 
hand-atomizer  or  syringe,  used  hourly  or  every  two  hours,  with  one  of  the 
following  remedies:  Squibb's  peroxide  of  hydrogen  (11  vol.)  rendered 
alkaline  and  reduced  by  water  at  the  time  of  use.  The  mother  or  nurse 
should  first  employ  it  upon  herself,  and  dilute  it  still  more  if  necessary  (see 
art.  Diphtheria).  Another  good  nasal  wash  is  Seller's  tablet,  one  tablet  to 
six  tablespoonfuls  of  water.  A  5  per  cent,  solution  of  common  salt  in 
warm  water  injected  into  the  nostrils  with  a  small  syringe  aids  materially 
in  removing  the  muco-pus  which  obstructs  the  respiration  and  in  establishing 
a  healthier  state  of  the  inflamed  surface.  The  following  formula  will  be 
found  tiseful  in  most  cases  of  this  form  of  coryza : 

B. 


Acidi  borici, 

Ei; 

Sodii  biborat., 

L,'" 

.=?ij; 

Aquae, 

l^ij 

R.  Sodii  chloridi,  ^j  ; 

Sodii  biborat.,  ^ij  ; 

Aquae,  Oj. — Misce. 

Half  a  teaspoonful,  used  warm,  should  be  mjected  into  each  nostril  several  times 
daily,  with  the  head  thrown  backward. 


820  LOCAL  DISEASES. 

The  treatment  proper  for  pseudo-membranous  or  diphtheritic  coryza  is 
detailed  in  our  remarks  on  the  therapeutics  of  diphtheria.  Chronic  coryza, 
since  it  depends  upon  a  dyscrasia  of  which  it  is  one  of  the  local  manifesta- 
tions, requires  remedies  appropriate  for  the  blood  disease.  Scrofula  needs 
the  syrup  of  the  iodide  of  iron  and  cod-liver  oil.  The  various  ferruginous 
preparations,  as  wine  of  iron,  tincture  of  the  chloride  of  iron,  iron  lozenges, 
and  the  vegetable  tonics  are  also  more  or  less  useful.  The  diet  should  be 
nutritious  and  plain,  and  out-door  exercise  and,  if  possible,  country  life  should 
be  enjoined. 

If  the  dyscrasia  be  syphilitic,  similar  invigorating  measures  are  required, 
and  mild  mercurial  inunctions  to  the  nasal  surface  are  especially  useful.  The 
following,  which  has  been  largely  employed  in  the  Out-door  Department  at 
Bellevue,  is  one  of  the  best  ointments  for  such  cases,  and  its  alterative  eflFect 
renders  it  also  useful  for  strumous  coryza  : 

R.  Ung.  hydrarg.  nitratis,       ^i]  ; 

Ung.  zinci  oxid.,  ^ij. — Misce. 

To  be  thoroughly  applied  to  the  Schneiderian  membrane  by  a  swab  or  camel's- 
hair  pencil  three  or  four  times  daily.  Recently  it  has  been  modified  by  the 
substitution  of  Squibb's  5  per  cent,  oleate  of  mercury  in  place  of  the  citrine 
ointment.  If  the  coryza  have  a  distinctly  syphilitic  origin,  the  application 
of  a  2  or  3  per  cent,  oleate  of  mercury  will  fully  meet  the  indication  and  be 
followed  by  improvement. 

Meigs  and  Pepper  recommend  the  following  ointment  in  chronic  coryza, 
to  be  applied  at  night  after  the  use  of  injections  through  the  day : 

R.  Unguenti  hydrargyri  nitratis,     ^ss  ; 
Extract!  belladonnse,  gr.  x  ; 

Axungise,  ^ss. — Misce. 

Astringent  injections  into  the  nostrils  are  not  often  required  in  the  treat- 
ment of  the  various  forms  of  coryza  ;  but  occasionally,  if  the  discharge  be 
protracted  and  abundant,  weak  astringent  applications  may  be  beneficial,  as 
two  or  three  grains  of  nitrate  of  silver  or  of  alum  or  tannin  to  the  ounce  of 
water.  It  should  be  borne  in  mind  that  washes  for  the  nasal  surface  should, 
as  a  rule,  be  employed  tepid. 


CHAPTER    II. 
LAEYNGITIS. 

Catarrhal  Laryngitis. 

Acute  catarrhal  laryngitis  occurs  at  all  ages,  but  it  is  so  common  in 
infancy  and  childhood  that  it  is  proper  to  treat  of  it  in  a  work  relating  to 
the  diseases  of  these  periods.  Like  other  inflammatory  affections  of  the  air- 
passages,  it  is  most  common  in  the  cold  months  or  when  the  weather  is 
changeable.^  Its  usual  cause  is,  therefore,  exposure  to  cold.  Protracted  and 
violent  crying  and  the  inhalation  of  acrid  vapors  are  occasional  causes. 
Catarrhal— or,  as  it  is  sometimes  designated,  simple — laryngitis  also  occurs 
in  connection  with  certain  constitutional  diseases,  among  which  may  be  men- 
tioned measles,  scarlatina,  and  variola.     Laryngitis  is  also  a  common  accom- 


LARYNGITIS.  821 

paniment  of  bronchitis  and  broncho-pneumonia,  though  its  symptoms  are 
liable  to  be  obscured  by  those  of  the  graver  disease.  It  often  likewise  accom- 
panies pharyngitis,  due  to  extension  of  the  inflammation. 

Symptoms. — Catarrhal  laryngitis  produced  by  the  impression  of  cold  is 
commonly  preceded  and  accompanied  by  coryza.  The  initial  symptom  is 
chilliness,  followed  by  sneezing  and  the  discharge  of  thin  mucus  from  the 
nostrils  in  consequence  of  irritation  of  the  Schneiderian  membrane. 

The  commencement  of  laryngitis  is  indicated  by  hoarseness,  which  is 
apparent  when  the  child  cries  or,  if  old  enough,  when  it  attempts  to  speak. 
There  is  often  in  severe  cases  complete  loss  of  voice,  so  that  speech  above  a 
whisper  is  impossible.  I  have  noticed  this  most  frequently  in  the  laryngitis 
which  accompanies  measles.  A  cough  occurs  which  is  at  first  dry  and 
husky,  but  becomes  loose  in  the  course  of  a  few  days.  Expectoration  is 
scanty,  unless  the  inflammation  have  extended  to  the  trachea  and  bronchial 
tubes. 

This  disease  is  often  accompanied  by  soreness  of  the  throat,  noticed  in 
the  act  of  coughing  or  when  the  larynx  is  pressed  with  the  finger.  In  laryn- 
geal catarrh,  when  uncomplicated,  the  respiration  remains  nearly  natural  and 
the  pulse  is  but  little  accelerated.  In  mild  cases  the  nature  of  the  disease  is 
often  not  apparent,  as  long  as  the  child  remains  quiet,  in  consequence  of  the 
absence  of  symptoms,  but  the  character  of  the  voice  when  it  cries  or  speaks, 
or  of  the  cough,  reveals  at  once  the  nature  of  the  aff"ection. 

Acute  laryngeal  catarrh  subsides  in  from  one  to  two  weeks.  Occasionally 
it  lasts  three  or  four  weeks  before  the  symptoms  entirely  disappear.  Death, 
which  is  rare,  is  due  to  some  complication. 

Chronic  laryngitis  is  much  less  frequent  than  the  acute  form.  Its  ana- 
tomical characters  are  similar  to  those  in  other  chronic  inflammations  affect- 
ing mucous  surfaces — to  wit,  thickening  and  more  or  less  infiltration  of  the 
mucous  membrane,  increased  proliferation  and  exfoliation  of  the  epithelial 
cells,  and  increased  functional  activity  of  the  muciparous  follicles. 

In  the  adult,  chronic  laryngitis  is  common  as  one  of  the  lesions  of  the 
syphilitic  or  tubercular  disease.  In  the  child,  syphilitic  and  tubercular  laryn- 
gitis is  more  rare,  but  the  latter  sometimes  occurs  in  connection  with  pulmo- 
nary or  bronchial  tuberculosis.  Such  patients  are  emaciated  and  have  the 
ordinary  symptoms  of  the  tubercular  disease.  Chronic  laryngitis  also  occurs 
in  young  children,  usually  infants,  as  one  of  the  manifestations  of  the  stru- 
mous diathesis.  I  have  records  of  several  such  cases,  mostly  nursing  infants. 
Some  of  these  patients  had  mild  bronchitis,  but  it  was  obviously  subordinate 
to  the  laryngitis.  Their  respiration  was  noisy  and  harsh,  continuing  of  this 
character  several  weeks  and  even  months.  The  cough  was  also  harsh  and 
loud,  conveying  the  idea  of  thickening  and  relaxation  of  the  mucous  mem- 
brane covering  the  vocal  cords.  Their  respiration  was  not  notably  accelerated 
and  the  blood  was  apparently  fully  oxygenated,  though  the  friends  were  often 
alarmed  by  the  noisy  breathing  and  cough. 

In  this  form  of  chronic  laryngitis  expectoration  is  scanty,  the  fever  slight 
or  absent,  the  appetite  remains  unimpaired,  and  the  general  condition  of  the 
child  is  good.  From  time  to  time  exacerbations  occur,  and  occasionally 
improvement  is  such  as  to  encourage  the  hope  of  speedy  cure  ;  but  in  the 
cases  which  I  have  seen  there  has  not  been  complete  intermission  in  the  dis- 
ease till  the  final  recovery.  Those  patients  whom  I  have  been  able  to  follow 
through  the  disease  have  recovered  in  from  three  to  four  months  or  one  year. 

Chi'onic  laryngitis  is  to  be  distinguished  from  frequent  attacks  of  acute 
laryngitis  which  are  due  to  fresh  exposures,  and  also  from  the  laryngitis 
which  is  associated  with  bronchial  phthisis.  It  is  to  be  distinguished  from 
protracted  acute  laryngitis,  which  sometimes  does  not  entirely  subside  in  less 


822  LOCAL  DISEASES. 

than  a  month  or  six  weeks,  by  its  longer  duration,  the  greater  thickening  of 
the  inflamed  membrane,  and  more  noisy  respiration.  Often  chronic  laryngitis 
results  from  the  acute  disease,  the  inflammation  being  perpetuated  by  the 
struma  or  dyscrasia  of  the  patients. 

Anatomical  Characters. — In  acute  catarrhal  laryngitis  the  mucous 
membrane  of  the  larynx  presents  the  usual  appearances  of  mucous  surfaces 
when  inflamed — namely,  redness  and  thickening.  It  is  also  more  or  less  soft- 
ened. Ulcerations  rarely,  perhaps  never,  occur  in  acute  primary  laryngitis. 
When  present  in  chronic  laryngitis  the  ulcers  are  small  and  situated  upon  or 
near  the  vocal  cords.  Tubercular  and  syphilitic  ulcers  of  the  larynx  are  much 
more  rare  in  children  than  in  adults.  The  inflammation  in  simple  acute  laryn- 
gitis usually  extends  over  the  whole  surface  of  the  larynx  and  also  to  the 
upper  part  of  the  trachea.  It  may  be  pretty  uniform  or  more  intense  in  one 
place  than  another,  and,  like  other  mucous  inflammations,  it  is  accompanied 
by  more  or  less  proliferation  and  exfoliation  of  epithelial  cells.  In  most  cases 
of  simple  laryngitis,  whether  acute  or  chronic,  the  inflammation  extends  to 
the  pharynx,  producing  redness  and  thickening,  though  generally  moderate, 
of  the  raucous  membrane  which  covers  it.  Examination  of  the  fauces  there- 
fore aids  in  diagnosis. 

In  the  adult  oedema  glottidis  occasionally  results  from  laryngitis.  In  the 
child  there  is  little  danger  that  this  will  occur,  in  consequence  of  the  anatom- 
ical character  of  the  larynx,  since  in  early  life  the  larynx  contains  but  little 
submucous  connective  tissue,  and  therefore  less  submucous  infiltration  or 
exudation  occurs  during  the  inflammation.  The  structural  changes  occurring 
in  catarrhal  laryngitis  of  infancy  and  childhood  relate  almost  exclusively  to 
the  mucous  membrane. 

Treatment. — Primary  and  uncomplicated  catarrhal  laryngitis  requires 
little  treatment.  Most  cases  do  well  by  the  employment  of  suitable  hygienic 
measures,  without  medicine.  Benefit  is.  however,  derived  from  the  use  of 
demulcent  drinks  and  an  occasional  laxative.  A  mixture  of  paregoric  and 
syrup  of  ipecacuanha  or  the  mist,  glycyr.  comp.  or  a  small  Dover's  powder 
will  relieve  the  cough.  For  restlessness  a  warm  foot-bath  is  also  useful. 
Inhalation  of  the  spray  of  glycerin  and  water  from  the  atomizer,  or  of  steam, 
plain  or  rendered  alkaline  by  the  use  of  lime-water  and  a  little  bicarbonate 
of  sodium,  is  also  useful.  In  the  N.  Y.  Foundling  Asylum  great  benefit 
appears  to  be  derived  from  the  constant  inhalation  from  a  croup-kettle  of 
the  vapor  of  one  ounce  of  turpentine  to  two  quarts  of  water.  Chronic 
laryngitis  dependent  on  syphilis  or  tuberculosis  requires  the  constitutional 
treatment  which  is  appropriate  for  that  disease.  The  chronic  laryngitis 
which  I  have  described  as  occurring  chiefly  in  infancy,  and  which  appears  to 
be  of  a  strumous  character,  is  in  most  cases  obstinate.  The  patient  should 
be  warmly  clothed,  and  constant  care  should  be  taken  that  there  be  no 
exposure  which  would  endanger  taking  cold,  as  this  would  produce  an 
exacerbation  of  the  disease  and  tend  to  counteract  what  had  been  gained 
by  remedial  measures.  This  form  of  chronic  laryngitis  is  most  satisfactorily 
treated  by  the  application  of  the  following  ointment  upon  the  neck  directly- 
over  the  larynx,  and  the  internal  use  of  cod-liver  oil  and  the  syrup  of  the 
iodide  of  iron : 

R  .  Plumbi  iodidi,  ^j  ; 

Ext.  belladonnse,  gj  ; 

Lanolini,  gj. — Misce. 

Spasmodic  Laryngitis. 

This  is  a  common  disease.  It  is  also  called  false  croup,  in  contradistinc- 
tion to  true  or  pseudo-membranous  croup,  and  by  some  Continental  writers 


LARYNGITIS.  823 

stridulous  angina  or  stridulous  laryngitis.  It  should  not  be  confounded  witli 
spasm  of  the  glottis,  which  is  a  form  of  internal  convulsions  and  is  not 
inflammatory.  It  occurs  ordinarily  between  the  ages  of  two  and  five  years. 
It  is  commonly  a  sporadic  affection,  but  Rilliet  and  Barthez  state  that  "  it  is 
incontestable  that  it  may  prevail  epidemically."  They  expi-ess  this  opinion, 
not  from  their  own  observations,  but  chiefly  from  those  of  Jurine,  made  in 
the  commencement  of  the  present  century. 

Causes. — Children  in  some  families  are  more  liable  to  false  croup  than  in 
others,  so  that  an  hereditary  tendency  to  it  must  be  admitted.  The  exciting 
cause  in  most  cases  is  exposure  to  cold.  False  croup  is  not  uncommon  in  the 
commencement  of  measles.  Narrowness  of  the  rima  glottidis  and  an  excita- 
ble state  of  the  nervous  system,  both  of  which  are  common  in  early  childhood, 
are  predisposing  causes. 

Symptoms. — Spasmodic  laryngitis  is  ordinarily  preceded  for  a  day  or  two 
by  a  slight  cough  and  fever,  by  symptoms  of  mild  nasal  catarrh,  such  as  all 
children  are  liable  to  on  taking  cold.  In  exceptional  cases  these  symptoms 
are  absent  and  the  disease  begins  abruptly.  Singularly,  it  commences  in 
most  patients  at  night  after  the  first  sleep,  between  ten  and  twelve  o'clock. 
The  sleep  is  usually  quiet  and  natural,  but  the  child  awakens  with  a  loud 
barking  cough.  There  is  great  dyspnoea,  and  the  respiration  is  harsh  or 
whistling,  on  account  of  the  narrowing  of  the  chink  of  the  glottis  from  the 
swelling  and  tension  of  the  vocal  cords.  The  face  is  flushed  and  expressive 
of  suffering.  The  child  cries,  moves  from  one  position  to  another,  wishes  to 
be  held  or  carried,  seeking  in  vain  for  relief.  The  skin  is  hot,  pulse  acceler- 
ated, the  voice  hoarse  or  even  whispering.  After  a  variable  period,  usually 
from  half  an  hour  to  two  or  three — not  more  than  half  an  hour  with  proper 
treatment — these  symptoms  abate.  The  patient  is  then  somewhat  exhausted 
and  falls  asleep.  The  face  is  less  flushed  or  even  pallid,  the  heat  abates,  and 
the  pulse  is  less  accelerated.  The  cough,  though  less  frequent,  remains  for 
a  time  barking  or  sonorous,  and  respiration,  though  greatly  relieved,  is  not  at 
once  entirely  natural,  but  it  gradually  becomes  so.  In  many  cases  the  spas- 
modic respiration  and  cough  do  not  recur,  but  sometimes  the  attack  is  repeated 
once  or  more,  especially  during  the  subsequent  nights.  The  symptoms  vary 
greatly  in  intensity  in  different  patients. 

As  the  attack  declines  the  disease,  losing  its  spasmodic  character,  becomes 
a  simple  inflammation.  In  some  patients  the  abatement  of  the  cough  and 
restoration  of  health  are  rapid,  but  oftener  the  inflammation  extends  not  only 
into  the  trachea,  but  also  into  the  larger  bi'onchial  tubes,  and  a  tracheo-bron- 
chitis  remains,  which  gradually  declines. 

The  termination  is  not  always  so  favorable.  Spasmodic  laryngitis  is,  in 
exceptional  instances,  the  precursor  of  other  serious  affections,  which  may 
prove  fatal.  It  has  been  stated  that  measles  often  begins  with  spasmodic 
laryngitis.  Bronchitis,  becoming  capillary,  may  occur  in  connection  with  it, 
as  may  also  pneumonia,  and  by  either  of  these  severe  inflammations  the 
prognosis  may  be  rendered  doubtful.  A  few  cases  have  been  recorded  in 
which  it  was  believed  that  spasmodic  laryngitis  was  of  itself  fatal.  In  some 
of  these  the  dyspnoea  was  extreme  and  persistent  and  was  the  cause  of  death. 
In  a  case  reported  by  Rogery,  on  the  other  hand,  the  respiration  became  easy 
before  death  and  the  pulse  more  and  more  frequent  and  feeble.  Death 
apparently  occurred  from  exhaustion.  It  is  not  improbable  that  had  careful 
post-mortem  examinations  been  made  in  those  cases  of  spasmodic  laryngitis 
which  have  ended  fatally,  other  lesions  would  have  been  discovered  besides 
those  located  in  the  larynx,  perhaps  tracheo-bronchitis,  with  an  accumulation 
of  mucus  in  the  larynx,  producing  suffocation,  or  perhaps  in  some  of  the 
cases  congestion  of  the  brain  or  lungs  and  serous  effusion. 


824  LOCAL  DISEASES. 

Anatomical  Characters  ;  Pathology. — The  opportunity  does  not 
often  occur  of  determining  the  anatomical  characters  of  spasmodic  laryngitis. 
I  have  witnessed  but  one  post-mortem  examination.  A  little  girl  nine  years 
old  was  taken  on  Friday  night  with  cough  and  dyspnoea,  indicating  a  pretty 
severe  attack.  The  mother,  acting  through  the  advice  of  a  friend,  gave 
kerosene  oil  to  her  in  considerable  quantity.  This  was  succeeded  by  obstinate 
vomiting  and  purging,  which  continued  during  Saturday  and  Sunday,  and 
terminated  fatally  on  Monday.  At  the  autopsy  we  found  uniform  and 
intense  hyperemia  throughout  the  whole  extent  of  the  larynx  and  trachea 
and  in  the  bronchial  tubes,  but  there  was  no  pseudo-membrane  on  the  inflamed 
surface  and  but  little  mucus  and  pus.  The  solitary  follicles  of  the  intestines 
and  Peyer's  patches  were  tumefied,  and  the  gastro-intestinal  surface  was 
injected  in  places.  The  cause  of  death  was  obviously  the  diarrhoea,  appar- 
ently of  an  inflammatory  character,  and  probably  produced  by  the  kerosene 
oil.  The  condition  of  the  mucous  membrane  of  the  larynx  was  that  which 
is  ordinarily  present  in  spasmodic  laryngitis,  though  in  some  cases  in  which 
post-mortem  examinations  have  been  made  the  evidences  of  laryngeal  inflam- 
mation were  slight.  Guersant  relates  a  case  in  which  the  surface  of  the 
larynx  seemed  to  be  nearly  in  its  normal  state.  Death  in  cases  of  slight 
laryngitis  is  due  to  causes  which  are  independent  of  the  larynx.  In  Guer- 
sant's  case  tuberculosis  was  present. 

There  is,  as  has  already  been  intimated,  another  and  a  more  important  ele- 
ment besides  the  inflammation  in  the  pathology  of  spasmodic  laryngitis — 
an  element  producing  those  phenomena  which  render  it  a  disease  distinct  from 
simple  laryngitis.  I  refer  to  spasm  of  the  laryngeal  muscles.  This  element 
pertains  to  the  nervous  system,  so  that  spasmodic  laryngitis  is  allied  both  to 
the  neuroses  and  to  inflammation. 

Diagnosis. — The  disease  for  which  spasmodic  laryngitis  is  most  fre- 
quently mistaken  is  pseudo-membranous  croup.  The  friends,  indeed,  usually 
make  this  mistake  in  forming  their  opinion  of  the  case  before  the  physician 
arrives ;  and  there  can  be  no  doubt  that  many  of  the  cases  which  have  been 
published  in  medical  journals  as  true  croup  were  examples  of  this  aff"ection. 
The  points  of  diff"erential  diagnosis  are  the  following :  True  croup  begins 
with  symptoms  which  at  first  are  slight,  so  as  scarcely  to  arrest  attention, 
but  which  gradually  increase  in  intensity.  The  cough  becomes  more  harsh 
and  the  respiration  more  difiicult  by  degrees.  This  increase  in  the  gravity  of 
the  symptoms  occurs  by  day  as  well  as  by  night.  On  the  other  hand,  false 
croup,  though  preceded  by  symptoms  of  nasal  catarrh,  commences  abruptly. 
The  symptoms  have  from  the  first  their  maximum  intensity,  and  the  time  at 
which  it  commences  is  at  night.  Again,  the  cough  in  spasmodic  laryngitis 
possesses  a  loud,  sonorous  character,  while  in  true  croup  it  is  harsh  or  rough 
from  the  presence  of  the  membrane,  and  having,  therefore,  less  fulness. 
The  voice  in  spasmodic  laryngitis  may  be  hoarse,  but  it  is  not  lost  or  is  lost 
only  for  a  short  time.  It  afterward  becomes  natural  or  is  slightly  hoarse. 
On  the  other  hand,  in  true  croup  the  voice,  from  being  natural  at  first,  is 
gradually  extinguished.  In  fatal  cases  it  soon  becomes  whispering,  and  con- 
tinues such  till  the  close  of  life ;  in  those  that  recover  the  voice  remains 
hoarse  several  days.  These  difi"erenees  are  important,  and  if  fully  appre- 
ciated are  in  most  instances  sufficient  to  establish  the  diagnosis.  Besides,  in 
a  large  proportion  of  cases  of  true  croup  portions  of  the  pseudo-membrane 
may  be  discovered  on  inspecting  the  fauces,  and  the  faucial  surface  is  deeply 
injected,  while  in  spasmodic  laryngitis  there  is,  with  rare  exceptions,  no 
false  membrane  upon  the  surface  of  the  fauces  and  but  a  moderate  amount 
of  congestion. 


LARYNGITIS.  825 

Laryngismus  stridulus  or  internal  convulsions  must  not  be  confounded 
with  this  disease.  It  is  not  inflammatory,  but  purely  spasmodic,  suddenly 
commencing  and  abating — identical,  it  is  believed,  in  character  with  tonic 
convulsions  of  the  external  muscles,  but  afi"ecting  the  internal  muscles  of 
respiration.     This  disease  has  already  been  fully  described. 

Prognosis. — Little  need  be  added,  as  regards  prognosis,  to  what  has 
already  been  stated.  While  a  favorable  opinion  in  reference  to  the  result 
may  ordinarily  be  expressed,  the  physician  should  not  forget  the  fact  that 
death  may  occur.  Symptoms  indicating  an  unfavorable  termination  are — 
great  and  continued  dyspnoea,  not  diminished  by  the  proper  remedial  mea- 
sures ;  stridulous  expiration  as  well  as  inspiration ;  lividity  of  the  prolabia 
and  fingers ;  pallor  and  coldness  of  surface ;  pulse  progressively  more 
frequent  and  feeble.  Convulsions  and  coma  may  also  occur  near  the  close 
of  life. 

Treatment. — The  indications  of  treatment  are  twofold :  first,  to  relieve 
the  spasmodic  action  of  the  laryngeal  muscles ;  secondly,  to  cure  the  laryn- 
gitis. To  meet  the  first  indication  a  warm  bath  of  the  temperature  of  about 
100°  should  be  employed  as  soon  as  possible  after  the  commencement  of  the 
attack.  The  patient  should  be  kept  in  it  ten  or  fifteen  minutes,  in  order  to 
obtain  its  full  relaxing  efi'ect.  In  mild  cases  a  warm  foot-bath  may  be  suf- 
ficient. A  second  means  is  the  use  of  an  emetic,  which  should  be  simulta- 
neous with  the  bath.  To  children  under  the  age  of  three  years  syrup  of 
ipecacvianha  should  be  given,  in  doses  of  one  teaspoonful  repeated  in  twenty 
minutes,  till  vomiting  occurs.  Children  over  the  age  of  three  years,  unless 
of  feeble  constitution,  are  best  treated  by  the  compound  syrup  of  squills  in 
teaspoonful  doses,  or  a  mixture  of  this  with  syrup  of  ipecacuanha.  It  is  not 
often  necessary  to  give  more  than  three  or  four  doses,  and  sometimes  one  or 
two  are  sufiicient  to  produce  vomiting. 

In  most  cases  by  the  use  of  the  warm  bath  and  the  emetic  the  symptoms 
are  rendered  milder,  and  convalescence  soon  commences. 

Dr.  R.  R.  Livingstone  ^  reports  a  case  of  laryngitis  treated  by  Squibb's 
ether.  It  is  stated  that  portions  of  pseudo-membrane  from  one-eighth  to 
three-fourths  of  an  inch  in  length  were  expectorated ;  but  the  symptoms 
certainly  indicated  a  spasmodic  element  as  decided  as  in  spasmodic  croup, 
and  the  benefit  from  the  ether  was  apparently  due  to  the  relaxation  of 
the  laryngeal  muscles  which  it  produced.  The  treatment  of  the  patient, 
who  was  two  years  old,  was  commenced  by  the  administration  by  the  mouth 
of  half  a  teaspoonful  of  the  ether,  and  followed  by  its  inhalation.  "  In  pre- 
cisely eight  minutes  from  the  time  the  patient  commenced  the  inhalation  the 
abnormal  muscular  exertion  ceased ;  a  general  relaxation  took  place ;  the 
pulse  (which  had  numbered  150)  fell  to  100."  Ether,  judiciously  employed, 
will  probably  prove  to  be  a  useful  remedial  agent  in  spasmodic  forms  of 
laryngitis,  whether  or  not  it  have  any  effect  on  pseudo-membranous  forma- 
tions. A  large  majority  of  cases,  however,  recover  speedily  without  its  em- 
ployment or  by  the  other  measures  recommended. 

Attention  should  always  be  given  to  the  state  of  the  bowels  in  spasmodic 
laryngitis ;  if  they  are  not  well  open  a  purgative  should  be  administered. 
For  those  that  are  robust  and  with  considerable  febrile  movement  the  saline 
cathartics  are  ordinarily  preferable,  as  Eochelle  salts,  or  a  purgative  dose 
of  calomel  may  be  administered.  The  cathartic  should  not  be  prescribed 
till  the  nausea  from  the  emetic  has  subsided.  By  its  derivative  efi'ect  it 
tends  to  diminish  the  laryngitis,  and  in  severe  cases  it  may  obviate  the 
need  of  depletion  by  leeches. 

Inhalation  of  the  vapor  of  hot  water  and  the  application  of  a  sinapism 
^  American  Journal  of  the  Medical  Sciences,  April,  1867. 


826  LOCAL  DISEASES. 

over  the  neck  and  upper  part  of  the  sternum,  followed  by  an  emollient  poul- 
tice, are  useful  adjuvants  to  treatment. 

The  most  convenient  and  effectual  way  of  employing  vapor  is,  however, 
by  the  atomizer,  and  as  the  chief  danger  is  that  the  inflammation  may 
become  pseudo-membranous,  I  am  in  the  habit  of  using  in  the  atomizer  the 
officinal  lime-water,  its  solvent  action  being  increased  by  the  addition  of  the 
sodium  bicarbonate,  two  di'achms  to  the  pint. 

When  the  spasmodic  element  in  the  disease  is  relieved  the  case  becomes 
one  of  simple  laryngitis,  and  the  general  plan  of  treatment  recommended  for 
that  malady  is  proper  for  this.  Small  doses  of  ipecacuanha  or  of  one  of  the 
antimonial  preparations,  as  the  compound  syrup  of  squills,  not  sufficient  to 
cause  nausea,  should  now  be  given  at  regular  intervals.  Phenacetin,  given 
every  third  hour  in  doses  of  half  a  grain,  one  grain,  or  one  and  a  half  grains, 
is  a  useful  remedy  if  the  temperature  reach  103°.  Its  efi'ect  should  be 
watched,  and  it  should  be  discontinued  when  its  sedative  influence  on  the 
circulation  begins  to  be  apparent. 

If,  however,  the  disease  do  not  speedily  terminate  by  recovery,  or  more 
rarely  by  death,  there  is  nearly  always  tracheo-bronchitis  or  a  more  serious 
affection  coexisting  with  the  laryngitis  or  following  it,  so  that  depressing 
measures  should  not  be  long  continued.  Expectorants  of  a  stimulating  cha- 
racter, as  carbonate  of  ammonium,  are  required  in  the  course  of  a  few  days, 
and  in  young  and  feeble  children  they  should  be  given  at  an  early  period. 

The  mode  of  treatment  recommended  above  is  appropriate  for  that  large 
class  in  whom  the  inflammatory  element  predominates.  In  a  smaller  number 
of  cases  the  nervous  element  predominates  over  the  inflammatory,  and  the 
treatment  should  be  in  some  respects  difierent.  Such  children  are  usually 
pallid  and  of  spare  habit,  having,  indeed,  the  nervous  temperament.  They 
are  liable  to  attacks  of  this  disease,  though  generally  of  a  mild  form,  on 
slight  exposure  to  cold,  and  with  a  very  moderate  amount  of  inflammation. 
The  treatment  in  these  cases  should  be  directed  more  to  the  nervous  system. 
My  plan  has  been  in  the  treatment  of  such  patients,  after  perhaps  the  use  of 
a  mild  emetic,  to  give  quinine,  one  grain  three  or  four  times  daily  to  a  child 
from  three  to  five  years  old,  prescribing  at  the  same  time  a  simple  expector- 
ant and  a  mildly  irritating  application  to  the  throat.  The  symptoms  in  these 
cases  are  not  severe,  and  active  measures  are  not  required,  though  the  peculiar 
cough  continues  longer  than  in  the  more  inflammatory  forms  of  the  malady. 

The  patient  with  spasmodic  laryngitis  should  be  kept  in  a  warm  room 
du.ring  the  paroxysms,  and  should  inhale  an  atmosphere  loaded  with 
moisture. 

Trousseau  recommends  a  mode  of  treatment  of  spasmodic  laryngitis  which 
was  first  suggested  by  Graves  of  Dublin.  It  consists  in  the  application 
underneath  the  chin,  so  as  to  cover  the  larynx,  of  a  sponge  soaked  in  water 
as  hot  as  can  be  borne ;  in  ten  or  fifteen  minutes  it  is  repeated.  This  red- 
dens the  skin,  producing  revulsion  from  the  larynx.  The  hoarseness, 
dyspnoea,  and  cough  diminish  with  this  treatment,  and  some  recover  without 
other  measures. 

In  rare  cases  of  spasmodic  laryngitis  the  dyspnoea  becomes  so  great,  not- 
withstanding active  treatment,  that  the  life  of  the  patient  is  in  danger 
whether  oedema  glottidis  or  thickening  and  infiltration  of  the  laryngeal 
mucous  membrane  be  present.  In  these  cases  intubation  with  O'Dwyer's 
tubes  will  give  prompt  relief.  Spasmodic  contraction  of  the  laryngeal  mus- 
cles probably  also  occurs  in  these  cases,  increasing  the  dyspnoea.  Recently, 
in  the  case  of  a  child  of  about  three  years,  the  dyspnoea  was  so  great  in 
about  three  hours  from  the  commencemejit  that  intubation  was  performed 
with  immediate  relief. 


LARYNGITIS.  827 

Guersant  and  others  speak  of  the  importance  of  prophylactic  management 
of  children  who  are  liable  to  this  disease.  Attention  should  be  given  to  the 
dress,  so  that  there  may  be  sufficient  protection  from  atmospheric  changes, 
and  there  should  be  an  equable  temperature  of  the  apartments  in  which  they 
reside.  Children  of  a  decidedly  nervous  temperament,  in  whom  the  slightest 
laryngitis  is  liable  to  be  spasmodic,  require  additional  prophylactic  measures. 
They  are  pallid  and  in  a  more  or  less  cachectic  state.  Such  children  are 
benefited  by  chalybeate  and  vegetable  tonics  and  by  exercise  in  suitable 
weather  in  the  open  air. 

Imperforate  nose  may  be  congenital ;  it  is  then  caused  by  a  membrane 
stretched  across  the  nostrils,  or  by  firm  fibrous  tissue,  or  by  simple  continuity 
of  the  integument.  In  congenital  closure  the  interference  with  respiration 
and  sucking  often  requires  an  early  operation.  In  most  cases  a  simple  in- 
cision carefully  made  through  the  obstructing  membrane,  and  the  opening 
maintained  by  strips  of  lint  or  a  short  elastic  cannula,  is  sufficient.  Some- 
times it  may  be  desirable  to  excise  a  portion  of  the  obstructing  tissue. 
When  there  is  no  indication  of  the  opening  of  the  nostril,  the  adherent  parts 
must  be  gi'adually  and  cautiously  divided  until  the  nasal  canal  is  restored. 

Hemorrhage  from  the  nose,  epistaxis,  is  of  very  common  occurrence  in 
children,  owing  to  the  immense  distribution  of  blood-vessels  throughout  the 
cavities,  and  the  existence  of  cavernous  bodies  between  the  periosteum  and 
mucous  membrane  of  the  turbinated  bones.  Bleeding  may  be  spontaneous 
or  result  from  injui'y,  and  when  severe  there  is  a  rupture  of  vessels.  The 
following  are  some  of  the  more  useful  remedies  : 

Place  the  patient  in  the  sitting  posture,  the  head  inclined  slightly  forward  ;  re- 
move all  articles  from  the  neck  which  prevent  the  free  flow  of  blood  ;  secure  the 
most  perfect  possible  state  of  rest  of  mind  and  body,  and  encourage  quiet  respi- 
ration without  speaking  or  blowing  the  nose.  The  simple  means  are  cold  to 
the  nose  and  forehead  or  to  the  back  of  the  neck,  elevation  of  the  arms  above  the 
head,  astringent  injection  or  spray,  as  of  alum,  tannin,  zinci  sulph.,  mustard  foot- 
baths. As,  in  a  large  number  of  cases,  the  bleeding  spot  is  near  the  anterior  and 
lower  border  of  the  septum,  the  bleeding  may  often  be  arrested  by  pressing  the  ala 
of  the  affected  side  against  the  septum  in  such  a  manner  as  to  close  the  nostril  and 
the  front  and  upper  part  of  the  nose  :  or  the  finger  may  be  applied  directly  in  the 
nostril ;  or  a  compress  of  lint,  tied  with  a  string  with  which  to  remove  it,  may  be 
introduced  into  the  nostril  •,  wicks  or  strips  of  linen  may  be  introduced  through  the 
nose  to  the  pharynx,  and  they  may  be  sprinkled  with  tannin  or  dipped  in  persul- 
phate of  iron  to  increase  their  styptic  c{ualities.  Antipyrine  in  aqueous  solution, 
1 :  30,  is  a  safe  and  powerful  haemostatic  applied  on  lint ;  insert  as  far  as  possible, 
and  then  compress  the  nose  so  as  to  bring  the  solution  in  contact  with  a  large  sur- 
face of  mucous  membrane.  Cocaine  applied  in  a  4  per  cent,  solution  relieves  con- 
gestion. Not  unfrequently  a  careful  examination  will  reveal  a  small  ulcer  just 
within  the  ala,  from  which  the  hemorrhage  occurs.  The  application  of  the  solid 
nitrate  of  silver  will  cause  rapid  cicatrization.  If  the  child  becomes  anaemic  from 
frequent  losses  of  blood,  the  liq.  ferri  persulphatis  in  3-  to  5-drop  doses  in  water  is 
very  useful. 

Foreign  bodies  are  often  introduced  into  the  nasal  cavities  by  children. 
The  substances  may  remain  long  in  the  nasal  cavities  without  causing  any 
trouble,  but,  in  general,  their  immediate  effect  is  circumscribed  inflammation, 
with  purulent,  bloody,  and  often  fetid  secretions.  The  diagnosis  is  made  out 
from  the  history  and  exploration.  If  the  history  is  doubtful,  inspect  the 
cavities,  remembering  that  the  foreign  body  may  be  covered  with  secretions ; 
finally,  explore  with  the  probe,  distinguishing,  by  the  sensation,  sound,  and 
mobility,  between  the  movable  body  and  the  bone.  Early  removal  must 
follow  detection  of  the  body.  Sneezing  and  the  douche  are  sometimes 
effective.     The  most  convenient  instruments  are  thin,  short,  straight  dressing- 


828  LOCAL  DISEASES. 

forceps  and  small  scoops.  Care  is  requisite  in  seizing  the  body,  lest  it  be 
pushed  more  deeply  into  the  cavity.  First  apply  a  4  per  cent,  solution  of 
cocaine  with  a  spray  apparatus. 


CHAPTER    III. 

DISEASES  OF  THE  LAEYNX. 

Foreign  bodies  entering  the  larynx  are  arrested  in  its  interior,  or  descend, 
according  to  their  size,  form,  and  weight.  When  arrested  in  the  larynx,  they 
may  lodge  in  one  of  the  ventricles  or  become  fixed  between  the  vocal  cords. 
Occasionally  they  are  arrested  at  the  junction  of  the  larynx  and  trachea. 
The  first  symptoms  of  the  entrance  of  the  body  into  the  air-passages  are 
usually  severe  and  characteristic:  the  patient  gasps  for  breath,  coughs  vio- 
lently, the  face  becomes  livid,  the  eyes  protrude,  the  body  is  contorted,  and 
he  is  like  one  choked  by  the  hand.  If  the  body  is  lodged  in  the  larynx,  the 
symptoms  will  vary  with  its  size  and  peculiarities.  It  may  be  so  large  as  to 
prove  fatal  by  suffocation,  or  so  small,  hard,  and  smooth  as  to  cause  but  slight 
symptoms.  Ordinarily  there  is  aphonia,  with  pain  and  soreness,  and  uneasi- 
ness in  that  region  ensues,  with  dyspnoea  and  a  whistling  sound  in  respiration  ; 
at  the  same  time  there  is  absence  of  tracheal  and  bronchial  disturbance.  If 
the  symptoms  are  not  so  urgent  as  to  require  immediate  tracheotomy,  apply 
a  -4  per  cent,  solution  of  cocaine  to  the  palate  and  pharynx  preparatory  to 
laryngoscopic  examination.  In  fifteen  minutes  examine  the  larynx.  If  the 
body  is  lodged  above  or  within  the  larynx,  with  properly  curved  forceps  it 
may  be  seized  and  removed  without  pain.  As  a  general  rule,  the  trachea 
should  be  opened  with  as  little  delay  as  possible  in  every  case  in  which  a 
foreign  body  is  certainly  known  to  be  retained  in  any  part  of  the  air-passages, 
for  by  this  means  the  immediate  safety  of  the  patient  is  secured  and  subse- 
quent expulsion  or  removal  aided. 

An  anaesthetic  should  always  be  given  when  the  symptoms  admit  of  delay,  but 
in  many  cases  there  is  not  a  moment  to  lose,  and  the  trachea  must  be  opened  at 
once  ]  even  if  the  patient  cease  to  breathe  befoi'e  this  is  accomplished,  the  operation 
should  be  completed  and  artificial  respiration  instituted  and  perseveringly  main- 
tained. In  those  cases  where  the  symptoms  are  so  slight  as  to  cause  hesitation 
before  adopting  such  severe  treatment  delay  is  dangerous,  for  an  interval  of  calm 
constantly  precedes  the  recurrence  of  urgent  symptoms,  and  temporary  freedom 
from  distress,  instead  of  contraindicating  the  operation,  aflFords  the  best  opportunity 
for  its  performance.  In  deciding  as  to  the  particular  form  of  operation  in  any  case, 
it  must  be  borne  in  mind  that  while  laryngotomy  is  simple,  easy,  and  free  from  risk, 
it  is  not  as  applicable  to  early  childhood  as  tracheotomy,  on  account  of  the  very 
limited  dimensions  of  the  crico-thyroid  space. 

Laryngotomy  is  performed  as  follows  (Fig.  231):  Place  the  patient  on  a  table 
with  the  head  and  shoulders  properly  elevated  and  firmly  fixed  (Fig.  232)  ;  feel  for 
the  thyroid  cartilage  at  the  lower  border  of  which  it  is  to  be  opened ;  make  an 
incision  with  a  narrow  scalpel  along  the  centre  of  the  larynx,  from  the  top  of  the 
thyroid  to  the  base  of  the  cricoid  cartilage  ;  this  incision  should  be  one  and  a  half 
inches  in  length  ;  if  the  crico-thyroid  artery  bleed,  it  must  be  twisted  or  tied  ;  divide 
the  crico-thyroid  membrane  in  the  same  direction  in  its  whole  extent ;  if  the  open- 
ing is  not  sufiiciently  large,  prolong  the  incision  into  the  contiguous  cartilages  or 
transversely. 

If  expulsion  should  not  immediately  take  place,  introduce  the  double 
cannula  (Fig.  333),  which  secures  freedom  of  respiration  and  stops  hemor- 
rhage; the  contracted  muscles  of  the  larynx  may  become  relaxed,  and  the 


DISEASES  OF  THE  LARYNX. 


829 


foreign  body,  set  at  liberty,  be  expelled.     When  the  patient  has  recovered 
from  the  immediate  effects  of  the  operation,  the  cannula  may  be  removed, 


Fig.  231. 


Fig.  232. 


Incision  in  laryngotomy. 


Position  of  patient  in  laryngotomy. 


and  the  larynx  explored  by  means  of  a  probe  ;  if  the  body  is  not  detected, 
use  a  larger  instrument,  as  an  elastic  catheter ;  the  laryngoscope  may  also  be 
used,  and  if  the  foreign  body  is  detected  it  may  be  extracted  with  curved 
forceps  (Fig.  234).    If  not  extracted,  the  patient  may  now  be  safely  inverted 


Fig.  233. 


Fig.  234. 


Double  tracheal  tube,  movable  plate,  silver. 


Laryngeal  forceps. 


and  the  back  struck  repeated  blows,  which  often  dislodges  smooth,  rounded 
bodies,  as  shot,  bullets,  or  pieces  of  money ;  if  these  means  all  fail,  the 
larynx  must  be  fully  exposed. 

Thyrotomy,  incision  of  the  thyroid  cartilage,  is  not  a  diflScult  operation,  and 
does  not  involve  mueh  risk.  Place  the  patient  in  the  position  already  given  (Fig. 
232)  ;  make  the  incision  through  the  cartilage  perpendicularly  upward  from  the 
opening  in  the  crico-thyroid  membrane  previously  made,  and  exactly  in  the  middle 
line.  Make  the  same  search  as  before,  and  when  the  foreign  body  is  removed  bring 
the  edges  of  the  incision  through  the  thyroid  body  together,  and  secure  them  by 
suture  ;  the  laryngeal  tube  may  be  retained  a  few  days,  until  all  indications  of  local 
mischief  have  passed  away. 

Burns  and  Scalds  result  from  inhalation  of  flames,  hot  vapors,  and 
attempts  to  swallow  boiling  liquids.  Violent  inflammation  follows,  with  great 
pain  in  attempting  to  swallow,  hoarseness,  dyspnoea,  and  croupy  symptoms, 
which  gradually  become  extreme.  In  a  fair  proportion  of  cases  little  other 
treatment  is  required  than  a  warm  bed,  the  application  of  a  hot  sponge  to 
the  larynx,  and  the  inhalation  of  warm,  moist  air.  In  more  severe  cases 
blisters  or  leeches  are  useful ;  but  if  the  symptoms  rapidly  progress  and 
laryngeal  spasm  occurs,  tracheotomy  must  be  promptly  performed,  chloroform 
being  given  without  fear. 

If  there  is  immediate  danger,  proceed  as  follows : 


830  LOCAL  DISEASES. 

The  patient  being  anaesthetized  or  not,  as  may  be  deemed  best,  and  firmly  held, 
the  shoulders  elevated  and  the  head  extended,  stand  at  his  right  side  and  place  the 
fore  finger  of  the  left  hand  on  the  left  side  of  the  trachea,  and  the  thumb  on  the 
right  side,  and  make  uniform,  steady,  deep  pressure  until  the  pulsation  of  both 
carotid  arteries  is  felt ;  now  slightly  approximate  the  finger  and  thumb  until  the 
trachea  is  firmly  and  securely  held  between  them,  and  maintain  this  grasp  until  by 
repeated  cuts  in  the  median  line  the  trachea  is  exposed ;  the  fore  finger  of  the  right 
baud  should  Ije  used  from  time  to  time  to  determine  the  relation  of  parts  ;  when 
the  trachea  is  exposed  it  may  be  opened  at  once,  or  seized  by  a  sharp  hook  and 
held  while  it  is  opened ;  make  the  opening  by  thrusting  the  point  of  the  knife,  the 
edge  directed  upward,  into  the  tube,  and  carrying  it  upward  to  a  sufiicient  extent. 

It  is  important  to  keep  strictly  in  the  median  line,  otherwise  the  cannula  will 
stand  away  in  the  wound,  and  its  extremity  will  be  turned  sharply  against  the 
membrane  of  the  trachea,  and  will  not  only  cause  irritation,  but  will  quickly 
become  blocked  with  mucus.  The  point  of  the  knife  must  certainly  penetrate  the 
mucous  membrane,  which,  if  swollen,  may  be  pushed  before  it ;  but  it  must  not  be 
thrust  too  deeply,  lest  it  penetrate  the  posterior  wall  and  the  oesophagus ;  if  the 
first  opening  is  too  small,  it  must  be  enlarged. 

If  there  is  not  immediate  danger,  proceed  as  follows : 

The  patient  being  in  position,  carefully  examine  the  region  and  determine  the 
precise  point  of  opening  the  tube ;  make  a  straight  incision  exactly  in  the  median 
line,  extending  from  just  above  the  cricoid  cartilage,  nearly  as  low  as  the  sternum  ; 
if  the  patient  has  a  short,  fat  neck,  make  the  first  incision  long  enough  ;  the  subcu- 
taneous fat  and  connective  tissue  being  divided,  the  sterno-hyoid  muscles  are  ex- 
posed, divided  by  a  faint  line,  along  which  make  an  incision  dividing  the  fascia  ; 
continue  the  dissection  cautiously  through  the  fascia  and  connective  tissue,  layer 
by  layer,  the  separated  tissues  being  held  aside,  and  every  bleeding  vessel  secured 
until  the  trachea  is  exposed  and  opened. 

In  every  case,  however  apparently  hopeless  it  may  have  become,  the  operation 
should  be  completed  and  the  tube  introduced,  even  though  the  patient  has  ceased 
to  breathe  before  this  can  be  accomplished ;  the  most  persevering  effort  should  be 
made  to  effect  resuscitation  by  aid  of  artificial  respiration,  and  by  sucking  out  the 
blood  that  may  have  entered  the  trachea,  for  recovery  has  repeatedly  been  effected 
in  cases  apparently  the  most  hopeless. 

The  last  stage  of  the  operation  varies  with  the  object  in  view ;  if  it  has 
been  undertaken  on  account  of  the  presence  of  a  foreign  body,  the  edges 
of  the  opening  should  be  held  well  apart  by  means  of  blunt  hooks  or 
dressing-forceps,  or  silk  or  wire  ligatures  may  be  passed  through  each  edge 
of   the   wound,  and   tied   behind  the   neck  of  the  patient ;    if  the  body  is 

comparatively  large    and    im- 
FiG.  235.  pacted  in  the  upper  part  of 

the  trachea,  it  is  better  to 
inti'oduce  a  cannula  into  the 
tracheal  wound,  and  wait  until 
all  spasm  has  had  time  to  sub- 
side ;  if,  however,  the  body  is 
comparatively  small  and  is  sit- 
uated in  the  lower  part  of  the 
trachea,  it  is  better  to  lose  no 
time  in  attempting  to  extract 
it  by  means  of  forceps,  lest  it 
Broad-beaked  forceps.  find  its  way  into  the  bronchi. 

The  forceps  best  adapted  to 
seize  the  body  has  a  peculiar  curve  (Fig.  235),  with  broad  beaks.  Or  it 
may  have  a  pliable  shaft  which  can  be  bent  at  any  curve,  and  will  retain 
that  position  (Fig.  236)  ;  when  introduced  it  may  be  closed  and  then  acts  as 
a  probe ;  if  the  foreign  body  is  felt,  the  blades  can  be  gently  protruded,  and 


PSEUDO-MEMBBANOUS  CBOUP.  831 

when  they  enclose  the  body  be  closed  upon  it,  and  removal  is  readily  effected. 
If  the  operation  is  undertaken  for  disease,  a  cannula  should  be  selected  which 

Fig.  236. 


Flexible  forceps. 

can  be  worn  with  comfort,  and  which  will  be  least  liable  to  obstruction.  It 
should  always  be  double,  and  so  curved  as  not  to  press  upon  the  anterior  wall 
of  the  trachea. 


CHAPTER    IV. 

PSEUDO-MEMBRANOUS  CEOUP   (TEUE  CEOUP). 

The  term  pseudo-membranous  laryngitis  or  laryngo-tracheitis,  or  true 
croup,  is  applied  to  a  common  and  fatal  disease,  the  essential  anatomical 
character  of  which  is  inflammation  of  the  larynx,  or  larnyx  and  trachea,  with 
the  formation  of  a  pseudo-membrane  upon  its  surface.  It  occurs  most  fre- 
quently between  the  ages  of  two  and  twelve  years,  but  infancy  after  the  age 
of  six  months  and  early  manhood  are  not  exempt  from  it. 

Etiology. — Wherever  diphtheria  or  pseudo-diphtheria  prevails  as  an 
endemic  or  epidemic  it  is  well  known  that  a  large  majority  of  the  cases  of 
membranous  croup  are  local  manifestations  of  one  or  the  other  of  these 
diseases  or  of  the  two  combined  (mixed  infection).  Whenever  the  laryngeal 
or  laryngo-tracheal  inflammation  reaches  a  certain  grade  of  severity  it  may 
be  attended  by  the  exudation  of  fibrin  and  the  formation  of  a  pseudo- 
membrane  ;  but  such  a  result  more  frequently  occurs  in  the  inflammation 
caused  by  diphtheria  or  pseudo-diphtheria  than  in  that  produced  by  other 
agencies. 

The  percentage  of  cases  of  diphtheria  and  pseudo-diphtheria  in  which  the 
larynx  becomes  implicated  and  croup  occurs  varies  in  different  epidemics  and 
in  different  seasons  and  localities.  In  epidemics  of  a  mild  type  the  cases 
appear  to  be  fewer  in  which  the  larynx  and  trachea  are  involved  than  in 
epidemics  of  a  severe  form.  In  New  York  the  percentage  is  large.  From 
December  1,  1875,  to  July,  1878,  I  preserved  records  of  all  the  cases  of 
diphtheritic  diseases  which  came  under  my  notice.  The  number  was  104, 
and  in  25  of  these,  or  about  1  in  4,  croup  occurred,  producing  the  usual 
obstructive  symptoms  and  constituting  the  chief  source  of  danger.  During 
the  two  and  a  half  years  embraced  in  these  statistics  the  disease  was  usually 
severe.  Subsequently  amelioration  occurred  in  the  type,  and  the  proportion 
of  croup  cases  has  not  been  so  large.  Since  the  differentiation  of  diphtheria 
and  pseudo-diphtheria  has  been  recent,  the  term  "  diphtheria  "  in  the  follow- 
ing statistics  necessarily  embraces  also  cases  of  pseudo-diphtheria. 

So  commonly  is  membranous  croup,  when  occurring  in  a  locality  where 
diphtheria  is  endemic  or  epidemic,  a  local  manifestation  of  diphtheria  that 
physicians  in  such  localities  come  to  regard  most  cases  of  this  disease  of  the 
larynx   as   produced  by  the   diphtheritic  poison.     In  Xew  York  physicians 


832 


LOCAL  DISEASES. 


scarcely  recognize  any  other  form  of  membranous  croup.  It  is  well,  there- 
fore, briefly  to  recall  the  evidences  that  croup  in  a  certain  proportion  of 
cases  results  from  other  causes  than  diphtheria.  The  occurrence  of  croup 
in  localities  where  diphtheria  is  unknown  of  course  indicates  the  operation 
of  some  other  agency  than  the  diphtheritic  poison.  Thus,  in  1842,  before 
diphtheria  was  established  in  this  country,  Dr.  John  Ware  of  Boston  pub- 
lished his  well-known  paper  on  croup,  and  in  7-i  of  the  75  cases  embraced  in 
his  statistics  the  membranous  exudation  was  present  upon  the  faucial  surface. 
The  statistics  relating  to  the  introduction  of  diphtheria  into  New  York  City 
and  the  recorded  death-statistics  of  this  city  were  annually  published,  and 
each  year  more  or  fewer  deaths  from  croup  were  reported.  The  first  death 
from  diphtheria  in  this  century  within  the  city  limits,  certified  by  a  physician, 
was  that  of  a  German  woman  at  638  Hudson  street  on  February  15.  1852. 
Two  other  fatal  cases  occurred  in  1857,  and  since  then  the  deaths  from  croup 
and  diphtheria  have  been  as  presented  in  the  following  table : 


Year. 
1858. 

1859  . 

1860  - 

1861  . 

1862  . 

1863  . 
1864. 
1865. 
1866  . 


Croup.     Diphtheria. 


478 
622 
599 
460 
685 
908 
754 
449 
368 


5 

53 
422 
453 
594 
981 
781 
534 
435 


Year. 
1867  . 
1868 

1869  , 

1870  , 

1871  , 

1872  . 

1873  . 

1874  . 

1875  . 


Croup.       Diphtheria. 


338 

251 

342 

276 

483 

328 

421 

308 

466 

238 

675 

446 

732 

1151 

594 

1665 

758 

2329 

Since  1875  weekly  bulletins  have  been  issued  instead  of  the  annual  reports. 

Thus,  in  the  first  years  after  the  introduction  of  diphtheria  the  deaths 
assigned  to  croup  so  greatly  outnumbered  those  of  diphtheria,  as  in  1858, 
when  5  died  of  diphtheria  and  478  of  croup,  that  it  is  evident  that  most 
of  the  cases  of  croup  in  those  years  were  attributable  to  other  causes  than 
diphtheria.  Since,  as  we  have  stated,  any  inflammation  of  the  surface  of  the 
larynx  and  trachea,  if  sufficiently  intense,  may  produce  a  pseudo-membrane, 
croup  may  occur  as  a  primary  disease  and  as  a  complication  of  various  mal- 
adies. From  the  fact  that  croup  was  prevalent  and  fatal  in  the  first  half  of 
the  present  century,  before  the  occurrence  of  diphtheria,  it  is  evident  that 
we  must  look  for  some  other  cause  for  it.  I  cannot  resist  the  conviction  that 
its  cause  prior  to  1850  was  pseudo-diphtheria ;  in  other  words,  the  presence 
and  action  of  the  streptococcus  and  staphylococcus.  According  to  my  obser- 
vations in  New  York  City,  the  chief  causes  of  croup,  arranged  in  the  order 
of  frequency,  would  be  about  as  follows :  Diphtheria,  pseudo-diphtheria,  or 
the  inflammation  caused  by  streptococci  and  staphylococci,  "  taking  cold," 
measles,  pertussis,  scarlatina,  typhoid  fever,  irritating  inhalations.  Did 
space  permit,  other  cases  might  be  cited  showing  the  causal  relation  between 
the  other  diseases  mentioned  above  and  croup. 

Scarlatina  is  so  often  complicated  by  diphtheria  that  there  seems  to  be  a 
close  affinity  between  the  two  diseases.  It  is  a  very  common  observation  in 
New  York  City  that  scarlet  fever  continues  two  or  three  days  in  its  usual 
form,  when  the  symptoms  become  suddenly  aggravated  and  the  aspect  of  the 
disease  more  severe.  On  inspecting  the  fauces  a  pseudo-membrane  is  dis- 
covered covering  this  region,  and  it  probably  appears  also  upon  the  nasal 
surface.  Although  severe  scarlatinous  inflammation  may  cause  a  fibrinous 
exudation,  yet  that  diphtheria  or  pseudo-diphtheria  has  supervened  upon 
scarlet  fever  in  a  considerable  proportion  of  cases  which  have  the  above 
history  has  been  demonstrated  by  the  microscope.  In  a  few  instances  in  my 
practice  the  fact  that  scarlet  fever  was  complicated  by  true  diphtheria,  and 


PSEUBO-MEMBBANOUS  CBOUP.  833 

the  scarlatinous  inflammations  first  in  order  were  intensified  by  the  presence 
and  influence  of  the  diphtheritic  virus,  was  shown  by  the  occurrence  of  diph- 
theria without  scarlet  fever  in  other  members  of  the  family. 

In  accordance  with  the  above  law  we  may  assume  that  a  child  who  has 
laryngo-tracheitis,  so  common  from  taking  cold  and  manifested  by  cough  and 
hoarseness,  is  more  prone  to  have  diphtheritic  croup  than  is  one  whose  air- 
passages  are  in  their  normal  state  when  diphtheria  commences.  A  supposed 
error  of  diagnosis  is  often  made  by  physicians,  always  to  their  discredit,  who 
diagnosticate  catarrhal  laryngitis,  but  find  after  two  or  three  days  that  their 
patients  really  have  membranous  croup.  A  considerable  number  of  such 
instances  have  come  to  my  notice,  always  with  the  ill-will  of  families  toward 
their  physicians.  Now,  it  cannot  be  doubted  that  in  many  of  these  cases  the 
physicians  have  been  right  in  their  first  diagnosis,  and  membranous  croup 
supervened  on  the  catarrhal  inflammation. 

Anatomical  Characters. — It  is  important  to  acquaint  ourselves  with 
the  anatomical  characters  of  croup,  especially  with  the  nature  of  the  pseudo- 
membrane,  that  we  may  know  what  measures  to  employ  in  order  to  remove  it 
and  prevent,  so  far  as  possible,  the  laryngeal  stenosis  from  which  so  many 
perish.  The  surface  of  the  larynx,  trachea,  and  in  severe  cases  that  of  the 
bronchial  tubes,  is  hyperaemic  and  swollen,  and  the  inflammatory  action 
involves  more  or  less  the  submucous  connective  tissue,  causing  infiltration 
or  oedema.  The  relation  of  the  exudation  to  the  mucous  surface  varies 
according  to  the  kind  of  epithelium  present.  Where  the  epithelium  is  of 
the  flat  or  squamous  variety  the  fibrinous  exudation  from  the  blood-vessels  is 
poured  out  around  the  epithelial  cells,  which  perish.  If  the  inflammation 
extend  more  deeply,  the  underlying  connective  tissue  is  also  embraced  in  the 
coagulation  and  perishes.  Prof.  Ziegler  of  Tiibingen,  who  has  made  repeated 
microscopic  examinations  of  the  pseudo-membrane,  says  :  "  It  sometimes  hap- 
pens that  the  dead  epithelial  cells  become  saturated  with  the  exuded  liquid 
and  then  pass  into  a  peculiar  condition  of  rigidity  akin  to  coagulation.  The 
seat  of  this  change  appears  to  the  naked  eye  as  a  dull,  raised,  grayish  patch 
surrounded  by  red  and  swollen  mucous  membrane.  The  exudation  is  rich  in 
albumen,  and  the  transformed  cells  take  on  the  appearance  of  a  kind  of 
coarse  meshwork  almost  or  altogether  devoid  of  nuclei."  This  is  superficial 
inflammation,  and  Prof.  Ziegler  next  describes  deep  or  parenchymatous 
inflammation,  as  follows :  "  It  is  characterized  by  the  coagulation  not  merely 
of  the  epithelium,  but  also  of  the  underlying  connective  tissue.  The  aff"ected 
patch  is  swollen  and  assumes  a  whitish  or  grayish  tint,  the  discoloration 
extending  through  the  epithelium  to  the  connective-tissue  structures.  The 
epithelium  in  some  cases  is  lost  altogether,  and  then  the  diphtheritic  patch 

consists  of  dead  connective  tissue  only The  dead  tissue  is  separated 

from  the  living  by  a  zone  of  cellular  inflammation.  Fibrinous  filaments  are 
seen  here  and  there  through  the  mass.  The  lymphatics  in  the  neighborhood 
contain  coagula  and  leucocytes." 

Squamous  epithelium  covers  the  nostrils,  buccal  cavity,  fauces,  and 
larynx  upon  and  above  the  superior  vocal  cord,  with  the  exception  of  its 
anterior  aspect.  The  pseudo-membrane,  therefore,  upon  all  these  surfaces 
lined  with  this  form  of  epithelium  consists  of  the  exudate  from  the  blood 
which  surrounds  and  permeates  the  epithelium  or  epithelium  and  subjacent 
connective  tissue.  These  two  distinct  elements,  that  poured  out  from  the 
blood-vessels,  and  the  normal  tissue  of  the  mucous  surface  now  dead,  incor- 
porated in  one  mass,  constitute  the  pseudo-membrane.  .  Its  intimate  relation 
with  the  surrounding  living  tissue  is  such  that  we  cannot  detach  it  without 
lacerating  the  latter  and  causing  hemorrhage. 

The  anterior  aspect  of  the  larynx  from  the  middle  of  the  epiglottis  down- 
53 


834  LOCAL  DISEASES. 

ward,  all  that  part  of  the  larynx  below  the  superior  vocal  cord,  the  entire 
trachea,  and  the  bronchial  tubes,  are  lined  by  columnar  epithelium.  When- 
ever this  variety  of  epithelium  is  present  the  exudate  from  the  blood  does 
not  become  incorporated  with  the  mucous  membrane,  but  escapes  to  the  sur- 
face and  coagulates  in  a  layer  over  it.  It  is,  therefore,  loosely  adherent  to 
the  underlying  tissues,  being  attached  to  it  by  some  fibrinous  threads,  and  when 
it  is  peeled  off  the  hyperaemic  and  swollen  mucous  membrane  is  seen  under- 
neath in  its  entirety,  unless,  as  is  commonly  the  case,  a  considerable  part  of 
its  epithelium  has  been  shed  and  been  expectorated.  The  loose  attachment 
of  the  pseudo-membrane  in  the  trachea  and  bronchial  tubes  is  of  the  greatest 
significance  in  its  relation  to  intubation  and  tracheotomy. 

The  epithelial  cells  embraced  in  the  pseudo-membrane  undergo  a  change. 
Cornil  and  Ranvier  say :  "  Wagner  admits  the  fibrinous  degeneration  of  the 

cells We    have   verified   the   description  given   by  Wagner,  but   we 

would  conclude  that  the  cells  are  filled  with  a  material  which  approaches 
mucin  rather  than  fibrin."  At  the  same  time  a  fibrinous  exudation  occurs, 
binding  together  the  cells.  In  the  first  week  the  pseudo-membrane  forms 
more  rapidly,  and  is  usually  thicker  and  more  extended,  producing  dyspnoea 
more  quickly  than  when  it  forms  in  the  declining  stage  of  the  disease.  If 
the  membrane  be  detached  by  the  forcible  coughing  of  the  patient,  it  is 
usually  quickly  reproduced,  unless  the  diphtheria  be  in  its  advanced  stage 
and  abating.  If  the  croup  continue  from  four  to  six  days,  the  pseudo-mem- 
brane begins  to  soften  from  commencing  decomposition  and  to  disintegrate. 
The  minute  fibres  which  attach  it  to  the  membrane  give  way,  and  in  favor- 
able cases  by  the  effort  of  coughing  or  vomiting  it  is  thrown  off.  Separation 
is  aided  by  the  muco-pus  which  collects  underneath. 

Symptoms. — Whenever  croup  is  a  local  manifestation  of  another  disease, 
such  general  or  constitutional  symptoms  are  present  as  commonly  pertain  to 
this  disease,  such  as  fever,  anorexia,  thirst,  and  progressive  loss  of  flesh  and 
strength.  The  temperature  in  the  commencement  in  croup  from  this  cause 
is  often  higher  than  at  an  advanced  period,  unless  some  complication  occur, 
as  pneumonia,  which  increases  the  heat  of  the  system.  The  temperature  is 
not,  however,  in  the  beginning  ordinarily  above  103°  or  104°.  Most  patients 
also  have  those  inflammations  which  commonly  attend  croup — i.  e.  pharyngi- 
tis and  more  or  less  coryza,  but  they  are  relatively  unimportant  in  compari- 
son with  the  croup,  for,  unlike  the  croup,  they  do  not  in  themselves  involve 
immediate  danger  to  life. 

Croup  commonly  begins  gradually  and  insidiously,  revealed  at  first  to  the 
physician  by  hoarseness  or  huskiness  of  the  voice  and  a  hoarse  or  harsh  cough. 
Both  voice  and  cough  are  feeble,  lacking  the  fulness  and  sonorousness  present 
in  spasmodic  laryngitis.  In  grave  cases  approaching  a  fatal  termination  the 
voice  becomes  more  and  more  indistinct,  and  finally  is  suppressed.  The 
cough  also,  which  in  the  beginning  of  the  croup  was  strong  and  expulsive, 
becomes  feeble  and  ineffectual,  and  less  frequent  as  the  fatal  result  draws 
near. 

The  amount  of  sputum  varies  considerably  in  different  cases.  If  the 
inflammation  extend  no  farther  downward  than  the  trachea,  it  is  scanty,  but 
if  there  be  coexisting  bronchitis,  it  is  more  abundant,  consisting  of  muco-pus 
with  occasional  flakes  of  pseudo-membrane.  By  vomiting  a  larger  quantity 
is  expelled  than  by  the  cough.  Occasionally  masses  of  pseudo-membrane  of 
considerable  size  are  expectorated,  even  moulds  of  some  part  of  the  respira- 
tory passage,  always  with  great  temporary  relief  to  the  patient.  A  pseudo- 
membrane  of  considerable  thickness  and  extent  obstructs  the  expectoration 
of  muco-pus,  which,  collecting  in  the  lower  part  of  the  trachea  and  in  the 
bronchial  tubes,  greatly  increases  the  dyspnoea.     The  respiration  is  somewhat 


PSEUDO-MEMBBANOUS  CBOUP.  835 

more  frequent  than  in  health,  but  it  is  not  notably  increased  except  when 
bronchitis  or  broncho-pneumonia  is  present.  At  an  advanced  stage,  when 
stupor  supervenes  from  non-oxygenation  of  the  blood,  the  respiration  may  be 
slower  than  in  health. 

Croup  in  its  commencement  and  in  the  active  period  of  diphtheria  without 
treatment  almost  never  remains  stationary  or  abates.  Little  by  little,  or  often 
quite  rapidly,  the  laryngeal  stenosis  increases,  and  soon  the  patient  begins  to 
experience  the  want  of  air.  He  becomes  restless,  has  an  anxious  expression 
of  the  face,  seeks  change  of  position,  reaching  out  his  arms  to  the  nurse  or 
mother  to  obtain  relief.  In  some  patients  only  a  few  hours  elapse,  and  in 
others  a  day  or  more  of  gradual  increase  in  the  obstruction,  when  it  becomes 
evident  that  death  must  soon  occur  unless  relief  be  afforded.  In  this  stage 
the  post-clavicular,  infraclavicular,  suprasternal,  and  inframammary  regions 
are  depressed  during  inspiration,  and  the  larynx  is  drawn  with  each  inspira- 
tory act  toward  the  sternum.  While  there  is  constant  suffering,  there  are  also 
occasionally  most  distressing  attacks  of  dyspnoea,  attended  by  an  increase  in 
the  lividity  of  the  features  and  extremities,  which  now  have  an  habitual  dusky 
palor.  Sometimes  these  attacks  are  perhaps  due  to  the  doubling  of  a  de- 
tached end  of  the  pseudo-membrane  on  itself,  or  perhaps  to  a  movement  of 
the  muco-pus  by  which  bronchial  tubes  are  occluded.  With  the  ear  applied 
over  the  larynx  or  upper  part  of  the  sternum,  a  loud  rhonchus  is  heard  both 
on  inspiration  and  expiration,  produced  by  the  passage  of  the  air  over  the 
obstruction,  and  obscuring  to  a  great  extent  other  sounds.  Moist  bronchial 
rales  are  also  common. 

Those  who  recover  from  membranous  croup  without  intubation  or  trache- 
otomy and  by  the  use  of  inhalations — and  thus  far  they  are  a  minority — 
usually  improve  gradually,  the  obstruction  diminishing  by  the  softening 
and  detaching  of  portions  of  the  pseudo-membrane.  After  the  detach- 
ment of  the  pseudo-membrane  several  days  elapse  before  the  thickening 
and  infiltration  of  the  mucous  membrane  disappear  and  the  epithelial  cells 
are  restored. 

Diagnosis. — Catarrhal  laryngitis  with  an  unusual  amount  of  thickening 
and  infiltration  of  the  mucous  membrane  and  of  the  underlying  connective 
tissue,  so  as  to  produce  stenosis  and  obstruct  respiration,  may  be  mistaken  for 
pseudo-membranous  laryngitis.  In  the  New  York  Foundling  Asylum  two 
children  have  at  different  times  died  with  the  symptoms  of  membranous 
laryngitis,  and  the  obstruction  was  found  to  be  due  entirely  to  the  thicken- 
ing and  infiltration  of  the  mucous  and  submucous  tissues  of  the  larynx  by 
newly-formed  corpuscular  elements.  Of  course,  death  from  catarrhal  laryn- 
gitis is  rare,  but  that  this  disease  may  produce  such  an  amount  of  laryngeal 
stenosis  as  to  cause  even  fatal  dyspnoea,  like  that  from  the  presence  of  pseudo- 
membrane,  these  two  cases  show.  In  most  instances  the  diagnosis  of  mem- 
branous laryngitis  from  catarrhal  laryngitis  is  easy  by  the  presence  of  patches 
of  pseudo-membrane  On  the  fauces  or  by  the  history  of  the  case,  which  evi- 
dently points  to  diphtheria  as  the  cause.  In  the  case  alluded  to  above  a  child 
in  my  practice  died  with  the  symptoms  of  acute  laryngeal  stenosis,  without 
any  pseudo-membrane  upon  visible  parts  and  with  only  a  moderate  phar- 
yngitis. This  case,  which  might  have  passed  as  one  of  catarrhal  laryngitis 
accompanied  by  an  unusual  amount  of  cellular  and  serous  infiltration,  as  there 
was  no  known  diphtheria  in  the  vicinity,  was  really  due  to  diphtheria,  and 
was  a  local  manifestation  of  that  disease,  for  immediately  after  the  death  of 
the  patient  the  two  nurses  had  unequivocal  symptoms  of  diphtheria.  The 
difficulty  in  using  the  laryngoscope  in  young  children  is  such  when  their 
fauces  are  swollen  that  it  has  not  heretofore  afforded  much  aid  in  the  differ- 
ential diagnosis  of  the  various  forms  of  acute  laryngeal   stenosis,  at  least 


836  LOCAL  DISEASES. 

when  employed  by  the  general  practitioner.  By  microscopic  examination 
the  character  of  the  croup  can  be  asc-ertained  as  stated  elsewhere. 

Prognosis. — In  New  York  City,  during  the  fifteen  years  ending  with 
1878,  the  percentage  of  recoveries  was  very  small,  both  under  medicinal 
treatment  and  tracheotomy.  During  this  long  period,  surgeons,  not  saving 
more  than  3  to  5  per  cent,  of  their  cases  by  tracheotomy,  performed  this 
operation  reluctantly.  But  since  1878  the  percentage  of  deaths  after 
tracheotomy  has  been  reduced,  and  still  further  reduced  by  intubation.  The 
mortality  from  croup  is  greater  the  younger  the  patients,  for  the  younger 
the  child  the  less  the  diameter  of  the  air-passages  and  the  more  quickly 
laryngeal  stenosis  results.  The  younger  the  child,  also,  the  more  difl&cult  is 
the  use  of  the  proper  remedies,  and  the  less  the  time  for  their  use  before 
fatal  dyspnoea  occurs.  The  result  also  largely  depends  upon  whether  the 
physician  is  summoned  at  the  beginning  of  croup  and  appropriate  remedies 
are  early  and  persistently  employed.  In  many  instances  the  friends  do  not 
take  alarm  and  the  physician  is  not  summoned  till  the  disease  is  well  under 
headway,  and  there  is  not  the  requisite  time  for  efficient  treatment.  Ob- 
viously, also,  croup,  beyond  all  other  diseases,  requires  faithful  and  intelligent 
nurses,  for  without  the  co-operation  of  such  nurses  night  and  day  in  the  care 
of  the  patient  the  most  judicious  measures  are  often  inefficient. 

Treatment. — Preventive. — In  attending  a  case  of  inflammation  of  the 
upper  air-passages  the  physician  should  notice  at  each  visit  whether  the 
patient  have  any  hoarseness  or  other  signs  indicating  implication  of  the 
larynx,  since  if  the  danger  be  recognized  at  its  inception  it  may  perchance  be 
averted.  Ineffectual  as  inhalations  may  be  for  fully-declared  croup,  expe- 
rience fully  justifies  the  belief  that  they  are  sufficient  in  a  large  propor- 
tion of  cases  to  relieve  that  degree  of  laryngitis  which  is  indicated  by 
simple  hoarseness,  and  which  if  it  continue  might  eventuate  in  serious 
obstructive  disease.  If  the  physician  observe  such  symptoms,  he  should 
immediately  recommend  that  the  air  in  the  apartment  be  kept  moist  by  the 
croup-kettle  or  pans  of  hot  water,  rendered  alkaline  by  lime-water  or  sodium 
bicarbonate.  The  efficiency  of  this  treatment  is  increased  by  employing  a 
tent.  I  prefer,  however,  in  most  instances,  to  employ  the  steam-atomizer 
either  with  or  without  the  croup-kettle.  It  should  throw  a  heavy  and  con- 
tinuous spray  as  long  as  the  premonitory  symptoms  of  croup  continue.  It 
obviates  the  necessity  of  heating  the  apartment,  which  in  hot  weather  is  very 
uncomfortable. 

It  is  proper,  in  this  connection,  to  consider  which  is  the  most  efficient  and 
the  best  agent  for  inhalation  in  croup.  Have  we  an  agent  that  can  be  safely 
used,  which  will  prevent,  when  inhaled,  the  formation  of  the  pseudo-mem- 
brane, or  which  will  dissolve  it  when  it  has  already  formed  ?  The  agents 
which  have  been  most  employed  for  this  purpose  are  lime-water,  lactic  acid, 
pepsin,  and  trypsin. 

In  selecting  the  one  that  is  safest  and  most  efficient  the  important  fact 
should  be  borne  in  mind  that  anything  which  irritates,  so  as  to  increase  the 
inflammation  of  the  mucous  surface,  is  injurious.  Whatever  intensifies  the 
inflammation  evidently  augments  the  thickening  and  infiltration  of  the  mucous 
membrane  and  increases  the  area  as  well  as  thickness  of  the  pseudo-mem- 
brane. It  is  therefore  harmful  instead  of  beneficial.  The  teachings  of  Bre- 
tonneau  and  Trousseau  did  immense  harm  in  the  fact  that  they  brought  into 
use  agents  far  too  irritating  to  the  sensitive  mucous  surface.  Since  the 
pressing  danger  in  croup  arises  from  the  obstruction  produced  by  the  pseudo- 
membrane  and  by  the  thickening  and  infiltration  of  the  mucous  membrane 
underneath,  that  agent  is  indicated,  if  it  can  be  found,  which  loosens  and 
dissolves  the  pseudo-membrane,  and  at  the  same  time  tends  to  diminish,  or 


PSEUDO-MEMBRANOUS  CROUP.  837 

at  least  does  not  increase,  the  inflammation  of  the  underlying  tissues  by  its 
irritating  action.  Alkalies  exert  a  solvent  action  on  fibrin  and  mucin,  and 
as  the  pseudo-membrane  consists  of  the  exudate  from  the  blood  largely  fibrin- 
ous, and  of  epithelium  and  connective  tissue  which  have  undergone  degenera- 
tion into  a  substance  resembling  fibrin  (Wagner)  or  perhaps  mucin  (Cornil 
and  Ranvier),  their  employment  seems  to  rest  on  a  sound  therapeutic  basis. 
Lime-water  slightly  turbid,  but  not  so  turbid  as  to  clog  the  point  of  the 
steam-atomizer,  with  its  alkalinity  increased  by  the  addition  of  an  unirritat- 
ing  alkali,  as  sodium  bicarbonate,  may  be  used  almost  continuously  by  inhala- 
tion. Dr.  E.  M.  Moore  ^  of  Rochester  recommends  insufflation  of  sodium 
bicarbonate  as  an  active  solvent  of  the  pseudo-membrane.  It  possesses  this 
advantage — that  it  is  but  slightly  irritating,  so  that  it  can  be  used  in  sub- 
stance or  with  but  little  dilution.  For  this  reason  it  should  be  preferred  to 
lime-water,  which  is  in  more  common  use. 

Recently  I  have  employed  in  the  steam-atomizer  the  following  formula, 
with  good  results : 

Trypsin,  ^ij  ; 

Sodii  bicarbonat.,  ^ij  ; 

Aquse  calcis,  Oj. — Misce. 

Trypsin  may  be  advantageously  used  with  this  liquid,  but  trypsin  in  powder 
is  very  likely  to  clog  the  atomizer.  The  liquid  trypsin,  as  prepared  by  Fair- 
child,  should  therefore  be  employed  with  the  lime-water.  The  following  for- 
mula may  also  be  used  in  the  hand  atomizer : 

Trypsin,  _:5j  ; 

Sodii  bicarbonat.,  gr.  xx  ; 

Aquffi  destillat.,  ^ij. — Misce. 

In  some  instances  insufflation  of  the  following  powder,  as  stated  in  our 
remarks  on  diphtheria,  has  been  useful  as  a  solvent  of  pseudo-membrane  in 
the  air-passages : 

R.  Papoid,  -\ 

Ti\ypsin,  j-  da.  ^ss  ; 

Sodii  bicarbonat.,     J 
Suljihur  sublimat.,  3J. 

For  insufflation. 

By  the  persistent  and  timely  use  of  such  inhalations  as  soon  as  hoarse- 
ness appears  croup  can  be  often  prevented.  But  we  all  know  how  fre- 
quently, notwithstanding  our  best  endeavors,  croup  occurring  in  the  first 
week  of  diphtheria  grows  hourly  worse.  In  these  acute  and  rapid  cases 
inhalations  of  the  best  agents  which  physicians  have  hitherto  used  act  too 
slowly  to  prevent  the  growth  of  the  pseudo-membrane,  and  in  a  few  hours  it 
becomes  painfully  evident  that  something  more  must  be  done  or  the  life  of 
the  child  is  lost.  In  those  many  cases  in  which  diphtheria  is  ushered  in  with 
croupous  symptoms,  and  in  which  within  a  few  hours  laryngeal  stenosis 
begins  to  occur,  the  experienced  physician  sees  at  a  glance,  often  at  his  first 
visit,  that  inhalations,  however  faithfully  employed,  will  be  inadequate,  and 
that  sufi"ocation,  the  most  painful  of  all  modes  of  death,  will  be  inevitable 
unless  other  and  energetic  measures  are  used. 

On  the  other  hand,  in  the  milder  forms  of  croup,  in  which  the  exudation 
has  but  moderate  thickness  and  forms  slowly,  inhalations  are  of  the  greatest 
service,  and  aided  by  internal  remedies  they  not  infrequently  arrest  the  dis- 
ease and  save  life. 

Calomel  has  long  been  used  in  the  treatment  of  croup,  and  has  done 
1  Transactions  of  the  N.  Y.  Medical  Association,  1885. 


838  LOCAL  DISEASES. 

much  harm  in  this  as  well  as  many  other  diseases.  But,  properly  employed, 
it  is  one  of  the  most  efficient  and  useful  remedies  in  croup,  though  the  nurse 
and  attendants  incur  the  risk  of  severe  and  prolonged  salivation.  Calomel 
has  long  been  employed  in  the  treatment  of  croup  in  small  and  repeated 
doses,  so  as  to  keep  up  a  daily  purgation  with  an  increase  of  the  weakness. 
This  eifect  has  been  pernicious,  and  it  is  believed  has  increased  the  mortality. 

The  following  method  can  be  recommended  from  ample  experience  with 
it  in  Brooklyn,  where  it  originated,  and  in  New  York,  as  probably  the  most 
effectual  of  the  medicinal  remedies  to  arrest  the  formation  of  the  pseudo- 
membrane  and  aid  in  its  detachment.  A  tent  about  five  feet  in  height  is 
erected  over  the  bed  in  which  the  child  lies,  and  the  sublimation  of  10  to  15 
grains  of  calomel  is  produced  upon  a  tin  plate  over  an  alcohol  lamp  alongside 
the  bed,  and  the  fumes  are  received  within  the  tent.  The  vapor  is  very  pun- 
gent and  irritating,  and  under  a  closed  tent  cannot  be  used  without  danger 
of  salivation  longer  than  twenty  minutes,  and  oftener  than  three  or  four 
hours.  In  the  New  York  Foundling  Asylum,  although  this  treatment  has 
apparently  saved  the  lives  of  foundlings  haAung  croup,  the  adults  outside  the 
tent  were  so  severely  salivated  in  a  succession  of  cases  that  this  remedy  is  no 
longer  used  in  this  institution.  A  physician  of  New  York  was  so  severely 
salivated  by  holding  his  head  under  the  tent  some  hours,  though  his  patient 
lived,  that  he  was  an  invalid  for  some  months  afterward.  The  children,  so 
far  as  I  am  aware,  have  not  suffered  from  the  deleterious  eifeets  of  this  medi- 
cine, but  if  it  be  employed  the  adults  should  make  use  of  precautionary 
measures  for  their  own  safety. 

Emetics. — These  have  been  largely  used  in  all  forms  of  croup,  and  in 
catarrhal  or  spasmodic  croup  they  usually  produce  some  relief.  Formerly, 
emetics  were  much  employed  in  the  treatment  of  membranous  croup,  but 
now  that  diphtheria  has  spread  throughout  the  country,  and  most  cases  of 
this  form  of  croup  occur  in  patients  suffering  from  diphtheritic  blood-poison- 
ing, depressing  emetics,  as  ipecacuanha  and  antimony,  have  fallen  into  disuse. 
In  my  practice  a  child  of  ten  years  with  severe  diphtheria  and  with  com- 
mencing croupy  symptoms  sank  rapidly  and  died  between  two  of  my  visits 
from  exhaustion  produced  by  a  single  large  dose  of  ipecacuanha  administered 
by  anxious  parents  without  my  advice. 

An  emetic  may  give  partial  relief  to  the  dyspnoea  in  certain  cases,  since  it 
assists  in  expelling  the  muco-pus  which  blocks  up  the  tubes  below  the  pseudo- 
membrane,  and  sometimes  portions  of  pseudo-membrane,  which  are  easily 
detached.  But  although  there  may  be  occasional  advantages  from  an  emetic, 
they  are  in  most  instances  more  than  counterbalanced  by  the  disadvantages, 
especially  the  prostration  which  results.  If  an  emetic  be  employed,  one 
should  be  selected  which  acts  promptly  with  but  little  depression,  and  as  a 
rule  it  should  only  be  used  at  the  commencement  of  croup. 

Surgical  Treatment. — Although  the  best  possible  treatment  by  inhala- 
tions and  internal  medication  be  early  employed  and  without  intermission, 
yet  it  is  the  common  experience  in  all  countries  that  such  treatment  is  in  a 
large  proportion  of  cases  inadequate,  and  that  many  perish  from  suffocation 
unless  relieved  by  surgical  interference.  We  have  stated  above  that  if 
croup  occur  at  the  commencement  of  diphtheria,  when  the  exudative  process 
is  active  and  the  pseudo-membranes  form  rapidly  and  abundantly,  death  is 
the  common  result  if  the  medicinal  treatment  only  be  employed.  But  if 
the  inflammation  be  less  intense  or  subacute,  as  in  the  second  week  in  diph- 
theria, so  that  there  is  more  time  for  the  action  of  medicines  and  inhalations, 
and  if,  as  is  sometimes  the  case,  the  stenosis  appears  to  be  at  a  standstill, 
without  any  marked  suffering  from  want  of  air,  resort  to  surgical  measures 
may  be  judiciously  postponed. 


INTUBATION.  839 

The  indications  for  surgical  interference  are  a  gradual  increase  of  the 
stenosis  and  consequent  dyspnoea,  notwithstanding  the  constant  and  judicious 
use  of  remedial  agents,  and  a  manifest  suffering  from  want  of  air,  as  shown 
by  restlessness  of  the  child  and  the  expression  of  suffering,  in  his  features, 
with  or  without  lividity  of  the  surface.  We  adults  may  have  some  faint 
conception  of  the  suffering  which  children  with  acute  laryngeal  stenosis 
undergo  when  we  have  severe  nasal  catarrh  and  attempt  to  breathe  with  the 
mouth  closed ;  and  the  paramount  duty  of  the  physician  to  relieve  suffer- 
ing should  prompt  a  resort  to  other  measures  when  medicines  prove  inade- 
quate, even  if  we  leave  out  of  account  the  important  object  of  saving  life. 
When,  therefore,  membranous  croup  is  found  to  be  progressive  after  having 
been  observed  and  properly  treated  from  sis  to  twenty-four  hours,  and  the 
child  begins  to  suffer  from  want  of  air,  the  propriety  of  surgical  measures 
should  be  considered. 


CHAPTER    V. 

INTUBATION. 

The  most  important  improvement  made  in  recent  years  in  the  treatment 
of  croup  is  intubation,  for  which  the  profession  is  indebted  entirely  to  the 
genius  and  perseverance  of  Dr.  Joseph  O'Dwyer.  Intubation  is  destined  in 
the  future  to  prevent  an  immense  amount  of  suffering  in  the  various  forms 
of  laryngeal  stenosis.  It  has  rescued,  and  will  rescue,  multitudes  of  chil- 
dren from  a  most  painful  death  by  suffocation.  It  is  an  operation  of  remark- 
able simplicity,  quickly  performed,  without  the  use  of  anaesthetics  and  with- 
out pain  to  the  patient.  In  this  respect  it  contrasts  strikingly  with  laryn- 
gotomy  or  tracheotomy,  which  is  a  painful  and  bloody  operation,  and  which, 
for  its  proper  performance,  requires  more  or  less  delay.  Those  who  have 
witnessed  the  slow  suffocation  of  children  in  membranous  croup  and  catarrhal 
croup  when  accompanied  by  oedema  and  infiltration  can  best  appreciate  the 
value  of  intubation. 

In  1858,  Bouchut  published  a  paper  on  the  treatment  of  croup  by  intu- 
bation of  the  larynx.  He  employed  a  straight  cylindrical  tube  nearly  an 
inch  long.  The  tube  was  introduced  by  means  of  a  male  catheter  open  at  its 
two  ends.  Intubation  excited  some  attention  and  discussion  at  the  time  in 
the  Parisian  capital,  and  M.  Gross  related  a  case  of  its  successful  employment. 
But,  performed  with  such  rude  instruments,  it  met,  as  might  be  expected, 
with  strong  opposition  from  the  first  by  such  men  as  Barthez  and  Trousseau, 
who  were  bringing  forward  tracheotomy,  and  it  soon  fell  into  disuse  and  was 
forgotten.  It  was  reserved  for  American  surgery  to  achieve  the  honor  of  its 
successful  employment.  Dr.  O'Dwyer,  wholly  ignorant  of  the  previous  his- 
tory of  intubation,  after  many  measurements  of  the  larynx  of  the  cadaver, 
many  discouragements,  and  many  modifications  in  the  tubes  to  facilitate  their 
introduction  and  retention,  has  so  improved  them  that  the  objection  to  their 
use  strongly  urged  by  Trousseau  thirty  years  ago,  that  they  caused  ulcera- 
tion, is  inapplicable  to  the  tubes  now  in  use.  Dr.  O'Dwyer  has  kindly  con- 
tributed the  following  paper  descriptive  of  this  operation : 

Intubation. 

By  Joseph  O'  Dwtter,  M.  D. 

In  the  following  pages  I  will  confine  myself  to  the  practical  details  of  this 
operation  as  applicable  to  those  forms  of  stenosis  of  the  larynx  that  occur 


840  LOCAL  DISEASES. 

almost  exclusively  in  children.  The  reader  is  referred  to  the  appropriate  sec- 
tions of  this  book  for  information  in  regard  to  the  diagnosis,  medical  treat- 
ment, etc.  of  croup  and  kindred  diseases. 

A  very  serious  impediment  to  the  success  of  intubation,  and  one  for  which 
there  is  no  remedy,  arises  from  the  large  number  of  grossly-imperfect  instru- 
ments that  are  constantly  being  made  and  sold  as  the  latest  improvements. 
I  will  therefore  first  endeavor  to  point  out  some  of  the  grosser  defects  referred 
to,  in  order  that  every  one  who  uses  these  tubes  may  be  able  to  distinguish 
the  good  from  the  bad. 

The  most  common  defect,  and  at  the  same  time  the  one  attended  with  the 
most  serious  consequences,  is  apparently  so  insignificant  that  it  is  often  over- 
looked by  the  manufacturers,  even  after  their  attention  has  been  repeatedly 
called  to  it.  It  results  from  filing  the  metal  so  thin  on  the  anterior  surface 
of  the  distal  extremity  as  to  produce  a  cutting  edge  at  this  point.  It  should 
be  remembered  that  this  part  of  the  tube  is  not  only  in  contact  with  the  ante- 
rior wall  of  the  trachea,  but  that  it  also  moves  up  and  down  over  a  space  of 
about  half  an  inch  during  every  act  of  swallowing.  This  position  is  pro- 
duced by  the  backward  pressure  of  the  base  of  the  tongue,  which  pushes  the 
epiglottis  and  the  upper  extremity  of  the  tube  before  it  with  considerable 
force,  tilting  the  lower  extremity  forward,  which  glides  upward  as  the  larynx 
is  raised  and  the  trachea  stretched,  to  fall  back  to  what  may  be  called  its  res- 
piratory position  as  soon  as  the  act  of  swallowing  is  completed. 

If  sharp,  or  even  in  the  slightest  degree  rough,  at  the  point  indicated,  a 
proportionate  degree  of  injury  will  be  inflicted  on  the  mucous  membrane, 
sometimes  amounting  to  a  deep  ulcer,  which  adds  to  the  danger  of  systemic 
infection  and  gives  rise  to  painful  deglutition  and  bloody  expectoration. 

In  the  perfect  tube  the  metal  on  the  autei'ior  surface  is  left  quite  thick 
and  smoothly  rounded  off  like  the  runner  of  a  sled,  so  that  it  will  glide  up 
and  down  over  the  tissues  without  injuring  them.  As  the  distal  extremity 
of  the  tube  seldom  impinges  on  the  posterior  wall  of  the  trachea,  and  never 
touches  the  sides,  the  metal  at  these  points  should  be  comparatively  thin,  to 
avoid  increasing  the  size,  but  the  whole  should  form  a  perfectly  smooth  probe- 
point  when  the  obturator  is  in  position.  If  the  obturator  do  not  project  far 
enough  beyond  the  end  of  the  tube  or  if  it  fit  imperfectly,  the  sharp  edges 
will  be  left  unprotected,  which  will  injure  the  tissues  while  passing  through 
the  narrowed  glottis. 

The  metal  is  also  left  thick  on  the  anterior  surface  of  the  upper  extrem- 
ity, in  order  to  prevent  the  formation  of  a  cutting  edge  under  the  epiglottis. 
The  head  or  shoulder  of  the  tube  which  rests  in  the  vestibule  of  the  larynx, 
and  which  is  compressed  by  the  action  of  the  constrictor  muscles  in  every 
act  of  swallowing,  should  be  absolutely  free  from  any  roughness  or  projecting 
angles  or  edges.  This  portion  of  the  tube,  about  a  quarter  of  an  inch  in 
length,  has  a  backward  curve  to  carry  it  away  from  the  base  of  the  epiglottis, 
where  a  perfectly  straight  tube  would  be  liable  to  produce  ulceration. 

Another  very  common  defect  is  the  imperfect  fitting  of  the  obturator, 
which  allows  the  tube  to  wabble  when  attached  to  the  introducer,  and  causes 
it  to  slip  off  if  the  operator  fail  to  place  it  in  the  larynx  on  the  first  attempt. 
The  instrument-makers  find  it  very  difficult  to  overcome  this  defect,  owing  to 
the  joint  in  the  shank  of  the  obturator  and  the  backward  curve  that  exists  in 
the  upper  portion  of  the  tube. 

If  properly  made,  the  tube  when  attached  to  the  introducer  and  ready 
for  use  should  be  as  free  from  motion  as  if  constructed  of  one  piece. 

I  have  also  noticed  in  many  of  the  sets  of  instruments  otherwise  perfect 
that  the  lines  indicating  the  years  on  the  scales  do  not  correspond  to  the 
length  of  the  tubes,  which  renders  it  difficult  for  a  beginner  to  select  the 


INTUBATION. 


841 


proper  size.  By  observing  the  following  rule  the  scale  can  be  dispensed 
with :  The  smallest  size  is  suitable  for  the  first  year  of  life,  the  second  for 
the  second  year,  the  third  size  for  from  two  to  four  years,  and  the  others  for 
two  years  each. 

A  set  of  intubation  instruments  suitable  for  children  up  to  the  age 
of  puberty  consists  of  six  tubes,  an  introducer  (1)  and  extractor  (3),  a 
mouth-gag  (2),  and  a  scale  of  years  (4)  ;   6,  introducer  and  tube ;  7,  a  large 

Fig.  237. 


Intubation  instruments. 


round  tube  used  for  the  expulsion  of  membrane.  Each  tube  is  supplied  with 
a  separate  obturator,  one  end  of  which  screws  on  to  the  introducer,  while 
the  other  extends  sufl&ciently  beyond  the  distal  extremity  of  the  tube  to 
convert  the  whole  into  a  probe-point.  The  numbers  on  the  scale  represent 
years,  and  indicate  approximately  the  ages  for  which  the  corresponding  tubes 
are  suitable.  For  example,  the  smallest  size  when  applied  to  the  scale,  in- 
cluding the  head  or  shoulder,  will  reach  the  line  marked  1,  and  is  suitable 


842  LOCAL  DISEASES. 

for  the  first  year  of  life,  but  raay  be  used  up  to  fifteen  or  eighteen  months  if 
the  child  is  small  for  its  age. 

The  next  size,  which  reaches  the  line  marked  2,  is  intended  for  children 
between  one  and  two  years,  but  may  be  used  up  to  three  years,  the  only 
objection  being  that  it  is  liable  to  be  coughed  out.  The  third  size,  marked 
3—1  on  the  scale,  should  be  used  between  the  ages  of  two  and  four  years ; 
and  so  on. 

The  largest  tube  in  the  set  may  be  used  in  the  early  years  of  adolescence 
by  having  a  string  attached,  but  is  of  no  use  in  the  adult  larynx,  as  it  would 
either  be  expelled  immediately  or  pass  through  into  the  trachea. 

When  the  proper  tube  for  the  age  is  coughed  out,  there  is  always  room 
for  the  next  larger  size.  In  one  case,  of  an  infant  aged  twenty  months,  in 
which  the  two-year-old  tube  was  twice  expelled,  I  was  obliged  to  insert  the 
3—4  size. 

Indications  for  Intubation. — As  the  indications  for  this  operation  are  the 
same  as  for  tracheotomy,  the  reader  is  referred  to  the  proper  section  of  this 
work  for  information  on  this  subject. 

31ethod  of  Operating. — A  tube  of  proper  size  for  the  age  is  first  selected, 
and  strong  silk  or  linen  thread  passed  through  the  eyelet  intended  for  this 
purpose.  In  case  the  tube  is  placed  in  the  oesophagus  instead  of  the  larynx, 
it  quickly  passes  into  the  stomach,  drawing  the  string  with  it,  unless  the 
latter  be  held.  To  guard  against  this  accident,  therefore,  the  thread  should 
be  left  long  enough  to  reach  the  stomach  and  still  protrude  from  the  mouth. 

The  obturator  is  then  screwed  tightly  to  the  introducer  and  passed  into 
the  tube  when  it  is  ready  for  use.  The  antero-posterior  or  long  diameter  of 
the  tube  should  then  be  in  a  line  with  the  handle  of.  the  introducer.  If  the 
obturator  be  found  to  turn  too  far  to  bring  it  in  this  position,  which  usually 
occurs  after  having  been  used  for  some  time,  a  washer  of  writing-paper  of 
one  or  more  thicknesses  can  be  added. 

It  is  always  advisable  to  push  the  tube  oif  once  or  twice  before  inserting 
it,  to  be  certain  that  it  works  easily.  The  person  who  holds  the  child  should 
be  seated  on  a  solid  chair  with  low  back,  and  the  patient  placed  on  the  lap 
with  its  head  resting  on  the  left  shoulder  of  the  nurse  to  avoid  interference 
with  the  gag.  The  hands  may  either  be  held  or  secured  by  the  sides  by 
passing  a  towel  or  napkin  around  the  body,  and  retained  in  that  position  until 
the  tube  is  inserted  and  the  string  removed.  Failure  to  pay  particular  atten- 
tion to  this  precaution  is  often  the  cause  of  much  annoyance  to  the  operator, 
for  if  the  child  gets  its  hands  free  for  an  instant,  it  seizes  the  thread  and 
removes  the  tube.  Fastening  the  hands  in  front  of  the  chest  or  thick  gar- 
ments in  the  same  location  are  objectionable,  as  they  render  it  difficult  to 
depress  the  handle  of  the  introducer  sufficiently  to  carry  the  tube  over  the 
dorsum  of  the  tongue. 

The  gag  should  be  inserted  in  the  left  angle  of  the  mouth,  well  back, 
between  or  behind  the  teeth  if  practicable,  and  opened  as  widely  as  possible 
without  using  too  much  force.  In  children  who  have  not  at  least  one  double 
tooth  on  the  left  side  the  gag  should  not  be  used,  as  it  slides  forward  on  the 
gums,  and,  besides  being  in  the  way,  is  likely  to  injure  the  incisor  teeth. 
There  is  little  difficulty  in  keeping  the  mouth  sufficiently  open  with  the 
finger,  and  no  danger  of  being  bitten  if  it  be  kept  well  to  the  patient's  right. 
The  necessity  of  using  force  is  obviated  by  allowing  the  child  to  compress 
the  finger  for  a  few  seconds  until  the  jaws  relax  before  carrying  back  into 
the  pharynx.  The  Denhard  gag,  which  is  shown  in  the  cut,  holds  better 
than  the  one  originally  devised  by  the  author,  and  seldom  slips  if  properly 
placed. 

An  assistant,  standing  behind,  holds  the  head  firmly  by  placing  one  hand 


INTUBATION. 


843 


on  either  side,  and,  if  without  experience,  should  be  requested  not  to  touch 
the  gag.  The  operator,  either  standing  or  sitting  in  front  of  the  patient,  the 
former  position  being  preferable,  holds  the  introducer  lightly  between  the 
thumb  and  fingers  of  the  right  hand,  with  the  thumb  resting  just  behind  the 
button  that  serves  to  detach  the  tube,  and  the  index  finger  in  front  of  the 
trigger-support  underneath.  Held  in  this  position,  it  is  impossible  to  use 
force  enough  to  make  a  false  passage,  while  if  firmly  grasped  in  the  hand  the 
beginner  is  very  liable  to  lacerate  the  tissues. 


Fig.  238. 


Intubation  of  the  larynx. 

The  index  finger  of  the  left  hand  is  now  quickly  passed  well  down  in  the 
pharynx  or  beginning  of  the  oesophagus,  and  then  brought  forward  in  the 
median  line,  raising  and  fixing  the  epiglottis,  while  the  tube  is  guided  beside 
the  finger  into  the  larynx. 

If  any  difficulty  be  experienced  in  feeling  the  epiglottis,  it  is  better  to 
seek  the  cavity  of  the  larynx,  a  cul-de-sac  into  which  the  tip  of  the  finger 
readily  enters,  and  which  cannot  be  mistaken  for  anything  else.  Once  in  this 
Cavity,  the  epiglottis  mvist  be  in  front  of  the  finger,  and  the  latter  is  then 
raised  and  carried  to  the  patient's  right  in  order  to  leave  room  for  the  tube 
to  pass  beside  it.  As  the  larynx  contracts  when  touched,  thereby  diminish- 
ing its  aperture,  it  is  necessary  to  keep  the  distal  extremity  of  the  tube  close 
to  the  finger,  or  even  directing  it  a  little  obliquely  to  the  right  in  order  to  get 
inside  the  left  aryepiglottic  fold.  This  is  particularly  important  in  very  young 
children,  in  whom  the  tip  of  the  finger  completely  covers  the  larynx. 

In  the  beginning  of  the  operation  the  handle  of  the  introducer  is  held 
close  to  the  patient's  chest,  and  rapidly  raised  as  the  lower  end  of  the  tube 
passes  behind  the  epiglottis ;  otherwise,  it  slips  over  the  larynx  into  the 
oesophagus. 

When  the  tube  is  inserted,  it  is  slipped  off"  by  pressing  forward  the  button 
on  the  upper  surface  of  the  handle  with  the  thumb,  while  counter-pressure 


844  LOCAL  DISEASES. 

is  made  by  the  index  finger  underneath.  In  removing  the  obturator  the  tube 
must  be  held  down  by  placing  the  finger  either  on  the  side  or  posterior  por- 
tion of  the  shoulder.  The  tube  should  be  carried  well  down  before  being 
detached,  otherwise  it  is  liable  to  become  occluded  with  false  membrane  when 
subsequently  pushed  home  with  the  finger.  When  the  tube  is  in  place  the 
gag  is  removed,  but  the  string  is  allowed  to  remain  for  about  ten  minutes, 
or  until  it  is  ascertained  with  certainty  that  the  dyspnoea  is  i-elieved  and  that 
no  loose  membrane  is  present  in  the  lower  portion  of  the  trachea. 

In  removing  the  thread  the  finger  must  be  reinserted  to  hold  the  tube 
down,  but  the  reinsertion  of  the  gag  is  rarely  necessary  for  this  purpose. 
The  extraction  of  the  tube  is  much  the  more  diflB.cult  operation,  and  at  the 
same  time  the  more  dangerous  as  far  as  injury  to  the  larynx  is  concerned. 
The  patient  is  held  in  the  same  position  as  for  insertion,  and  the  extractor  is 
guided  along  beside  the  finger,  which  is  first  brought  in  contact  with  the  head 
of  the  tube,  and  then  carried  to  the  right  in  order  to  uncover  the  aperture  and 
leave  room  for  the  instrument  to  enter  beside  it. 

Before  inserting  the  extractor  it  should  be  ascertained  with  certainty  that 
the  tube  is  still  in  the  larynx.  This  can  be  determined  by  the  tubal  charac- 
ter of  the  cough,  which  is  characteristic,  the  difiiculty  of  swallowing,  and, 
lastly,  by  the  sense  of  touch  if  necessary. 

Difficulties  of  the  Operation. — Few  who  have  not  practised  intubation 
recognize  the  fact  that  it  is  a  difficult  operation  to  perform,  and  that  it  is 
difficult  simply  because  it  must  be  done  quickly  and  at  the  same  time  gently. 
Sufficient  dexterity  to  fulfil  both  of  these  requirements  can  only  be  acquired 
by  a  great  deal  of  practice,  and  if  this  be  gained  on  the  living  subject  it  must 
be  at  the  expense  of  a  great  deal  of  unnecessary  suff"ering  and  the  sacrifice 
of  many  lives  as  well.  It  is  the  sense  of  touch  alone  that  is  to  be  relied 
upon,  and  that  requires  to  be  educated ;  consequently,  the  accomplished 
laryngologist  who  has  only  educated  his  sense  of  sight  is  no  more  competent 
to  perform  the  operation  than  one  who  has  never  seen  the  larynx  in  its  nor- 
mal position. 

The  operator  has  so  many  movements  to  make,  involving  both  hands,  in 
such  a  brief  space  of  time  that  unless  he  have  had  sufficient  practice  to  make 
some  of  these  movements  to  a  certain  extent  automatic,  he  cannot  operate 
with  safety  to  his  patient  nor  with  credit  to  himself.  The  epiglottis  must  be 
found,  raised,  and  held  in  this  position  as  the  tube  is  glided  down  in  contact 
with  the  finger,  otherwise  the  operator  does  not  know  where  it  is ;  it  has  to 
be  slipped  off"  at  the  right  moment,  and  held  down  while  the  obturator  is 
being  removed  ;  and  to  be  safe  all  these  movements  must  be  completed  in  less 
than  ten  seconds. 

Intubation  should  therefore  never  be  attempted,  except  in  case  of  emer- 
gency, without  some  preliminary  practice,  either  on  the  cadaver,  on  one  of  the 
smaller  animals,  or  on  a  larynx  removed  from  the  body.  Let  the  beginner 
who  has  never  performed  either  operation  choose  tracheotomy  rather  than 
intubation,  as  being  the  safer,  because  in  the  former  he  can  see  what  he  is 
doing  and  his  patient  can  breathe  during  the  progress  of  the  operation.  Prac- 
tice on  a  child's  cadaver  is  within  the  reach  of  comparatively  few,  but  it  can 
be  done  on  that  of  one  of  the  smaller  animals,  such  as  a  cat  or  dog,  with  prac- 
tically the  same  result — -viz.  education  of  the  sense  of  touch  and  automatism 
in  some  of  the  movements. 

In  addition  to  a  moderate  amount  of  this  kind  of  practice,  every  young 
operator  should  keep  a  small  larynx  in  preservative  fluid  on  which  he  can 
continue  to  practise  at  frequent  intervals  by  placing  it  upright  in  the  neck 
of  a  bottle  or  other  receptacle  in  the  same  relative  position  which  it  occupies 
in  the  body. 


INTUBATION.  845 

There  is  no  doubt  that  dexterity  in  the  use  of  these  instruments  can  be 
acquired  in  this  manner ;  and  this  is  particularly  important  in  extracting  the 
tube,  which  is  so  difficult  to  do  without  injuring  the  larynx. 

The  difficulty  sometimes  experienced  in  intubating  older  children  who 
offer  resistance  is  to  a  great  extent  obviated  by  placing  their  legs  between 
the  knees  of  the  person  acting  as  nurse  and  holding  them  firmly  in  that 
position. 

Accidents  and  Dangers  of  Intubation. — The  most  serious  of  the  avoidable 
accidents  attending  this  operation  is  asphyxia,  from  holding  the  finger  too 
long  in  the  throat.  It  should  be  remembered  that  when  intubation  is  called 
for  the  patient  is  getting  very  little  air,  and  can  afford  to  dispense  with  this 
little  only  for  a  very  short  time  without  danger  to  life.  After  the  insertion 
of  the  gag  an  expert  can,  as  a  rule,  place  a  tube  in  the  larynx  in  five  seconds 
or  less,  and  without  any  shock  worth  considering.  The  novice,  on  the  con- 
trary, having  so  many  other  things  to  occupy  his  attention,  is  very  liable 
to  forget  how  long  his  finger  has  been  in  the  throat,  and  that  during  this 
time  respiration  is  practically  suspended.  A  fatal  issue  under  these  circum- 
stances is  almost  invariably  attributed  to  pushing  down  membrane,  which 
is  not  a  common  accident,  and  has  never  proved  immediately  fatal  in  my 
hands. 

There  is  seldom  any  danger  from  repeated  failures  to  intubate,  provided 
the  finger  be  not  retained  in  the  pharynx  longer  than  ten  seconds  at  a  time, 
and  the  child  be  given  a  chance  to  get  its  breath  between  the  attempts. 

It  is  well  for  the  beginner  always  to  have  another  physician  present, 
who  while  holding  the  head  will  watch  the  patient  closely  and  be  prepared 
to  give  some  prearranged  signal  to  stop  when  he  thinks  there  is  danger  of 
asphyxia. 

The  ventricles  of  the  larynx  seldom  offer  any  obstruction  to  the  entrance 
of  the  tube,  as  they  are  usually  obliterated  by  the  swollen  mucous  mem- 
brane and  covered  over  by  the  fibrinous  deposit  in  croup  ;  but  this  should  be 
remembered  if  any  resistance  be  encountered,  as  it  does  not  require  much 
force  to  make,  a  false  passage  at  these  points. 

Pushing  down  a  mass  of  pseudo-membrane  before  the  tube  is  the  most 
serious  of  the  unavoidable  accidents  attending  intubation  in  croup.  In  the 
majority  of  cases  the  offending  membrane  is  expelled  on  the  withdrawal  of 
the  tube,  if  the  latter  be  inserted  quickly  and  as  quickly  removed  when  the 
respiration  is  found  to  be  suspended ;  and  even  if  none  be  expelled,  the 
patient  is  in  no  worse  condition  than  he  was  in  before  the  operation. 

I  have  devised  and  tried  various  instruments  for  the  removal  of  pseudo- 
membrane  from  the  trachea,  but  I  have  found  short  cylindrical  tubes  of  large 
calibre  the  most  successful.  Being  short,  they  do  not  accumulate  masses  of 
membrane  before  them,  and,  while  overcoming  the  obstruction  in  the  glottis, 
afford  relief  to  the  dyspnoea  where  the  long  tubes  fail.  They  are  only 
intended  for  temporary  use,  as,  owing  to  their  large  size,  extensive  ulcera- 
tion would  result  if  long  retained.  The  string  should  be  left  attached  and 
secured  behind  the  ear,  by  which  the  tube  can  be  removed  at  the  end  of  four 
or  five  hovirs  whether  any  false  membrane  be  expelled  or  not.  The  amount 
of  dilatation  from  the  pressure  accomplished  in  this  time  will  usually  secure 
several  hours  of  relief  from  dyspnoea  and  give  ample  time  for  the  physician 
to  reach  the  patient  and  reintubate,  if  necessary.  Should  the  offending 
membrane  still  be  retained,  it  is  better  to  use  the  same  tube  on  the  recur- 
rence of  dyspnoea  than  to  again  run  the  risk  of  producing  apnoea  by  insert- 
ing the  long  one  ;  otherwise  the  latter  is  preferable. 

These  tubes  (Fig.  237,  7)  have  no  retaining  swell,  the  size  alone  being 
sufficient  to  retain  them.     The  metal  of  which  they  are  constructed  is  made 


846  LOCAL  DISEASES. 

very  thin,  in  order  to  have  as  hirge  a  lumen  as  possible,  and  they  can  also  be 
used  to  facilitate  the  expulsion  of  foreign  bodies  from  the  lower  air-passages. 
Under  these  circumstances  they  can  be  left  in  position  for  a  much  longer 
time  without  danger  from  pressure,  because  the  mucous  membrane  of  the 
larynx  is  in  the  normal  condition. 

A  separate  introducer  with  long  curve  is  necessary  for  these  tubes  in 
order  to  carry  them  well  through  the  subglottic  division  of  the  larynx  before 
removing  the  obturator. 

Danger  of  Asphyxia  from  Loose  llembrane  heloio  the  Tube. — The  ex- 
istence of  loose  membrane  below  the  tube — that  is,  in  the  lower  portion  of 
the  trachea — usually  gives  rise  to  the  following  signs :  A  flapping  sound  with 
the  respiratory  movements,  a  hoarse  or  croupy  character  of  the  cough,  and 
obstructed  expiration,  especially  when  forced,  as  in  the  act  of  coughing.  In 
some  cases  there  is  no  difficulty  while  the  breathing  is  quiet,  but  the  egress 
of  air  is  completely  cut  ofi"  with  the  first  attempt  at  coughing.  The  vis  a 
tergo  thus  developed  is  often  sufficient  to  eaiise  the  expulsion  of  both  tube 
and  pseudo-membrane,  but  this  does  not  always  occur,  and  precautions  should 
be  taken  to  avoid  the  danger  of  sudden  death  from  this  cause. 

The  safest  plan  is  to  leave  a  string  attached,  by  which  any  one  who  is 
present  can  remove  the  tube  in  case  of  threatened  asphyxia.  Should  this 
not  be  practicable,  owing  to  the  age  or  from  other  causes,  a  smaller  tube  than 
that  indicated  by  the  scale  of  years  should  be  used,  which  would  be  more 
likely  to  be  coughed  out  in  the  event  of  its  sudden  occlusion.  Either  of 
these  methods  should  be  resorted  to  if  the  symptoms  of  loose  membrane  in 
the  lower  part  of  the  trachea,  absent  at  the  time  of  operation,  subsequently 
show  themselves. 

Premature  expulsion  of  the  tube  seldom  occurs  when  the  proper  size  has 
been  used,  and  is  rarely  attended  with  danger,  provided  the  patient  be  within 
easy  reach. 

Dangers  of  Extraction. — Cases  have  been  reported  in  which  the  tubes  as 
now  made,  with  large  heads,  have  passed  through  into  the  trachea.  This 
accident  can  only  occttr  when  the  tissues  of  the  larynx,  cartilages  included, 
have  been  extensively  lacerated  by  the  extractor  by  passing  it  down  on  the 
outside  of  the  tube  and  withdrawing  it  with  force.  This  danger  has  been 
minimized  to  a  great  extent  by  the  addition  of  a  regulating  screw  to  the 
extractor,  which  prevents  the  blades  from  opening  any  wider  than  is  necessary 
to  hold  the  tube  firmly. 

No  force  is  necessary  to  remove  a  tube  from  the  larynx,  and  if  any 
appreciable  resistance  be  encountered,  it  is  pretty  certain  that  the  instrument 
is  caught  in  the  tissues.  Severe  hemorrhage  often  results  from  a  very  moder- 
ate laceration  produced  in  this  manner. 

When  the  Tube  should  be  Removed. — In  a  large  number  of  recoveries 
following  intubation  in  croup  the  average  time  the  tube  was  retained 
amounted  to  five  days.  The  longest  time  in  my  own  practice  was  twenty- 
nine  days.  The  older  the  child,  as  a  rule,  the  sooner  it  can  be  dispensed 
with.  In  very  young  children,  when  progressing  favorably  or  if  the  patient 
be  not  within  easy  reach,  it  is  better  to  leave  it  in  position  for  seven  or  eight 
days.  The  frequent  removal  of  the  tube,  unless  specially  indicated  by  a 
recurrence  of  the  dyspnoea  or  for  other  cause,  is  bad  practice,  principally 
because  of  the  irritation  produced  on  each  occasion.  In  protracted  cases,  in 
which  the  dyspnoea  returns  soon  after  the  second  or  third  removal  at  regular 
intervals  of  four  or  five  days,  it  is  safer  to  leave  it  in  position  continuously 
for  two  or  three  weeks,  unless  some  special  indication  for  its  removal  arises 
in  the  interim.  If  the  tube  be  properly  constructed  and  well  plated,  it  will 
•do  no  harm  when  retained  for  this  length  of  time. 


INTUBATION.  847 

Management  after  Intubation. — One  of  the  greatest  advantages  of  intuba- 
tion ovei"  tracheotomy  is  the  fact  that  no  skilled  nursing  is  required  after  the 
operation.  The  most  important  part  of  the  after-treatment  consists  in  getting 
the  patient  to  take  a  sufficient  amount  of  nourishment.  The  difficulty  here- 
tofore experienced  in  this  matter  has  been  greatly  reduced  by  the  method 
suggested  by  Dr.  W.  E.  Casselberry  of  Chicago.  It  consists  in  feeding  while 
the  patient's  head  is  lower  than  the  body.  By  this  means  advantage  is  taken 
of  gravitation,  thus  allowing  any  fluid  that  may  have  entered  the  tube  to 
escape  without  the  act  of  coughing.  The  little  patient  soon  learns  this,  and 
ceases  to  object  to  the  uncomfortable  position.  For  very  young  children  at 
least  the  best  position  is  lying  on  the  back  across  the  lap,  with  the  head 
hanging  well  below  the  level  of  the  body,  and  feeding  from  a  spoon  or  bottle. 
Older  children  may  be  allowed  to  assume  any  position  they  wish,  provided 
the  head  be  lower  than  the  chest. 

Fig.  239. 


Feeding  in  the  upright  position  should  always  be  by  spoon,  at  least  for 
the  first  two  or  three  days,  and  the  patient  be  given  time  and  encouraged  to 
cough  between  the  acts  of  swallowing.  By  this  means  any  danger  from  the 
entrance  of  food  is  obviated.  Nourishment  in  the  solid  and  semi-solid  forms 
— which  are  swallowed  better  than  liquids — should  be  given  the  preference 
when  children  can  be  induced  to  take  them. 

Rectal  feeding  is  rarely  necessary,  but  when  resorted  to  the  food  should 
be  given  in  small  quantities — not  over  two  ounces — and  at  intervals  of  three 
or  four  hours. 

No  food  or  medicine  should  be  given  for  two  or  three  hours  after  intuba- 
tion, unless  the  presence  of  the  tube  fail  to  excite  sufficient  cough  to  get  rid 
of  accumulated  secretions.  It  is  principally  by  the  act  of  coughing  that  the 
tube  is  kept  clear,  and,  if  this  does  not  occur  voluntarily,  it  may  be  excited  by 


848  LOCAL  DISEASES. 

giving  some  irritating  substance,  such  as  carbonate  of  ammonia,  brandy  strong 
or  slightly  diluted,  etc.  If  this  plan  be  adopted  and  the  air  of  the  room  be 
kept  well  saturated  with  warm  vapor,  it  will  rarely  be  found  necessary  to 
remove  a  tube  for  the  purpose  of  cleaning  it.  The  presence  of  a  tube  in  the 
larynx  does  not  contraindicate  the  use  of  an  emetic,  which  is  sometimes 
necessary  when  the  bronchi  are  loaded  with  secretions. 


CHAPTER    VI. 

TRACHEOTOMY. 

Prior  to  the  employment  of  intubation  by  O'Dwyer  tracheotomy  was  one 
of  the  most  important  operations  in  surgery.  Properly  performed  and  at  the 
proper  time,  with  judicious  after-treatment,  it  has  rescued  many  children 
from  a  most  painful  death.  The  details  of  this  operation  are  given  in  surgi- 
cal treatises,  but  some  general  remarks  relating  to  it  will  not  be  inappropriate 
here. 

Lange  says  that  the  operator  should  have  three  assistants,  at  least  one 
of  them  a  physician.  One  should  administer  chloroform,  one  use  the 
sponge,  and  the  third,  a  physician,  should  be  ready  to  assist  in  handing 
instruments,  ligating  vessels,  etc.  The  operation  is  simple  and  devoid  of 
danger,  or  difficult  and  dangerous,  according  to  circumstances.  The  younger 
the  child,  the  greater  the  danger,  other  things  being  equal.  The  greatest 
difficulty  and  risk  attending  tracheotomy  is  in  fleshy  infants  with  thick  and 
short  necks,  and  in  patients  who  have  extreme  dyspnoea  and  are  nearly  mori- 
bund, so  that  the  operator  is  compelled  to  hurry  in  the  operation  through 
fear  that  death  will  occur  before  the  trachea  is  opened.  The  operator  should 
have  time  for  slow  and  cautious  dissection,  that  he  may  avoid  wounding 
vessels  and  other  important  parts. 

Tracheotomy  may  be  performed  above,  through,  or  below  the  thyroid  isthmus ; 
the  latter  place  gives  more  room  for  the  cannula  and  is  to  be  preferred.  Provide 
a  firm  table  covered  with  several  folds  of  blankets;  bichloride  solution  1:1000; 
iodoform  and  iodoform  gauze  ;  carbolized  sponges ;  hot  and  cold  water.  The  fol- 
lowing instruments  are  useful :  A  scalpel ;  two  blunt  hooks  with  bulbous  ends ; 
catch  forceps  ;  two  tenacula  for  holding  the  wound  apart ;  two  tenacula  with  hooks 
at  right  angles  with  the  shaft  to  transfix  and  hold  the  trachea  when  it  is  opened ; 
two  grooved  directors  ;  artery  forceps  ;  forceps  with  fine  teeth  ;  the  oculist" s  spring 
hook  to  open  the  wound ;  tracheotomy-tube  with  two  cylinders  ;  pigeon's  quills. 

Place  the  patient  on  the  table ;  elevate  the  shoulders  with  a  pillow,  and  support 
the  neck  with  a  firm  compress  or  covered  block  of  wood,  so  as  to  throw  the  head 
well  backward.  Wrap  the  child  in  a  sheet,  enclosing  the  arms  and  legs  to  control 
its  movements.  One  assistant  gives  the  chloroform  or  holds  the  head ;  a  second 
takes  charge  of  the  instruments,  and  a  third  of  the  sponges.  Standing  on  the  right 
side,  the  surgeon  gently  compresses  the  trachea  between  the  thumb  and  finger  of 
the  left  hand  and  defines  the  median  line.  Commencing  at  the  cricoid  cartilage,  he 
makes  an  incision  through  the  skin  within  a  third  of  an  inch  of  the  sternum.  With 
hooks  the  wound  is  kept  open,  and  he  proceeds  to  cut  the  tissues  down  to  the 
trachea,  or  with  the  blunt  hooks  inserted  into  them  in  the  median  line  he  may,  by 
traction  in  the  axis  of  the  trachea,  tear  through  these  tissues  without  hemorrhage. 
The  wound  should  be  frequently  wet  by  sponges  moistened  in  the  bichloride  solu- 
tion. Care  should  be  taken  not  to  make  lateral  traction,  in  order  not  to  draw  the 
trachea  to  one  side.  All  bleeding  vessels  should  be  secured  before  the  trachea  is 
opened.  The  dissection  may  be  made  on  a  director  introduced  under  the  tissues  in 
the  median  line,  or  the  operator  may  seize  the  tissues  on  one  side  with  toothed 


TRACHEOTOMY.  849 

forceps  and  an  assistant  do  the  same  on  the  other  side,  and,  making  the  parts  tense, 
the  tissues  are  divided  in  the  median  line. 

The  isthmus  of  the  thyroid  will  be  met  with,  and  must  be  drawn  upward  or 
downward  according  as  the  opening  is  made  above  or  below  this  body.  If  it  is 
found  necessary  for  any  reason  to  divide  it,  ligatures  should  first  be  passed  around 
it  on  either  side  and  tightened  to  prevent  hemorrhage  when  the  incision  is  made 
through  it.  The  trachea  is  recognized  by  its  white  appearance  and  its  rings.  When 
exposed  the  connective  tissue  should  be  removed  from  the  anterior  surface  where  the 
opening  is  to  be  made  so  as  to  prevent  emphysema.  In  opening,  steady  the  trachea 
with  the  thumb  and  fingers,  or  insert  a  hook  into  the  upper  part  and  make  traction 
upward  in  the  median  line  sufficiently  strong  to  steady  the  tube.  The  point  of  the 
bistoury  or  narrow-bladed  knife  should  be  introduced  between  two  rings  of  the 
trachea,  the  cutting  edge  upward,  and  three  or  four  rings  be  divided.  Air  escapes 
with  a  loud  hissing  sound,  and  mucus  with  blood,  perhaps  membrane,  is  ex- 
pelled. The  wound  should  be  drawn  apart  with  hooks  or  toothed  forceps,  and 
the  operator  should  be  prepared  to  seize  any  protruding  membrane  which  may  be 
loose.  The  first  inspirations  may  be  difficult,  but  very  soon  the  mucus  and  shreds 
are  dislodged  and  the  breathing  becomes  more  tranquil.  If  there  are  evidences 
of  the  presence  of  the  loosened  exudation,  curved  forceps  may  be  introduced 
cautiously  and  search  made.  It  is  frequently  useful  to  have  the  patient  inhale 
hot  vapor,  and  sponges  moistened  with  hot  water  may  be  held  with  forceps  over 
the  opening.  Everything  being  in  readiness,  the  double  cannula  is  gently  inserted, 
and  a  tape  fastened  to  the  rings  is  tied  behind  the  neck. 

Much  of  the  success  in  tracheotomy  for  croup  and  diphtheria  depends  on 
the  efficiency  of  the  treatment  after  the  operation  and  subsequent  manifesta- 
tions are  completed.  The  patient  should  be  put  to  bed  in  a  room  at  a  tem- 
perature of  not  less  than  70°  F.,  for  a  certain  amount  of  chilliness  usually 
ensues,  proportionate  to  the  amount  of  hemorrhage  during  the  operation  and 
to  the  intensity  of  dyspnoea  before  it ;  the  external  opening  should  be  covered 
with  a  fold  of  woollen  gauze  or  scarf,  straddled  upon  a  tape  or  strip  of  plaster 
applied  above  the  wound,  which  protects  the  trachea  from  dust  and  warms 
the  air  a  little  as  it  is  inhaled ;  the  risk  of  pneumonia  is  thereby  lessened, 
and  the  liability  diminished  to  clogging  of  the  tube  by  the  accumulation  of 
desiccated  crusts  and  fragments  of  false  membrane.  The  atmosphere  of  the 
room  should  be  kept  moist  as  well  as  warm  by  means  of  steam  escaping  in 
the  immediate  vicinity  of  the  patient,  or,  if  this  means  be  lacking,  flat  sec- 
tions of  sponge  wrung  out  of  hot  water  should  be  kept  over  the  tube ;  if  the 
reaction  from  the  chill  be  tardy,  warm  aromatic  drinks  should  be  administered, 
and  flying  sinapisms  should  be  applied  to  the  trunk  and  limbs,  which  will 
cause  restlessness  to  subside  and  sleep  ensue.  Sleep,  indeed,  often  comes  on 
before  the  dressings  are  completed,  and  occasionally  on  the  operating  table 
as  soon  as  the  cannula  has  been  inserted.  The  membrane  will  probably  be 
coughed  through  the  unobstructed  oriflce. 

The  removal  of  the  cannula,  especially  during  the  flrst  twenty-four  hours, 
necessitates  a  skilled  hand  for  its  reintroduction.  When  it  cannot  be  replaced, 
or  its  presence  prevents  expulsion  of  obstructing  products,  some  other  method 
of  keeping  the  orifice  open  must  be  employed,  and  the  dilating  retractor,  if 
retractors  are  employed,  will  be  of  great  use  ;  hooks  may  be  improvised  from 
hair-pins,  and  may  be  held  in  position  by  tapes  passed  around  the  neck. 
Skilled  judgment  is  necessary  for  the  recognition  of  these  important  points 
and  foi"  their  proper  management ;  an  officious  nurse  may  interfere  unneces- 
sarily on  the  one  hand  and  do  injury  on  the  other.  The  obstructed  character 
of  the  respiration  is  a  guide  for  interference :  under  all  circumstances  the 
condition  of  the  inner  cannula  should  be  observed  every  two  or  three  hours, 
to  clear  it  of  any  viscid  secretions  that  may  have  adhered  to  it ;  these  should 
be  carefully  examined  in  water,  so  as  to  detect  membranes,  which  will  float 
out  in  flat  pieces,  their  amount  indicating  how  the  case  is  progressing.  At 
54 


850  LOCAL  DISEASES. 

the  end  of  twenty-four  hours  or  thereabouts  the  cannula,  soiled  as  it  is  with 
blood  and  sputum,  should  be  removed  for  cleansing,  and  be  replaced  by  a 
clean  one  ;  it  is  best  to  do  this  by  daylight,  and  with  the  child  in  the  same 
position  as  when  it  was  inserted  ;  this  removal  is  followed  by  cough  and  dis- 
charge of  morbid  products ;  the  tube  being  removed,  the  parts  are  to  be  care- 
fully inspected  and  carefully  cleansed.  If  everything  has  gone  on  well,  the 
tube,  if  of  silver,  though  soiled  by  mucus,  pus,  and  blood,  will  not  be  tar- 
nished. If  blackened,  mortification  is  indicated  at  the  corresponding  point 
of  the  wound  ;  if  the  tissues  are  healthy,  the  parts  will  be  normal  in  color 
and  soft,  and  the  edges  of  the  wound  will  be  everted.  Sometimes  the  parts 
will  be  so  pliable  as  to  turn  inward  and  occlude  the  tracheal  incision  ;  then  a 
dilator  should  be  introduced  to  keep  the  wound  open  until  a  tube  is  inserted ; 
meanwhile,  if  indicated,  search  may  be  made  for  false  membrane.  The  can- 
nula should  be  changed  once  a  day,  and  the  wound  dressed  if  need  be ;  when 
air  begins  to  pass  by  the  natural  passage,  as  tested  by  covering  the  external 
wound  with  the  finger-tip,  the  tube  may  be  left  out  for  a  few  minutes  after 
each  dressing,  to  be  replaced  immediately  should  respiration  become  embar- 
rassed ;  from  day  to  day  the  tube  may  be  dispensed  with  for  increasing  inter- 
vals, until  it  is  finally  put  aside.  One  of  the  most  favorable  indications  for 
this  procedure  is  expectoration  by  the  mouth. 

As  the  cannula  exposes  the  patient  to  the  risk  of  bronchitis  and  broncho- 
pneumonia, it  should  be  removed  at  the  earliest  possible  period  ;  to  determine  how 
necessary  the  instrument  is,  close  the  external  opening  from  time  to  time  and  watch 
the  effects ;  it  should  not  be  withdrawn  unless  the  patient  can  breathe  for  some 
hours  with  the  orifice  plugged.  The  wound  usually  closes  rapidly  after  the  cannula 
is  removed. 

Foreign  bodies  passing  through  the  larynx  and  trachea  generally  enter 
the  right  bronchus,  owing  to  the  peculiar  anatomical  arrangement  at  the 
bifurcation ;  the  symptoms  produced  and  the  obstruction  to  respiration 
depend  upon  whether  the  substance  is  fixed  or  movable,  its  size,  nature,  and 
precise  position :  if  impacted  in  one  of  the  bi'onchi,  the  entrance  of  air  into 
the  corresponding  lung  is  more  or  less  impeded,  or  the  obstruction  may  be 
complete,  with  entire  loss  of  respiratory  murmur  on  the  affected  side.  The 
body  may  not  occupy  the  whole  calibre  of  the  bronchus,  when  the  vesicular 
murmur  will  be  diminished,  or  it  may  be  lodged  in  one  of  the  primary  or 
secondary  divisions,  causing  an  entire  absence  of  the  murmur  over  a  certain 
limited  space  ;  natural  resonance  on  percussion  is  usually  preserved  ;  but  as 
a  rule  the  chest  rises  less,  during  inspiration,  on  the  affected  than  on  the 
sound  side,  and  the  respiration  is  puerile  in  the  obstructed  lung ;  fixed  pain 
referred  to  the  upper  part  of  the  chest  when  the  body  is  immovable,  or  con- 
stant pain  with  a  sense  of  weight  on  one  side,  sometimes  indicates  the  posi- 
tion of  the  foreign  body ;  the  voice  may  be  hoarse,  the  respix'ation  wheezing, 
the  cough  aggravated  by  deep  inspiration  ;  inflammation  adds  to  these  symp- 
toms a  copious  and  offensive  expectoration,  paroxysms  of  fever,  night-sweats, 
and  exhaustion.  When  the  symptoms  indicate  that  the  foreign  body  is  in 
one  of  the  bronchi,  tracheotomy  should  be  performed,  and  the  opening  should 
be  of  considerable  extent  and  as  low  down  as  possible.  The  removal  may 
sometimes  be  effected,  if  the  foreign  body  is  globiilar,  by  inversion  of  the 
patient  and  giving  the  posterior  wall  of  the  chest  a  blow,  but  care  must  be 
taken  that  the  substance  does  not  lodge  in  the  larynx  and  cause  suffocation. 
If  it  is  not  dislodged,  it  must  be  extracted  by  instruments  :  first  explore  with 
a  long  probe  in  order  to  learn  the  exact  position  of  the  body,  then  introduce 
suitably  curved  forceps  and  seize  and  remove  it. 


BRONCHITIS.  851 

CHAPTER    VII. 
BEONCHITIS. 

Inflammation  of  the  bronchial  tubes,  or  bronchitis,  is  probably  the  most 
frequent  disease  of  early  life.  It  is  usually  associated  with  more  or  less 
inflammation  of  the  mucous  membrane  of  the  nostrils,  larynx,  and  trachea. 
We  designate  the  disease  coryza,  laryngitis,  or  bronchitis  according  as  one  or 
the  other  inflammation  predominates.  Sometimes  bronchitis  occurs  with  but 
slight  inflammation  elsewhere,  and  often  the  coryza  and  laryngitis  abate 
while  the  bronchitis  is  still  active. 

Bronchitis  occurs  both  as  a  primary  and  secondary  disease.  The  sec- 
ondary form  is  common  in  connection  with  measles,  whooping  cough,  pneu- 
monia, and  pulmonary  phthisis,  and  it  is  not  uncommon  in  remittent  and 
continued  fevers.  Bronchitis  is  acute,  subacute,  or  chronic,  and  according  to 
its  extent  it  is  mild  or  severe.  If  the  smallest  bronchial  tubes  are  involved, 
the  inflammation  is  designated  capillary  bronchitis — a  term  not  well  chosen, 
but  which  is  conveniently  employed  in  a  description  of  the  malady.  Bron- 
chitis is  commonly  bilateral,  afi"ecting  the  tubes  on  the  two  sides  with  about 
equal  intensity.  When  due  to  tubercles  or  to  pneumonia  it  is  often  unilateral, 
being  confined  to  those  tubes  or  nearly  to  those  which  lie  in  the  tubercular 
or  inflamed  pulmonary  tissue. 

Causes. — The  causes  of  secondary  bronchitis  are  obviously  the  diseases 
in  connection  with  which  it  occurs.  The  cause  of  primary  bronchitis  is  the 
same  as  that  of  simple  acute  laryngitis  or  coryza — namely,  sudden  change 
of  temperature  from  warm  to  cold,  exposure  to  currents  of  air,  the  practice 
of  sending  children  without  sufiicient  clothing  from  heated  rooms  into  the 
open  air,  the  throwing  ofi'  of  bedclothes  at  night,  etc. 

Anatomical  Characters. — In  the  most  common  form  of  bronchitis  the 
larger  bronchial  tubes  only  are  aifected.  They  are  the  seat  of  the  inflamma- 
tion in  most  of  those  cases  which  are  designated  "  colds  "  by  families,  and 
which  are  often  treated  without  the  aid  of  the  physician.  The  lining  mem- 
brane of  the  bronchial  tubes  presents  the  ordinary  anatomical  characters  of 
mucous  inflammations.  It  is  reddened  uniformly  or  in  patches,  intensely  or 
in  that  milder  degree  known  as  arborescence,  according  to  the  severity  of  the 
inflammation. 

The  secretion  of  the  muciparous  follicles  is  at  fii'st  arrested  and  the  sur- 
face of  the  membrane  is  dry.  In  the  course  of  a  day  or  two  the  secretory 
function  is  re-established,  and  the  surface  is  covered  with  thin  and  transpa- 
rent mucus.  A  day  or  two  later  the  secretion  becomes  thicker,  consisting  of 
mucus  and  pus.  Mixed  with  these  substances  are  epithelial  cells,  which  are 
exfoliated  in  abundance  from  the  inflamed  surface.  At  the  same  time  the 
mucous  membrane  becomes  thickened  and  more  or  less  softened.  If  the 
inflammation  be  severe,  the  vessels  of  the  submucous  connective  tissue  are 
also  injected.  • 

Usually  in  about  a  week  in  the  young  child,  in  from  one  to  two  weeks  in 
older  children,  the  inflammation  begins  to  abate.  Gradually  the  inflamed 
membrane  returns  to  its  normal  consistence,  thickness,  and  vascularity,  and 
with  this  return  to  the  healthy  state  the  muco-purulent  secretion  abates. 

In  this,  which  is  the  simplest  and  most  common  form  of  bronchitis,  there 
is  no  ulceration,  and  rarely  any  pseudo-membranous  formation  if  the  disease 
be  idiopathic.  Pseudo-membranous  bronchitis  is  not  unusual  as  an  accom- 
paniment of  pseudo-membranous  laryngo-tracheitis. 


852  LOCAL  DISEASES. 

Were  bronchitis  limited  to  the  larger  bronchial  tubes,  it  would  indeed  be 
a  simple  affection,  but,  unfortunately,  it  has  a  tendency  to  extend  downward. 
Commencing  in  the  larger,  it  gradually  invades  the  smaller  tubes  in  a  similar 
manner  to  the  extension  of  erysipelas  upon  the  skin.  More  rarely  the  inflam- 
mation commences  simultaneously  in  the  larger  and  smaller  tubes.  The  grav- 
ity of  bronchitis  is  proportionate  to  the  degree  of  its  extension  downward.  It 
may  stop  at  any  point  in  its  progress,  but  if  it  reach  the  smaller  tubes  it  is 
one  of  the  most  serious  affections  of  early  life. 

The  mucous  membrane  of  the  minute  tubes,  those  next  to  the  air-cells,  is 
delicate,  with  but  little  submucous  connective  tissue,  and  it  frequently,  at 
post-mortem  examinations,  does  not  present  to  the  eye  those  distinct  inflam- 
matory changes  which  are  observed  in  tubes  of  larger  diameter.  It  is  some- 
times not  notably  thickened  nor  its  vascularity  much  increased,  even  when 
there  is  reason  to  believe  from  the  symptoms  that  it  was  the  seat  of  active 
phlegmasia.  As  we  pass  from  these  minute  tubes  to  those  of  larger  calibre 
the  inflammatory  lesions  become  more  distinct.  The  inflammation  produces 
minute  and  abundant  points  of  redness  and  the  membrane  is  evidently  thick- 
ened ;  often  it  is  rough  or  granular. 

The  minute  bronchial  tubes  are  very  small,  especially  under  the  age  of 
three  years,  and,  since  in  capillary  bronchitis  a  large  proportion  of  them  are 
inflamed,  the  source  of  the  danger  is  apparent.  It  is  with  difficulty  that 
the  patient  with  capillary  bronchitis  can  by  the  effort  of  coughing  free  the 
tubes  from  the  secretions  which  are  constantly .  collecting  in  them.  In 
weakly  children  under  the  age  of  two  years  expectoration  is  most  difficult, 
and  hence  the  great  and  increasing  dyspnoea  from  which  such  patients  suffer. 

In  severe  and  unfavorable  cases  of  bronchitis,  which  are  chiefly  those  in 
which  the  small  as  well  as  large  tubes  are  inflamed,  the  following  anatomical 
changes  commonly  occur :  The  muco-purulent  secretion,  which  is  tenacious, 
collects  more  rapidly  in  the  smaller  tubes  than  it  is  expectorated  by  the  child, 
whose  strength  begins  to  be  exhausted.  The  accumulation  of  the  secretion 
is  chiefly  in  the  tubes  which  lie  in  the  posterior  and  inferior  portions  of  the 
lung.  As  the  obstruction  from  the  muco-pus  increases  in  these  tubes,  less 
and  less  air  passes  through  them  into  the  alveoli  with  which  they  communi- 
cate, while  the  quantity  of  air  which  passes  through  the  unobstructed  tubes 
into  the  anterior  and  superior  portions  of  the  lung  is  proportionately  increased. 
The  effect,  as  regards  the  state  of  the  lung,  is  obvious.  In  cases  having  a 
fatal  issue,  and  in  which  we  are  therefore  able  to  inspect  the  lesions,  we  find 
that  the  lower  and  inferior  portions  of  the  organ,  from  which  air  was  to  a 
greater  or  less  extent  excluded,  have  a  diminished  crepitation  ;  that  they  lie 
a  little  below  the  general  level,  or  that  certain  lobules  do  ;  and  that  they  pre- 
sent a  congested  appearance,  for,  while  they  contain  too  little  air,  they  have 
an  excess  of  blood.  We  shall  also  find  that  the  upper  and  anterior  parts  of 
the  organ,  perhaps  the  entire  upper  lobe,  contain  more  than  the  normal  quan- 
tity of  air,  so  as  to  rise  above  the  general  level.  There  is  distention  of  the 
alveoli  in  these  parts,  so  that  they  are  probably  visible  to  the  naked  eye, 
and  may  appear  to  be  emphysematous ;  but  this  is  a  state  distinct  from 
emphysema.  It  is  merely  an  inflation  of  the  alveoli  to  nearly  their  full 
capacity. 

Here  and  there  in  the  portion  of  lung  in  which  the  inflation  has  been 
incomplete  lobules  may  be  observed  which  are  entirely  collapsed,  having  a 
dusky-red  color  and  no  crepitation  ;  while  in  other  parts,  if  the  bronchitis 
have  continued  some  days,  there  are  nodules  of  pneumonia.  Often  when 
the  bronchitis  is  severe  the  inflammation,  commencing  in  the  bronchial 
tubes,  extends  to  the  lungs,  usually  to  lobules  in  the  lower  lobes,  constitut- 
ing broncho-pneumonia.     The    occurrence    of   pneumonia  is   announced  by 


BRONCHITIS.  853 

an  aggravation  of  symptoms,  and  frequently  by  the  expiratory  moan.  The 
incised  surface  of  these  portions  of  the  lung  to  which  the  access  of  air  has 
been  prevented,  whether  they  ai'e  collapsed  fully  or  partially  or  not,  has  a 
reddish  color  from  congestion  and  is  moist  from  serum  and  blood.  On  com- 
pressing the  lung  the  muco-purulent  secretion  appears  upon  the  surface  in 
points,  having  escaped  from  the  divided  ends  of  the  tubes.  (For  other  facts 
relating  to  Atelectasis  the  reader  is  referred  to  the  chapter  in  which  this  mal- 
ady is  described.) 

Exceptionally,  even  when  not  accompanied  by  laryngeal  croup,  fibrinous 
exudation  occurs  in  the  bronchial  tubes,  forming  a  delicate  film  here  and 
there,  and  readily  detached  from  the  surface  underneath,  while  in  rai'e 
instances  it  occurs  as  a  firm  and  continuous  membrane,  forming  a  mould 
of  the  tubes,  increasing  greatly  the  dyspnoea,  constituting  a  true  bronchial 
croup.  If  the  patient  with  severe  bronchitis  survive,  the  inflammation  of 
the  mucous  membrane  soon  begins  to  abate.  The  tubes  which  have  been 
the  seat  of  the  disease  and  the  alveoli  which  have  been  secondarily  involved 
may  return  to  their  normal  state  almost  immediately  ;  but  in  other  instances 
such  anatomical  changes  occur  in  them,  even  when  there  is  no  pneumonia 
nor  atelectasis,  that  full  restoration  to  their  normal  state  is  necessarily  some- 
what slow.  When  the  function  of  a  lobule  ceases,  as  it  does  when  the  tube 
leading  to  it  is  obstructed,  not  only  hypergemia  occurs,  with  or  without  col- 
lapse, as  already  stated,  but  its  cells  and  nuclei,  and  perhaps  other  parts, 
begin  to  undergo  fatty  degeneration.  These  elements  become  granular, 
somewhat  enlarged  and  opaque,  and  here  and  there  mixed  with  them  are 
other  large  cells  filled  with  oil-globules.  These  are  the  compound  granular 
cells  of  pathologists,  and,  occurring  in  this  situation,  are  produced  by  meta- 
morphoses of  the  epithelial  cells.  They  are  epithelial  cells  which  have  pro- 
gressed more  rapidly  than  others  in  fatty  degeneration,  having  reached  that 
stage  of  it  which  immediately  precedes  liquefaction.  We  often  with  the 
microscope  observe  not  only  these  corpuscles,  but  their  fragments  as  they  are 
dissolving. 

Minute  abscesses,  usually  directly  under  the  pleura,  have  occasionally 
been  observed  at  the  autopsies  of  those  who  have  recently  had  general  bron- 
chitis, and  pathologists  are  not  agreed  as  to  the  mode  in  which  they  are  pro- 
duced. Some  of  them,  if  not  all,  are  evidently  connected  with  the  minute 
bronchial  tubes,  and  the  quantity  of  pus  contained  in  each  is  not  usually 
more  than  one  or  two  drops.  The  most  reasonable  view  of  their  causation  is 
that  they  are  produced  in  the  terminal  tubes  where  the  mucus  and  pus  col- 
lect. The  pus  acts  as  an  irritant  and  causes  inflammation,  and  the  inflamma- 
tion increases  the  quantity  of  pus.  The  walls  of  the  tube  which  is  now  the 
seat  of  an  abscess  are  destroyed  by  ulceration,  and  probably  also  some  of  the 
contiguous  air-cells.  The  little  cavity  is  soon  surrounded  by  a  delicate  mem- 
brane, the  same  in  character,  though  less  thick  and  firm,  as  that  which  con- 
stitutes the  walls  of  larger  abscesses.  The  pus  presents  the  usual  appear- 
ance of  this  liquid,  or  it  may  be  tinged  by  the  presence  of  blood-cells,  or, 
again,  it  may  be  thick  from  partial  absorption  of  the  liquor  puris,  so  as  to 
resemble  softened  tubercle. 

The  abscess  is  ordinarily  located  in  the  centre  of  a  collapsed  lobule.  In 
certain  cases  it  approaches  the  surface  of  the  lungs,  so  as  to  produce  circum- 
scribed pleurisy,  with  adhesion  of  the  costal  and  visceral  pleura.  At  the 
autopsy  of  such  a  case,  on  separating  the  adhesions  and  attempting  insuffla- 
tion, the  air  passes  through  the  aperture,  so  that  the  lung  on  that  side  can- 
not be  inflated  unless  the  aperture  be  closed.  Occasionally  pneumothorax 
results  from  opening  of  the  abscess  into  the  pleural  cavity. 

In  severe  protracted  bronchitis  dilation  of  certain  of  the  bronchial  tubes 


854  LOCAL  LISEASES. 

sometimes  results.  The  alveoli  in  the  upper  lobes  may  also  be  distended 
beyond  their  physiological  capacity,  so  as  to  produce  emphysema,  but,  as  we 
have  stated  above,  their  maximum  distention  within  physiological  limits 
must  not  be  mistaken  for  emphysema.  Emphysema  in  the  upper  lobes  is 
common  in  feeble  young  children  with  relaxed  and  weakened  tissues,  occur- 
ring even  without  any  severe  disease  of  the  respiratory  organs.  It  may  be 
vesicular  or  interstitial.  If  it  be  interstitial,  the  sacs  of  air  often  attain 
considerable  size,  h'ing  as  wedges  between  the  alveoli  or  like  little  bladders 
upon  the  surface  of  the  lung,  where  the  entrance  of  air  is  least  obstructed 
and  greatest. 

Sy:mptoms. — It  is  evident,  from  the  description  which  has  been  given  of 
the  anatomical  characters  of  bronchitis,  that  its  symptoms  vary  greatly  in 
severity  in  diiferent  patients.  It  usually  commences  with  more  or  less 
eoryza.  The  symptoms  are  headache,  flushed  face,  elevation  of  temperature, 
acceleration  and  fulness  of  pulse.  In  the  mildest  cases  these  symptoms  are 
scarcely  appreciable.  The  child  is  observed  to  sneeze  and  have  some  deflux- 
ion  from  the  nostrils,  and  this  is  followed  by  an  occasional  mild,  almost  pain- 
less cough,  which  declines  in  the  course  of  a  few  days.  The  respiration  and 
pulse  are  scarcely  accelerated  and  the  appetite  is  but  slightly  impaired. 
There  may  be  a  little  fretfulness,  but  the  child  is  not  confined  to  his  bed  or 
room,  and  usually  amuses  himself  with  his  playthings.  Auscultation  in 
these  mild  cases  reveals  coarse  mucous  rales  in  the  larger  bronchial  tubes, 
while  the  smaller  tubes  are  free  from  mucus.  Sibilant  and  sonorous  rales 
are  also  observed,  especially  in  the  commencement  of  the  bronchitis,  at  which 
time  the  secretion  of  mucus  is  suppressed  or  scanty.  The  cough  in  the 
commencement  is  for  the  same  reason  dry.  It  becomes  looser  by  the  second 
or  third  day,  the  sputum  consisting  of  frothy  mucus,  with  the  admixture 
of  pus  and  epithelial  cells.  The  pus  becomes  more  abundant  as  the  disease 
continues.  Expectoration  from  the  mouth  does  not  usually  occur  till  after 
the  age  of  four  or  five  years ;  under  this  age  the  sputum  is  ordinarily 
swallowed. 

The  mild  form  of  bronchitis  described  above,  that  in  which  only  the 
larger  tubes  are  afi"ected,  is  common  in  infancy  and  childhood,  but  bronchitis 
of  a  more  severe  type  is  also  common,  due  to  extension  of  the  inflammation. 
It  has  already  been  stated  that  there  is  a  tendency  in  bronchial  inflam- 
mation to  extend  downward,  and  symptoms  are  proportionate  in  gravity 
to  the  degree  of  this  extension.  In  severe  bronchitis  the  pulse  rises  to 
120  or  130  per  minute,  and  the  respiration  is  in  a  corresponding  degree 
accelerated.  The  cough  is  frequent  and  painful,  the  pain  being  referred  to 
the  sternum,  and  often  there  is  a  steady  dull  pain  in  this  region.  The  face 
is  flushed  and  indicative  of  suffering,  the  temperature  is  considerably  ele- 
vated, and  the  appetite  is  greatly  impaired  or  lost.  There  is  frequently  an 
exacerbation  of  symptoms  in  the  latter  part  of  the  day.  Depression  of  the 
inframammary  region  during  inspiration  and  dilation  of  the  al^e  nasi  accom- 
pany grave  attacks  of  the  inflammation. 

Auscultation  in  severe  bronchitis  reveals  the  presence  of  rales  in  all  parts 
of  the  chest,  sibilant  and  sonorous  sparingly,  coarse  mucous  and  subcrepitant 
more  abundantly. 

General  bronchitis  or  suff"ocative  catarrh,  the  most  dangerous  form  of  this 
inflammation,  is  less  frequent  than  bronchitis,  which  is  limited  to  the  larger 
tubes  or  to  the  larger  tubes  and  those  of  medium  size.  It  may  commence 
quite  abruptly,  but  ordinarily  it  results  from  the  milder  form  of  the  disease. 
The  symptoms  at  first  are  such  as  occur  in  the  common  form  of  bronchial 
inflammation,  but,  instead  of  abating  or  remaining  stationary,  they  grad- 
ually increase  in   severity  till  suddenly  marked   dyspnoea   supervenes.  "The 


BRONCHITIS.  855 

inflamiuatiou  has  no^v  reaelied  the  minute  tubes,  and  what  promised  to 
be  an  ordinary  attack  of  bronchitis  becomes  one  of  great  severity  and 
danger. 

The  respiration  in  severe  bronchitis  is  short  and  hurried.  Sixty  to  eighty 
inspirations  per  minute  are  not  infrec^uent,  while  the  pulse  also  is  greatly 
accelerated,  attaining  as  high  a  number  as  140  to  160  or  180  beats  per  minute. 
The  cough  is  frequent,  and  the  sputum,  which  collects  in  abundance,  is 
expectorated  with  difficulty.  If  expectorated  so  as  to  be  examined,  it  is 
found  to  consist  largely  of  frothy  mucus  with  epithelial  cells.  After  a  few 
days,  if  the  patient  live,  it  becomes  more  purulent.  Sometimes,  as  in  bron- 
chitis of  the  adult,  streaks  of  blood  appear  upon  the  mucus.  In  the  first 
days  of  severe  acute  bronchitis  the  temperature  is  considerably  elevated,  the 
face  flushed,  and  the  breathing  oppressed.  The  patient  is  restless,  moving 
from  one  part  of  the  bed  to  another,  seeking  in  vain  for  relief.  The  diges- 
tive function  is  impaired,  as  in  all  severe  inflammations :  the  tongue  is  moist 
and  covered  with  a  light  fur ;  the  appetite  is  nearly  or  quite  lost.  The 
infant  takes  the  breast  with  difficulty,  frequently  relinquishing  it  on  account 
of  the  dyspnoea ;  older  children  take  no  solid  food  in  consequence  of  the  ano- 
rexia and  the  dyspnoea,  and  even  drinks  are  swallowed  hastily  and  apparently 
without  relish,  since  deglutition  interferes  with  respiration.  On  auscultation 
in  bronchitis  of  the  minute  tubes  sibilant,  and  after  a  day  or  two  subcrepi- 
tant,  rales  are  observed  in  every  part  of  the  chest.  Percussion  elicits  a 
good  resonance  unless  the  substance  of  the  lung  have  become  involved.  As 
the  disease  approaches  a  fatal  termination  the  pulse  becomes  greatly  acceler- 
ated ;  the  respiration  is  also  in  a  corresponding  degree  frec[uent  and  panting, 
the  inspiration  being  accompanied  by  increased  iuframammary  depression 
and  dilation  of  the  alae  nasi.  The  face  becomes  pallid,  the  prolabia  livid,  and 
the  tips  of  the  fingers  livid  and  cool.  The  mucus  and  pus,  accumulating  in 
the  air-passages,  increase  more  and  more  the  obstruction  to  the  entrance  of 
air,  and  finally  death  occurs  from  apnoea.  The  nursing  infant  usually  ceases 
to  nurse  several  hours  before  death,  and  a  state  of  stupor  commonly  pre- 
cedes the  fatal  event,  due  to  the  accumulation  of  carbonic  acid  in  the  blood. 
In  young  infants,  especially  those  under  the  age  of  six  months,  not  only  in 
bronchitis  of  the  minute  tubes,  but  in  severe  ordinary  bronchitis,  I  have 
often  observed  toward  the  close  of  life  intermission  in  the  respiration.  It 
occurs  after  every  six  or  eight  or  ten  respirations,  and  equals  in  duration  the 
time  occupied  in  perhaps  half  a  dozen  respiratory  movements.  It  is  there- 
fore an  unfavorable  prognostic  sign,  but  some  in  whom  it  occurs  recover  by 
active  stimulation. 

The  DURATION  of  acute  bronchitis  varies  according  to  the  extent  of  the 
inflammation.  In  the  mildest  form  the  patient  is  convalescent  after  three  or 
four  days,  and  in  severe  cases  that  terminate  favorably  the  disease  begins 
ordinarily  to  decline  by  the  close  of  the  first  week  or  in  the  second.  The 
progress  of  bronchitis  is  somewhat  more  rapid  in  young  children  than  in 
those  of  a  more  advanced  age.  When  convalescence  is  fully  established  it 
is  not  unusual  for  the  cough  to  continue  three  or  four  weeks,  though  grad- 
ually declining.  It  is  loose  and  painless,  and  is  scarcely  regarded  by  the 
patient. 

Death  sometimes  occurs  as  early  as  the  second  or  third  day  in  severe  gen- 
eral bronchitis.  The  younger  the  infant,  with  the  same  extent  and  intensity 
of  inflammation,  of  course  the  sooner  the  fatal  result.  The  ordinary  dura- 
tion of  fatal  bronchitis  is  from  six  to  eight  days.  If  the  patient  pass  beyond 
the  tenth  day.  decline  of  the  inflammation  may  be  confldently  expected,  with 
recovery,  unless  there  be  a  complication. 

Occasionally  bronchitis  becomes  chronic,  lasting  several  months  before  it 


856  LOCAL  DISEASES. 

entirely  ceases.  Tlie  chrome  form  may  result  from  mild  as  well  as  severe 
bronchitis.  The  acute  fever  and  accelerated  respiration  which  characterize 
the  acute  affection  abate,  and  the  general  health  is  nearly  or  quite  restored  ; 
but  an  occasional  cough  continues,  and  the  respiration  is  often  audible,  from 
the  mucus  which  collects  in  the  tubes  or  from  thickening  of  the  mucous 
membrane.  Sometimes  there  is  moderate  fever,  especially  in  the  latter  part 
of  the  day.  On  auscultation  coarse  mucous,  with  perhaps  sibilant  and  sono- 
rous, rales  are  observed  in  the  chest. 

There  is  great  liability  in  chronic  bronchitis  to  exacerbations.  The  dis- 
ease often  seems  to  be  abating  and  there  is  prospect  of  its  speedy  cure,  when 
all  the  symptoms  are  intensified.  The  exacerbations  are  due  to  the  fact  that 
the  bronchial  surface,  when  it  has  been  a  considerable  time  inflamed,  is  very 
sensitive  to  the  impression  of  cold.  Even  when  the  disease  is  entirely 
relieved,  it  is  very  liable  to  return  by  exposure  to  currents  of  air  or  changes 
of  temperature.  Chronic  bronchitis  occurs  most  frequently  in  the  winter, 
spring,  and  autumn,  when  the  weather  is  changeable,  and  is  most  intractable 
in  these  periods  of  the  year.  Many  cases  of  chronic  bronchitis  are  associated 
with  dilation  of  the  bronchial  tubes  or  with  emphysema.  The  general  health 
in  this  form  of  bronchitis,  when  not  depending  on  a  tubercular  deposit,  ordi- 
narily remains  good.  Tubercular  bronchitis,  which  is  the  result  of  a  grave 
disease,  is  treated  of  in  our  remarks  on  Tuberculosis.  It  is  attended  with 
emaciation,  and  is  obstinate  on  account  of  the  nature  of  the  primary  aff'ec- 
tion.  It  is  due  to  the  irritating  effect  of  tubercular  matter  lying  against  the 
bronchial  tubes. 

Diagnosis. — Bronchitis  can  ordinarily  be  diagnosticated  by  the  character 
of  the  respiration  and  cough.  The  absence  of  hoarseness,  stridulous  inspira- 
tion, and  croupy  cough  excludes  laryngitis,  and  the  absence  of  the  expiratory 
moan  and  of  the  stitch-like  pain  on  coughing,  which  characterize  pneumonia 
and  pleurisy,  excludes  these  diseases.  Accurate  diagnosis,  however,  can  be 
most  readily  made  by  percussion  and  auscultation.  Examination  of  the  chest 
enables  us  to  state  with  positiveness  not  only  the  nature,  but  the  extent,  of 
the  affection.  If  the  inflammation  be  confined  to  the  larger  bronchial  tubes, 
coarse  rales  are  discovered  in  them,  while  finer  mucous  rales  are  absent.  If 
the  bronchitis  be  in  the  minute  tubes,  subcrepitant  rales  are  discovered  in 
them.  Percussion  gives  clear  resonance  on  both  sides,  except  in  those  instances 
in  which  atelectasis  or  pneumonia  has  supervened. 

Prognosis. — Bronchitis  limited  to  the  larger  bronchial  tubes  or  to  these 
and  those  of  medium  size  terminates  favorably  in  a  large  majority  of  cases. 
Occasionally,  severe  inflammation,  not  extending  to  the  smaller  tubes,  proves 
fatal  to  young  infants  or  those  of  feeble  constitution.  Bronchitis  extending 
to  the  minute  tubes  is.  on  the  other  hand,  a  disease  of  great  danger.  It  may 
be  fatal  at  any  period  of  childhood,  but  the  younger  and  more  feeble  the 
patient  the  greater  the  liability  to  a  fatal  result.  Under  the  age  of  one  year 
it  is  one  of  the  fatal  diseases  of  early  life. 

The  prognosis  in  the  commencement  of  all  cases  of  bronchitis  of  average 
severity  in  the  young  child  should  be  guarded,  on  account  of  the  tendency 
of  the  inflammation  to  extend,  as  has  been  already  stated  in  the  preceding 
pages.  After  five  or  six  days  extension  ceases,  and  if  during  that  time  no 
increase  in  the  severity  of  symptoms  occurs  the  prognosis  is  favorable. 
Signs  which  indicate  an  unfavorable  result  are  increasing  frequency  of  pulse 
and  respiration,  difficult  and  scanty  expectoration,  restlessness,  a  countenance 
expressive  of  suffering,  and  a  progressively  greater  accumulation  of  mucus 
in  the  bronchial  tubes,  as  determined  by  auscultation.  Pallor  and  coldness 
of  the  face  and  extremities,  lividity  of  the  tips  of  the  fingers,  rapid  and 
feeble    pulse,  drowsiness,  diminution  of   cough,  while  the    mucus    and  pus 


BRONCHITIS.  857 

accumulate  in  the  broncliial  tubes,  and,  in  young  children,  intermissions  in 
the  respiration,  indicate  the  near  approach  of  death.  Cases  may,  however, 
recover  by  proper  treatment,  although  the  symptoms  are  most  unfavorable. 

It  is  unnecessary  to  mention  the  favorable  prognostic  signs  of  bronchitis. 
This  disease,  when  fully  estabUshed,  continues  a  certain  number  of  days  what- 
ever remedial  measures  are  employed,  and  if  the  symptoms  do  not  increase 
in  severity  during  the  first  five  or  six  days,  a  favorable  result  is  highly  prob- 
able. The  prognosis  in  chronic  bronchitis  is  ordinarily  favorable,  so  far  as 
life  is  concerned,  provided  that  no  emaciation  occurs.  If  there  be  emaciation, 
the  bronchitis  may  be  due  to  tubercles  in  the  bronchial  glands  or  lungs,  and 
of  course  the  prognosis  is  less  favorable. 

Treatment. — Bronchitis  may  be  rendered  much  milder,  and  perhaps 
prevented,  by  an  emetic  employed  in  the  first  twelve  or  twenty-four  hours 
in  conjunction  with  a  warm  bath.  The  physician  is  not,  however,  ordinarily 
called  sufficiently  early  to  render  this  treatment  effectual. 

Mild  Bronchitis. — In  mild  bronchitis,  the  inflammation  being  limited  to 
the  larger  tubes  or  to  these  and  those  of  medium  size,  simple,  soothing, 
expectorant,  and  laxative  remedies  are  required.  Mild  counter-irritation  may 
be  produced  by  camphorated  oil  or  the  following  : 

R.  Olei  caryophjlli,  3^,1  ! 

Olei  campliorati,  5iv. 

For  external  use. 

And  one  of  the  following  mixtures  may  be  given :  The  late  Dr.  James  Jack- 
son of  Boston,  in  his  letters  to  a  young  physician,  writes  of  the  treatment : 
"  For  young  children  I  employ  the  following :  Take  of  either  almond  or  olive 
oil,  of  syrup  of  squills,  of  any  agreeable  syrup,  and  of  mucilage  of  gum  acacia 
equal  parts,  and  mix  them.  Of  this  mixture  a  teaspoonful  may  be  given 
to  a  child  two  years  of  age ;  a  little  less  if  younger  and  increased  if  older, 
so  as  to  double  the  dose  to  one  in  the  sixth  year.  This  may  be  given  from 
three  to  six  times  in  the  twenty-four  hours.  Sometimes  a  little  opiate  must 
be  added  at  night  to  appease  the  urgent  cough."  Another  good  medicine  is 
the  mistura  glycyrrhizse  composita,  half  a  teaspoonful  of  which  should  be 
given  every  two  hours  to  a  child  of  three  years  and  one  teaspoonful  to  one 
of  six  years.  The  syrupus  ipecacuanhas  compositus  of  the  French  Pharma- 
copoeia, the  contre  de  la  toux,  consisting  of  ipecacuanha,  senna,  thyme,  poppy, 
sulphate  of  magnesia,  orange-flower  water,  wine,  water,  and  sugar,  being 
soothing  and  slightly  laxative,  is  also  a  useful  remedy.  These  cases  also 
do  well  with  simple  mucilaginous  drinks  and  confinement  in  a  warm  room. 
Bronchitis  affecting  the"  Medium-sized  or  Smallest  Tubes. — In  all  eases 
of  this  disease  in  which  the  cough  is  dry  and  painful,  or  so  frequent  as  to 
attract  attention,  the  air  of  the  room  should  be  constantly  moist.  I  prefer 
the  u-se  of  the  croup-kettle  or  steam-atomizer: 

R.  Sodii  bicarbonat.,  ^ij  ; 

Aq.  calcis,  Oij.— Misce. 
Or, 

R.  Terebinth  inse,  5J_; 

Aquae  pura?,  Oij. — Misce. 

In  the  New  York  Foundling  Asylum  the  constant  inhalation  of  air  con- 
taining the  turpentine  vapor  has  been  a  favorable  mode  of  treatment.  It 
must  be  recollected  that  the  muco-pus  in  the  bronchial  tubes  contains  numer- 
ous microbes,  and  they  descend  deeper  during  inspiration,  and,  if  not  expec- 
torated, by  their  irritating  action  tend  to  produce  a  downward  extension  of 


858  LOCAL   DISEASES. 

the  inflammation.  The  inhaLation  of  vapors  like  those  mentioned  above  not 
only  renders  the  muco-pus  thinner  and  more  easily  expectorated,  but  to  a 
certain  extent  also  produces  a  disinfectant  action. 

Local  treatment  applied  to  the  chest  in  bronchitis  is  important,  since,  if 
properly  made,  it  increases  the  comfort  and  obviously  diminishes  the  intensity 
of  the  inflammation.  Henoch,  whose  ample  experience  and  sound  judgment 
command  attention,  if  not  acceptance  of  his  views,  says  of  local  treatment: 
"  I  strongly  advise  hydropathic  applications  to  the  chest  from  the  neck  to  the 
umbilicus.  A  napkin  or  diaper  is  dipped  in  water  at  the  temperature  of  the 
room,  well  wrung  out,  and  then  placed  around  the  chest,  without  exercising 
any  compression,  so  that  the  arms  are  free ;  this  is  surrounded  by  a  roll  of 
batting  and  then  covered  by  a  layer  of  oil-silk  or  gutta-percha  paper.  When 
the  fever  is  high  these  applications  should  be  renewed  at  least  every  half 
hour  ;  later  they  may  be  kept  on  for  one  or  even  two  hours,  and  this  continued 
for  several  days  and  nights.  I  have  occasionally  continued  it  for  a  week,  the 
cool  water  being  changed  to  a  temperature  of  26°  to  27°  R  "  (90.5°  to  92.8° 
Fahr.). 

The  benefit  derived  from  the  cold-water  application  is,  according  to 
Henoch,  threefold :  First,  the  deep  inspiration  which  the  application  of  cold 
causes,  thus  expanding  portions  of  the  lungs  which  are  liable  to  atelectasis ; 
secondly,  "  derivative  irritation  of  the  skin ;"  and,  thirdly,  the  production  of 
moisture  in  the  air  surrounding  the  child,  which  he  inhales.  Deep  inspira- 
tions are,  in  my  opinion,  caused  to  a  greater  extent  by  medicines  which  excite 
cough,  as  ammonia  and  warm  applications  certainly  produce  more  derivation 
to  the  surface  than  cold.  One  benefit  from  the  application  of  cold  Henoch 
does  not  allude  to,  and  that  is  the  reduction  of  temperature.  But  I  prefer 
for  this  purpose  frequent  sponging  of  the  upper  extremities  and  face  with 
cold  water,  and  perhaps  its  constant  application  to  the  head.  I  have  observed 
marked  relief  from  this  use  of  cold  water. 

For  years,  in  my  practice,  the  following  external  treatment  has  been 
employed  with  apparent  benefit  in  nearly  every  case.  For  infants  under  the 
age  of  three  months  who  have  accelerated  respiration  and  painful  cough, 
indicating  the  need  of  external  treatment,  two  poultices  of  ground  flaxseed 
are  prepared,  covered  by  thin  muslin  and  made  so  moist  that  they  wet  the 
hand  in  holding  them.  They  are  made  as  thin  as  the  pasteboard  cover  of  a 
book,  and  of  such  a  size  that,  applied  in  front  and  behind,  they  cover  the 
entire  chest.  Camphorated  oil  is  smeared  over  their  under  surface  three  or 
four  times  daily,  and  over  their  exterior  oil-silk  is  applied.  For  infants  over 
the  age  of  six  months  I  prefer  poultices  of  the  following : 

Bt.  Pulv.  sinapis,  5J  ; 

Pulv.  seminis  lini,  5^^- 

The  poultice,  to  give  most  relief,  should  be  so  wet  as  to  cause  constant  moist- 
ure of  the  surface,  and  so  irritating  as  to  cause  con.stant  redness  without 
necessitating  its  removal.  Vesication  should  never  be  produced.  Flannel 
wrung  out  of  warm  water  made  slightly  irritating  by  mustard  and  covered 
by  oil-silk  also  answers  the  purpose.  External  treatment  should  be  employed 
in  most  instances  so  long  as  the  respiration  is  hurried  and  cough  painful. 
During  the  stage  of  convalescence,  instead  of  the  poultice,  cotton  wadding  or 
batting  around  the  chest  increases  the  comfort  and  prevents  taking  cold. 
Derivation  to  the  surface,  early  made  and  continued,  tends  to  check  the 
downward  extension  of  bronchitis.  Often  improvement  in  the  symptoms  is 
observed,  especially  less  dyspnoea  and  restlessness,  immediately  on  the  em- 
ployment of  the  local  measures  recommended  above. 


BROXCHITIS.  859 

Internal  Treatment. — Medicines  are  indicated  Avliich  have  a  tendency  to 
diminisli  the  inflammation,  to  prevent  its  dov\-nward  extension  to  the  minute 
bronchial  tubes,  and  to  promote  expectoration.  The  bowels  should  be  kept 
open  in  all  cases  of  bronchitis.  For  robust  children  at  or  over  the  age  of 
six  months  the  following  prescription  is  useful  in  the  commencement  of  the 
attack  : 

R.  Syr.  ipecac, 

Spts.  sether.  nitr.,  da.  ^ij  ; 

01.  ricini,  ^iij  ; 

Syr.  bal.  tolut.,  §j. — Misce. 

Dose :  Half  a  teaspoonfal  to  one  teaspoonful,  every  second  hour,  for  the  age  of 
one  to  two  years. 

But  the  medicinal  agent  which  experience  has  shown  to  be  the  most  use- 
ful in  the  bronchitis  of  children  is  one  of  the  salts  of  ammonium.  In  the 
treatment  of  infantile  bronchitis  depression  must  be  avoided.  The  cough 
should  be  strong  and  frequent,  for  the  chief  danger  occurs  from  the  accumu- 
lation of  viscid  mucus  in  the  minute  tubes,  so  as  to  obstruct  the  entrance  of 
air  into  the  alveoli,  leading  to  atelectasis  and  causing  the  dyspnoea  which  is 
so  painful  and  prominent  a  symptom  in  this  disease.  Ammonii  carbonas  or 
chloridum  better  than  any  other  agent  promotes  expectoration  by  exciting 
cough  and  rendering  the  mucus  less  viscid,  and  it  does  not  reduce  the  strength. 
When  anxious  parents  ask  me  to  prescribe  something  to  relieve  the  cough,  I 
reply  that  the  more  frequent  the  cough  the  better  it  is  for  the  infant,  since  it 
affords  the  means  of  freeing  the  tubes  from  the  accumulating  mucus.  Gas- 
tric catarrh  has  been  found  in  infants  who  have  perished  after  repeated  doses 
of  the  ammonium  carbonate  administered  for  pulmonary  diseases.  I  there- 
fore prescribe  it  in  water,  and  direct  it  to  be  administered  in  milk.  In  feeble 
cases  and  cases  attended  by  dyspnoea  the  carbonate  is  preferable  to  the  chlo- 
ride, since  it  is  more  stimulating  and  it  promotes  the  cough  by  slightly  irri- 
tating the  fauces.  The  ammonii  chloridum  may  in  most  instances  be  given 
with  benefit  from  the  commencement,  both  in  mild  and  severe  bronchitis,  in 
infants  under  the  age  of  one  year,  but  in  severe  cases  it  is  apparently  less 
efficient  than  the  carbonate.  The  following  is  a  convenient  formula  for  its 
employment : 

R.  Ammonii  chloridi,  ,^j  ; 

Syr.  bal.  tolut.,  §ij. — !Misce. 

Fifteen  drops  contain  one  grain,  which  is  the  dose  at  the  age  of  three 
months.  Five  drops  should  be  given  at  the  age  of  one  month,  and  thirty  at 
the  age  of  six  months,  in  a  little  water.  This  expectorant  should  be  given 
frequently,  as  every  half  hour  or  every  hour  in  cases  of  severity.  The  urgent 
symptoms  are  relieved  by  free  expectoration,  which  this  medicine  tends  to 
produce.  It  should  be  given  night  and  day.  at  the  short  intervals  mentioned, 
until  amelioration  of  symptoms  occurs.  The  benefit  from  its  use  is  most 
apparent  under  the  age  of  eighteen  months,  or  at  the  age  when  caj)illary 
bronchitis  and  atelectasis  are  most  liable  to  occur. 

Medicines  which  exert  a  greater  controlling  effect  on  the  action  of  the 
heart  than  those  which  we  have  mentioned  are  often  required  during  the 
progress  of  severe  '■  bronchitis."  If  the  patient  give  evidence  of  declining 
strength  while  the  pulse  is  unusually  rapid  and  the  temperature  elevated, 
quinine  given  in  moderate  doses,  as  two  grains  every  fourth  hour  to  a  child 
of  two  years,  has  seemed  to  me  useful  as  a  heart  tonic.  It  may  be  employed 
in  the  following  formula  : 


860  LOCAL  DISEASES. 

R .  Quinife  sulphatis,  ^^s  ; 

Syr.  yerbse  saiitse  comp.,  gij. — Misce. 

Give  one  teaspoonful  every  fourth  hour. 

The  tincture  of  digitalis  in  doses  of  one  or  two  drops  every  second  hour 
for  infants  between  the  ages  of  six  months  and  two  years  is  also  useful 
as  a  heart  tonic.  In  a  case  recently  under  treatment  by  Dr.  Jacobi  and 
myself  the  infant,  aged  twenty-three  months,  having  a  temperature  varying 
from  1022°  to  1052°,  respiration  82  to  105,  and  pulse  165  and  higher,  took 
four  drops  of  tincture  of  digitalis,  besides  the  quinine  and  ammonii  chloridum, 
three  days,  with  apparently  a  good  result  from  the  digitalis.  This  remedy 
was  afterward  continued  in  two-drop  doses,  and  the  patient  recovered. 

For  robust  children,  with  a  strong  and  rapid  pulse,  with  a  temperature 
above  102°,  the  use  of  an  antipyretic  is  indicated.  Tincture  of  aconite, 
drop  j,  or  phenacetin,  gr.  j,  with  citrate  of  cafFein.  gr.  ss,  may  be  given  every 
third  hour  to  an  infant  of  one  year.  If  the  temperature  fall  to  102°,  the 
antipyretic  should  in  ordinary  eases  be  discontinued,  since  it  is  in  a  measure 
depressing.  Its  use  is  seldom  required  longer  than  two  or  three  days.  For 
feeble  children,  or  those  who  have  atelectasis  or  pneumonia  complicating  the 
bronchitis,  quinine  is  preferable  to  either  of  the  above  antipyretics. 

When  and  how  to  employ  opiates  to  procure  the  needed  rest  in  the  bron- 
chitis of  children  should  be  carefully  considered.  We  have  stated  that  a 
frequent  and  strong  cough  is  required  in  the  infant  in  order  to  prevent  clog- 
ging of  the  minute  tubes  with  muco-pus  and  to  prevent  atelectasis.  Still, 
some  respite  from  the  cough,  if  it  be  frequent,  is  required  to  prevent  exhaus- 
tion. I  prefer  for  young  infants  to  give  the  opiate  separately  from  the  ex- 
pectorant, and  only  occasionally  as  they  may  need  sleep.  The  following  is  a 
useful  formula  for  an  infant  of  six  months  if  it  be  restless  and  without  the 
proper  amount  of  sleep  : 

R.  Liq.  opii  composit.  (Squibb),  gtt.  x  ; 

Potass,  bromidi,  3j  ; 

Syr.  rubi  idsei  (raspberry),  §j  ; 

Aquae,  ^iss. — Misce. 
Dose :  One  teaspoonful  when  needed. 

Eight  drops  of  paregoric  may  be  given  in  place  of  the  above.  Twice  the 
dose  of  either  of  these  opiates  is  sufficient  at  the  age  of  twelve  months.  For 
older  children  Dover's  powder — an  eligible  form  of  which  is  Squibb's  liquid 
Dover's  powder,  the  tinctura  ipecacuanhas  composita,  one  minim  of  which 
corresponds  to  one  grain  of  the  powder — is  a  useful  remedy  to  procure  sleep. 

During  convalescence  medicines  should  be  administered  less  and  less  fre- 
quently or  in  smaller  doses.  Emetics  in  oi'dinary  cases  of  bronchitis  are  not 
required,  except  in  the  commencement.  In  severe  bronchitis,  however,  espe- 
cially when  the  smaller  tubes  are  inflamed,  they  sometimes  appear  to  be  use- 
ful. The  cases  which  may  need  their  administration  are  those  in  which  mucus 
and  pus  collect  in  the  tubes  more  rapidly  than  they  are  expectorated,  so  as 
to  give  rise  to  urgent  dyspnoea.  An  emetic  administered  under  such  circum- 
stances may  give  prompt  and  decided  relief.  The  object  to  be  gained  is 
obviously  very  diff"erent  from  that  in  the  commencement  of  bronchitis,  and 
such  agents  should  be  employed  as  act  promptly  with  little  depression. 
Ipecacuanha  is  probably  the  best  emetic  for  this  purpose. 

Infants  oppressed  by  the  accumulation  of  mucus  and  pus  may  sometimes 
be  relieved  by  tickling  the  fauces  with  the  finger.  This  provokes  vomiting, 
and  the  viscid  mucus  which  collects  at  the  entrance  of  the  glottis  is  removed 
by  the  finger. 


*  ATELECTASIS.  861 

The  diet  should,  as  a  rule,  be  nutritious  through  the  entire  disease ;  but 
robust  patients  or  those  who  have  ordinary  health,  if  over  the  age  of  two 
years  and  affected  with  primary  bronchitis,  are  sufficiently  nourished  by  light 
diet,  chiefly  farinaceous,  in  the  first  days  of  the  attack,  after  which  animal 
broths  are  proper.  Whatever  food  is  given  in  severe  bronchitis  must  be  in 
the  form  of  drinks,  since  the  appetite  is  lost  and  solid  food  is  not  taken, 
while  the  thirst  is  such  that  liquids  are  less  likely  to  be  refused. 

In  primary  bronchitis,  if  mild  or  of  ordinary  severity,  alcoholic  stimu- 
lants are  not  required.  In  secondary  bronchitis  they  are  often  needed,  and 
also  in  severe  primary  bronchitis  if  there  be  dyspnoea  with  evidences  of 
prostration. 


CHAPTER   YIII. 

ATELECTASIS. 

In  certain  new-born  infants  the  lungs  do  not  undergo  inflation  or  only  a 
portion  of  the  lobules  is  inflated — to  wit,  those  in  the  upper  lobes — while  the 
remainder  of  the  organ  continues  unchanged  from  the  foetal  state.  This  non- 
inflation  of  the  lung  is  designated  congenital  atelectasis.  It  is  apparently 
not  due,  unless  in  rare  instances,  to  defective  formation  of  the  respiratory 
apparatus,  for  at  the  autopsies,  of  cases  which  have  ended  fatally,  as  most 
cases  do  at  an  early  period,  insufilation  is  easy,  there  being  no  occlusion  of 
the  air-passages  nor  unusual  adhesion  of  the  walls  of  the  alveoli  to  prevent 
the  admission  of  air.  Physicians  have  believed  that  in  some  instances  they 
discovered  the  cause  in  an  enlarged  thymus  gland,  which  compressed  the 
lower  part  of  the  trachea,  but  this  cause  has  not  seemed  to  exist  or  was 
exceptional  in  cases  which  I  have  observed ;  for  although  the  thymus  at 
birth  is  large,  having  nearly  the  size  of  an  unexpanded  lung,  it  has  not 
seemed  to  me  to  be  unduly  enlarged  in  most  atelectatic  cases  which  I  have 
examined  after  death. 

The  ordinary  proximate  cause  of  atelectasis  neonatorum  is  feebleness  of 
inspiration,  whether  due  to  general  debility,  as  in  infants  born  prematurely, 
or  weakened  by  placental  hemorrhage  in  the  last  months  of  foetal  life,  or,  as 
is  frequently  the  case,  to  injury  of  the  brain  and  consequent  impairment  of 
the  function  of  the  pneumogastrics  during  birth.  I  have  more  fully  treated 
of  this  form  of  atelectasis  in  the  chapters  which  relate  to  the  maladies  inci- 
dental to  the  birth  of  the  child,  and  to  these  the  reader  is  referred. 

Acquired  atelectasis,  or  collapse  of  lung,  is  less  extensive  than  con- 
genital atelectasis,  being  confined  to  a  portion  of  a  lobe  and  often  to  only  a 
few  lobules.  It  occurs  chiefly  during  the  period  of  infancy  and  in  feeble 
children.  It  is  a  common  malady  in  foundling  asylums  in  wasted  infants 
who  perish  before  the  close  of  the  first  year.  I  have  frequently  at  the 
autopsies  of  such  infants  observed  it  along  the  thin  inferior  margins  of  the 
lower  lobes  and  in  the  tongue-like  prolongation  of  the  left  upper  lobe.  In 
this  class  of  cases  catarrh  of  the  bronchial  tubes  appears  to  have  little  or  no 
agency  in  causing  the  collapse.  The  cause  is  found  in  the  impaired  functional 
activity  of  the  lungs.  In  the  state  of  debility  the  heart  beats  feebly  and 
the  stream  of  blood  from  it  to  the  lungs  is  small  and  slow,  so  that  the  inspira- 
tion of  a  small  amount  of  air  suffices  for  its  decarbonization.  The  inspira- 
tions also  are  seen  to  be  feeble,  causing  little  expansion  of  the  walls  of  the 


862  LOCAL  DISEASES.  » 

thorax.  Consequently,  the  entire  lung  is  imperfectly  inflated,  as  is  seen  in 
fatal  cases,  but  the  distant  thin  portions  of  the  organ  are  least  expanded. 
These,  receiving  little  or  no  air,  soon  begin  to  contract  from  the  presence  of 
the  elastic  tissue,  and  collapse  or  atelectasis  ensues. 

This  has  been  the  most  common  form  of  atelectasis  in  cases  of  this  malady 
which  I  have  observed  in  foundling  asylums,  and  it  probably  occurred  in  the 
manner  which  I  have  described. 

Another  case  of  acquired  atelectasis  to  which  all  writers  allude  is  bron- 
chial catarrh,  which,  commencing  in  the  larger  tubes,  extends  downward  into 
those  of  smallest  size.  By  the  swelling  of  the  mucous  membrane  and  the 
accumulation  of  viscid  muco-pus,  which  cannot  be  expectorated,  certain  of 
these  tubules  become  occluded,  so  that  the  inspired  air  is  shut  ofi"  from  the 
alveoli  situated  beyond  them.  Occlusions  are  obviously  most  likely  to  occur 
in  the  bronchitis  of  feeble  infants  whose  cough  has  little  expulsive  force, 
so  that  debility  is  also  a  factor  in  the  production  of  this  form  of  atelectasis. 
The  portion  of  lung  withdrawn  from  the  respiratory  function  soon  collapses, 
the  air  which  it  contained  being  probably  in  part  expired,  but  chiefly  absorbed. 

Atelectasis  is  not,  however,  so  important  or  frequent  a  complication  of 
bronchitis  as  was  formerly  supposed,  for  catarrhal  pneumonitis  due  to  exten- 
sion of  the  inflammation  from  the  bronchioles  into  the  lung  has  been  mistaken 
for  it.  Solid  non-crepitant  nodules  or  portions  of  lung  are  frequently  observed 
at  the  autopsies  of  infants  who  have  perished  of  severe  bronchitis,  and  these 
may  be  atelectatic  or  pneumonic,  but  they  are  more  frequently  the  latter  than 
was  formerly  supposed. 

The  possibility  of  insufilating  these  solid  portions  when  removed  from  the 
body  after  death  was  till  within  a  few  years  regarded  as'  decisive  proof  of 
atelectasis.  It  is  now  known  that  this  is  not  a  reliable  test,  since  a  lung 
solidified  by  recent  catarrhal  pneumonitis  can  be  almost  as  readily  inflated  as 
one  which  is  collapsed  ;  but  the  inflated  pneumonic  lung  is  more  solid  and 
resisting  when  pressed  between  the  thumb  and  fingers  than  is  the  collapsed 
lung.  The  decisive  proof  is  afi'orded  by  the  microscope,  by  which  cell-pro- 
liferation is  discovered  within  the  alveoli  in  catarrhal  pneumonitis,  while  it  is 
lacking  in  simple  collapse.  An  increase  of  the  dyspnoea  not  infrequently 
occurs  in  severe  infantile  bronchitis,  without  either  pneumonia  or  collapse 
from  the  accumulation  in  the  bronchioles  of  the  secretion  which  is  with 
difficulty  expectorated,  but  if  dulness  on  percussion  and  other  physical  signs 
indicate  solidification  of  the  lung  at  some  point,  of  course  pneumonia  or  col- 
lapse has  occurred.  If  a  sufficient  amount  of  lung  be  involved  to  produce 
well-marked  physical  signs,  the  disease  is  in  most  instances  pneumonia  and 
not  collapse,  though  it  may  be  the  latter.  Both  these  pathological  states 
may,  however,  occur  in  the  same  lung  as  complications  of  severe  bronchitis. 
The  severe  paroxysmal  cough  of  pertussis,  especially  when  accompanied  by 
considerable  secretion,  frequently  produces  collapse  of  portions  of  the  lower 
lobes,  while  it  causes  emphysema  in  the  upper  lobes. 

Symptoms. — Atelectasis  resulting  from  bronchitis  gives  rise  to  no  new 
symptoms.  So  far  as  it  has  any  appreciable  effect,  it  aggravates  certain 
symptoms  of  the  primary  disease,  but  as  it  is  ordinarily  limited  to  a  small 
area,  this  effect  is  not  very  marked.  When  a  bronchial  tube  is  so  occluded 
by  muco-pus  that  the  alveoli  with  which  it  communicates  collapse,  there  is 
ordinarily  at  the  same  time  more  or  less  accumulation  of  this  secretion  in 
other  tubes  throughout  the  lungs.  Therefore,  the  entrance  of  air  into  the 
alveoli  with  which  these  tubes  communicate  is  slow  and  difficult,  but  usually 
without  complete  obstruction  and  without  true  atelectasis,  but  with  a  semi- 
collapse  such  as  we  observe  in  fatal  croup.  This  explains  the  dyspnoea  which 
is  present  in  these  cases.     If  the  secretion  be  expectorated  from  these  tubes. 


ATELECTASIS.  863 

the  dyspnoea  abates,  even  if  the  plug  which  has  completely  occluded  a  tube 
and  the  consequent  atelectasis  remain. 

Atelectasis  occurring  in  wasted  and  feeble  infants  in  consequence  of  the 
diminished  force  of  the  inspirations  does  not  in  most  instances  give  rise  to 
any  prominent  symptom,  since  it  occurs  chiefly  in  distant  thin  portions  of 
the  lungs.  I  have  observed  an  occasional  short,  nearly  painless,  cough  in 
such  infants  when  the  autopsy  revealed  no  pulmonary  lesion  excej)t  the 
atelectasis. 

Anatomical  Characters. — The  portion  of  lung  which  is  affected  with 
recent  atelectasis  has  a  dark-brown  or  dark-bluish  color.  It  is  depressed 
below  the  general  level  of  the  lung,  is  firm  and  non-crepitant  on  pressure,  and 
its  incised  surface  is  smooth.  Hypergemia  supervenes,  because  a  portion  of 
lung  in  which  the  circulation  continues,  but  from  which  air  is  excluded,  becomes 
congested.  In  acquired  atelectasis  the  congestion  is  especially  marked,  since 
the  vessels  which  have  been  adapted  by  growth  for  a  larger  area  are  com- 
pressed into  one  of  smaller  extent,  so  that  they  become  tortuous  and  bulging 
within  the  lumina  of  the  alveoli,  while  the  free  flow  of  blood  through  them 
is  retarded  by  the  constriction  of  the  elastic  fibres  of  the  lung.  An  obvious 
and  certain  result  of  the  hypergemia  is  the  transudation  of  serum  into  the 
alveoli,  producing  oedema.  This  union  of  pulmonary  hyperaemia  with  oedema, 
by  which  air  is  excluded  from  the  alveoli,  constitutes  the  state  known  to 
pathologists  as  splenization,  and  in  proportion  as  it  occurs  the  lung  depressed 
by  the  atelectasis  rises  toward  the  general  level.  It  may  even  rise  above  it, 
and  it  now  has  a  doughy,  elastic  feel.  The  pathology  of  these  oedematous 
atelectatic  spots,  heretofore  obscure,  has  been  clearly  explained  by  Rindfleisch. 

If  the  patient  live  and  the  atelectatic  lobules  do  not  soon  return  to  a 
state  of  health,  they  undergo  further  changes.  Rindfleisch  says  :  "  From  the 
series  "  (of  changes,  provided  inflammation  do  not  occur)  "  we  especially  ren- 
der prominent  two  conditions — inveterate  oedema  and  slat2/  induration.  But 
inflammation  does  commonly  occur  after  a  time  in  a  collapsed  lung."  Those 
who  are  familiar  with  the  post-mortem  examination  of  infants  will  fully 
agree  with  Rindfleisch  when  he  says :  "  Splenization,  quite  generally  taken, 
appears  to  present  extraordinarily  favorable  preliminary  conditions  for  the 
occurrence  of  inflammatory  changes.  It  may  directly  represent  the  initial 
hypergemia  of  acute  inflammation,  and  be  followed  by  lobular  and  lobar,  but 
constantly  catarrhal,  infiltrates."  It  is  well  known  by  pathologists  that  pro- 
tracted congestion,  active  or  passive,  of  whatever  organ  or  tissue,  is  very 
liable  to  pass  from  a  state  of  simple  stasis  of  blood  to  one  of  cell-prolifer- 
ation, and  the  atelectatic  lung,  as  I  have  myself  observed  at  autopsies,  aff'ords 
a  common  example  of  this.  I  have  several  times  made  or  have  procured 
microscopic  examinations  of  the  atelectatic  portions  of  lungs  of  infants 
who  had  died  for  the  most  part  in  a  wasted  and  enfeebled  state,  and  have 
found  in  them  clear  evidence  of  the  presence  of  a  catarrhal  pneumonia. 
The  interesting  fact  therefore  must  be  recognized  that  atelectasis  frequently 
passes  to  a  state  of  inflammation,  so  as  to  present  the  characters  of  ordinary 
hypostatic  pneumonia,  and  no  doubt  undergo  the  same  subsequent  changes. 

Atelectasis  when  recent  and  simple  or  uncomplicated  may  soon  disappear 
by  the  expectoration  of  the  obstructing  secretion,  if  such  be  present  or  if 
there  be  no  obstruction  by  increased  force  of  inspiration.  If  it  do  not  soon 
disappear,  it  undergoes  one  of  the  ulterior  changes  alluded  to  above,  and 
henceforth  the  symptoms  and  history  are  those  of  the  new  malady  which 
has  supervened. 

Treatment. — The  treatment  of  acquired  atelectasis  is  simple.  If  it  be 
recent  and  there  be  evidence  that  it  is  due  to  the  accumulation  of  the  secre- 
tion in  the  bronchial  tubes,  an  emetic  which  acts  promptly  and  with  the 


864  LOCAL  DISEASES. 

least  possible  depression  may  be  very  useful.  It  is  especially  indicated  if 
there  be  little  or  no  pneumonia,  the  strength  not  greatly  reduced,  and  there 
be  dyspnoea  with  insufficient  decarbonization  of  blood  in  consequence  of  the 
abundance  of  the  secretion  in  the  smaller  tubes.  An  emetic  which  acts 
promptly  and  with  little  prostration  may  aid  greatly  in  establishing  the  res- 
piratory function  in  collapsed  lobules  by  expelling  the  obstruction  and  pro- 
ducing a  freer  and  deeper  inspiration.  One  of  the  best  if  not  the  best 
emetic  for  this  purpose  is  sulphate  of  copper,  given  in  a  dose  of  one  or  two 
grains  to  a  child  of  one  year.  With  or  without  the  use  of  the  emetic,  our 
main  reliance  must  be  on  sustaining  and  stimulating  measures,  by  which  the 
cough,  the  cry,  and  the  inspirations  acquire  more  volume  and  force.  Most 
cases  require  alcoholic  stimulants  and  the  ammonium  carbonate.  Rube- 
facient applications  to  the  chest  are  also  commonly  employed,  and  are 
probably  useful. 


CHAPTER    IX. 


PNEUMONIA. 


Catarrhal  pneumonia  is  the  common  form  of  pneumonia  under  the  age 
of  three  years.  In  most  cases  it  results  from  bronchitis  by  extension  of  the 
inflammation.  Hence  it  is  designated  by  the  terms  broncho-pneumonia  and 
lobular  pneumonia. 

Etiology. — Catarrhal  pneumonia,  as  we  have  stated  above,  commonly 
results  from  simple  bronchitis.  The  inflammation,  affecting  first  the  larger 
bronchial  tubes,  extends  to  the  bronchioles,  and  from  them  to  the  air-cells 
in  certain  lobules.  Its  causes  under  such  circumstances  are  evidently  the 
same  as  those  of  the  bronchitis  which  precedes  and  accompanies  it.  It  often 
occurs  as  a  complication  of  certain  infectious  maladies,  among  which  we  may 
mention  pertussis,  measles,  diphtheritic  croup,  influenza,  and,  more  rarely, 
scarlatina,  variola,  typhoid  fever,  and  erysipelas.  Ill-nourished,  rachitic,  and 
anaemic  children  with  little  power  of  resistance  are  most  liable  to  it.  It  is 
in  the  cities  especially  common  among  the  children  of  the  tenement-houses, 
who  live  in  small,  overcrowded,  overheated,  and  dirty  apartments,  and  are 
frequently  taken  from  these  apartments  to  the  lower  temperature  of  the 
streets  or  are  exposed  at  open  windows.  Diff"erent  opinions  have  been 
expressed  as  to  the  mode  in  which  pneumonia  supervenes  upon  capillary 
bronchitis.  We  have  already  called  attention  to  the  theory  of  Buhl,  that 
the  alveoli  become  inflamed  by  the  entrance  into  them  from  the  bronchioles, 
during  inspiration,  of  inflammatory  products,  which  act  as  an  irritant.  A  form 
of  subacute  catarrhal  pneumonia  sometimes  results  from  hypostasis  or  passive 
congestion.  It  is  not  uncommon  in  infant  asylums  in  infants  enfeebled  by 
chronic  disease,  who  have  weak  action  of  the  heart  and  languid  circulation. 
Lying  in  their  cribs  day  after  day,  with  little  movement  of  the  body,  they 
are  very  liable  to  passive  congestion  of  depending  portions  of  their  lungs,  and 
this  by  and  by  eventuates  in  a  pneumonia  presenting  some  peculiarities  of 
the  catarrhal  form.  It  is  sometimes  designated  hypostatic  pneumonia.  It  is 
so  frequent  in  foundling  asylums,  where  feeble  infants  are  received  and  treated, 
that  certain  physicians,  whose  observations  have  been  largely  in  such  institu- 
tions, have  almost  ignored  any  other  form  of  pneumonia  in  infants.  Billard, 
a  close  and  accurate  observer,  wrote  nearly  half  a  century  ago  :  •'  Pneumonia 
of  infancy  presents  peculiar  characters,  in  which  it  diflfers  from  the  same 
aff'ection  in  adults.  Instead  of  being  an  idiopathic  afiection  arising  fi'om 
irritation  developed  in  the  pulmonary  tissue  under  the  influence  of  atmo- 


PNEUMONIA.  865 

spheric  causes,  -whicli  often  escite  disease,  the  pneumonia  of  young  infants 
is  evidently  the  result  of  a  stagnation  of  blood  in  their  lungs.     Under  these 

circumstances  this  blood  may  be  regarded  as  a  kind  of  foreign  body 

It  would  therefore  appear  that  inflammation  of  the  lungs,  which  produces 
hepatization,  arises  in  infants,  in  general,  from  some  mechanical  or  physical 
cause.'"  Yalleix  also  states  that  he  found  the  lesions  of  pneumonia  in  a 
majority  of  the  infants  who  died  in  the  Hopital  des  Enfants  Trouves.  The 
statements  of  Valleix  are  applicable  also  to  the  Infants'  Hospital,  the  Found- 
ling Asylum,  and  the  Xursery  and  Child's  Hospital  of  New  York  City,  as 
regards  those  cases  in  which  death  results  from  chronic  disease.  We  shall 
see  hereafter  that  hypostatic  pneumonia  is  also  a  common  complication  of 
chronic  infantile  entero-colitis,  the  summer  complaint  of  the  cities. 

Catarrhal  pneumonia  of  infants  sometimes  results  from  atelectasis  or 
collapse.  It  is  not  unusual  to  find,  at  the  autopsies  of  infants  who  have 
died  in  a  state  of  emaciation  and  feebleness,  portions  of  the  lungs  remote 
from  the  bronchi  collapsed,  as,  for  example,  the  thin  edges  of  the  inferior 
lobes  and  the  tongue-like  process  of  the  upper  lobe,  the  process  which  lies 
over  the  heart.  The  immediate  cause  of  the  collapse  has  been  a  bronchitis, 
or  it  has  resulted  directly  from  the  general  weakness  of  the  infant  and  its 
feeble  respirations.  Now,  a  collapsed  lung  soon  becomes  the  seat  of  passive 
congestion.  The  functional  activity  of  an  organ  favors  circulation  through 
it.  and  if  the  function  be  abolished  the  flow  of  blood  in  the  part  is  retarded 
and  stasis  more  or  less  complete  results.  The  hyperjemic  state  of  collapsed 
pulmonary  lobules  presents  the  same  anatomical  condition  for  the  superven- 
tion of  pneumonia  as  occurs  in  cases  of  hypostatic  congestion.  Consequently, 
cell-proliferation  soon  begins  in  the  collapsed  alveoli,  the  volume  of  the  afi"ected 
lung  increases,  and  it  becomes  firmer  and  more  resisting  to  the  touch,  and  the 
microscope  reveals  the  characters  of  a  subacute  but  genuine  catarrhal  pneu- 
monitis. I  have  made  or  have  procured  microscopic  examinations  of  a  con- 
siderable number  of  such  specimens,  and  have  found  the  alveoli  more  or  less 
filled  with  cells  of  the  epithelial  character.  (See  chapter  on  Atelectasis.) 
Pneumonia  resulting  from  hypostatic  congestion  and  that  occurring  from 
atelectasis  are  not  only  subacute,  but  usually  protracted. 

Anatomical  Chakacters. — If  we  have  an  opportunity  to  make  a  post- 
mortem inspection  of  the  inflamed  lung  when  broncho-pneumonia  has  con- 
tinued a  few  days,  we  will  find  the  pleura  covering  it  either  normal  or  covered 
in  spots  with  a  thin  film  of  fibrin.  The  bronchial  tubes  contain  muco-pus,  and 
their  walls  are  thickened  and  congested.  The  inflamed  lobules  are  few  or 
many,  and  they  are  more  numerous  in  the  lower  lobes  and  in  its  posterior 
portion  than  elsewhere.  Their  incised  surface  is  not  granular,  as  in  croupous 
pneumonia,  but  smooth,  and  its  color  in  recent  cases  is  a  pale  red  or  deep  red. 
In  protracted  cases  the  color  may  be  grayish,  but  the  change  from  red  to 
gray  hepatization  does  not  occur  as  early  as  in  lobar  or  croupous  pneumonia, 
so  that  weeks  after  the  commencement  of  inflammation  in  the  lobule  its  color 
may  be  red.  White  points  or  lines  in  the  lobule  indicate  the  location  of  the 
bronchioles.  The  inflamed  lobule  is  in  some  cases  very  distinct  from  the 
surrounding  healthy  parenchyma,  but  in  other  instances  it  gradually  blends 
with  it. 

In  some  cases  the  air-vesicles  contain  chiefly  pus,  in  others  chiefly  epithe- 
lial cells  or  epithelial  cells  and  pus.  and  in  others  still  epithelium,  pus.  and 
fibrin.  Mixed  with  these  inflammatory  products  we  detect  also  red  blood- 
corpuscles.  The  capillaries  in  the  walls  of  the  vesicles  are  large  and  sinuous. 
The  amount  of  inflammatory  products  in  the  alveoli  varies  greatly  in  difi"erent 
eases.  The  alveoli  may  be  only  partially  filled,  or  they  may  be  so  packed 
that  it  is  difficult  to  detect  the  alveolar  walls.     The  adjacent  non-hepatized 


866  LOCAL  DISEASES. 

lobules  do  not  exhibit  any  marked  change,  except  that  their  epithelial  cells 
may  be  somewhat  swollen  and  more  distinct  than  in  health.  The  bronchial 
tubes  not  only  contain  more  or  less  muco-pus  and  epithelial  cells,  but  their 
walls  are  frequently  thickened  and  infiltrated  with  pus-cells  and  connective- 
tissue  cells.  This  infiltration  causes  the  bronchioles  to  appear  as  white  lines 
or  dots  in  the  inflamed  area. 

In  protracted  cases  the  red  color  changes  to  gray,  this  change  commencing 
in  the  interior  of  the  lobules  and  extending  outward.  In  gray  hepatization 
the  epithelial  and  pus-cells  have  undergone  granulo-fatty  degeneration.  If 
resolution  do  not  occur  and  the  disease  reach  a  still  more  advanced  stage,  the 
granulo-fatty  degeneration  becomes  more  complete,  and  the  lobules  enter  the 
stage  of  cheesy  degeneration,  becoming  yellowish-white  and  hard  and  homo- 
geneous, the  elements  which  make  up  the  lobules  being  no  longer  discernible. 
The  ulterior  change  in  the  gravest  cases  is  softening  and  the  formation  of 
cavities,  or  interstitial  pneumonia  may  supervene,  with  an  increase  of  the 

Fig.  240. 


~S-, 


Fig.  240  represents  an  inflamed  air-vesicle  from  the  lung  of  a  child  who  died  of  catarrahal 
pneumonia  supervening  on  pertussis.    From  Delafield's  Pathological  Anatomy. 

connective  tissue.  Cheesy  degeneration  and  interstitial  pneumonia  are  much 
more  frequent  in  lobular  pneumonia,  the  disease  which  we  are  describing, 
than  in  lobar  or  croupous  pneumonia,  and  when  the  stage  of  cheesy  degen- 
eration is  reached  the  conditions  are  present  in  which  tuberculosis  is  likely 
to  supervene. 

In  a  large  proportion  of  instances,  when  broncho-pneumonia  has  not  con- 
tinued longer  than  two  or  three  weeks,  the  inflamed  lobules  can  be  inflated 
after  death.  We  would  infer  that  this  would  be  possible  in  cases  in  which 
the  alveoli  are  only  partially  filled  with  the  cellular  elements.  It  was  for- 
merly supposed  that  if  an  infant  died,  having  had  the  dyspnoea  and  other 
symptoms  characteristic  of  severe  bronchitis  or  broncho-pneumonia,  and  por- 
tions of  the  lungs  were  found  firm  and  without  air,  if  they  could  be  inflated, 
the  pathological  state  was  atelectasis ;  if  they  could  not  be  inflated,  it  was 
pneumonia.  But  I  have  many  times  been  able  to  inflate  lobules  that  were 
undoubtedly  inflamed,  though  when  inflated  they  were  still  semi-solid  on 
palpation,  so  that  other  tests  besides  the  fact  of  insufflation  or  non-insufflation 
enable  us  to  determine  whether  atelectasis  or  pneumonia  be  present.  Still, 
as  we  have  elsewhere  stated,  a  lung  primarily  collapsed  is  very  liable  to  take 
on  a  low  grade  of  pneumonia. 


PNEUMONIA.  867 

Croupous  pneumonia,  also  designated  fibrinous  and  lobar,  is  the  common 
form  of  pneumonia  in  the  adult,  and  it  is  not  infrequent  in  children  over  the 

Fig.  241. 


Fig.  241  represents  lobular  pneumonia  of  a  more  severe  grade,  some  fibrin  being  present  in  the 
centre  of  the  air-vesicle.    From  Delafleld's  Pathological  Anatomy. 

age  of  five  years.  It  rarely  occurs  under  the  age  of  three  years,  but  cases 
have  been  reported.  It  involves  an  entire  lobe  or  a  large  part  of  a  lobe. 
Besides  the  parenchyma,  the  smaller  bronchial  tubes  also  participate  in  the 
inflammation.  Croupous  pneumonia  is  usually  a  primary  disease,  but  it  is 
occasionally  secondary,  as,  for  example,  when  it  occurs  in  certain  debilitating 
diseases,  as  nephritis,  or  in  infectious  diseases,  as  in  measles  and  pertussis. 

Etiology. — Formerly  croupous  pneumonia  was  commonly  attributed  to 
catching  cold,  but  the  microscopic  examinations  and  experiments  of  Klebs, 
Friedlander,  and  Frankel  have  shown  that  this  disease  is  microbic,  and  the 
two  latter  gentlemen,  it  is  believed,  have  detected  the  microbe  which  causes 
the  inflammation  in  ordinary  cases,  and  they  have  given  it  the  name  pneumo- 
coccus.  It  has  a  breadth  of  about  one-third  its  length,  and  it  occurs  in 
groups  of  two  or  more  surrounded  by  a  gelatinous  envelope.  According  to 
the  observations  of  Salvioli,  Eberth,  and  Nauwerk,  it  appears  that  the 
pneumococci  may  also  enter  the  general  circulation,  and,  being  conveyed  to 
distant  organs,  may  excite  inflammation  in  them  ;  as,  for  example,  nephritis, 
meningitis,  and  pericarditis.  In  ordinary  cases  of  croupous  pneumonia  it  is 
probable  that  the  pneumococcus  has  entered  the  lungs  by  inspiration  of 
infected  air,  and  certain  observers  believe  that  it  sometimes  enters  the 
blood  and  produces  disease  elsewhere,  while  the  lungs  escape.  Croupous 
pneumonia  is  more  common  in  certain  yeai'S  and  certain  seasons  than  in 
others.  Its  frequency  in  the  spring  months  has  been  mentioned  by  physi- 
cians in  different  countries.  It  was  common  among  children  in  April,  1890, 
in  New  York  City  after  a  mild  and  very  rainy  winter,  the  disease  commencing 
suddenly  with  considerable  elevation  of  temperature,  and  the  physical  signs 
of  pneumonia  being  sufficient  for  diagnosis  on  the  second,  third,  or  fourth 


868  LOCAL  DISEASES. 

day.  Epidemics  of  croupous  pneumonia  sometimes  occur  in  certain  localities, 
lasting  weeks  or  months,  and  there  are  also  certain  infected  houses  in  which 
new  cases  of  this  inflammation  occur  during  many  months.  In  the  Amberg 
prison  in  1880,  161  cases  of  pneumonia  were  treated,  and  in  the  ceiling  of 
the  dormitory  in  which  most  of  the  cases  occurred  Keller  detected  pneumo- 
cocci.  cultivated  them,  and  successfully  inoculated  animals  with  them.  Bad 
ventilation,  overcrowding,  and  uncleanliness  favor  the  occurrence  of  pneumo- 
nia, and  epidemics  have  ceased  when  troops  were  removed  from  crowded  and 
infected  barracks  to  those  that  were  more  spacious  and  cleaner. 

It  is  the  opinion  of  some  good  observers  that  other  microbes  besides  the 
pneumococcus  may  cause  croupous  pneumonia — that  when  this  form  of  pneu- 
monia occurs  in  the  common  infectious  diseases,  as  scarlet  fever,  pertussis, 
and  measles,  the  specific  microbes  of  these  diseases  enter  the  alveoli  and 
excite  the  inflammation.  Prof.  Prudden,  who  has  given  much  attention  to 
the  pathology  of  pneumonia,  expresses  the  opinion  that  while  the  pneumo- 
coccus ordinarily  causes  croupous  pneumonia,  it  may  result  from  other 
microbes,  especially  when  it  occurs  as  a  complication  of  the  common  microbic 
or  infectious  diseases.  It  is  a  question  also  whether  it  does  not  sometimes 
occur  without  the  agency  of  microbes — especially  from  taking  cold,  in  accord- 
ance with  the  popular  belief — and  in  those  rare  cases  in  which  it  results 
from  severe  injuries  it  seems  probable  that  the  microbe  is  not  the  causal  agent. 

Anatomical  Characters. — Croupous  or  lobar  pneumonia  afiects  an 
entire  lobe  or  even  an  entire  lung.  Its  first  stage  is  that  of  congestion,  which 
is  characterized  by  distention  of  the  arterioles  and  an  increased  afilux  of  blood 
to  the  part.  In  the  second  stage,  or  that  of  red  hepatization,  the  lung  becomes 
more  solid  and  resisting  on  palpation,  and  at  the  same  time  it  breaks  down 
easily  on  pressure.  Its  color  is  a  deep  red,  and  its  section  presents  the 
appearance  of  granules  closely  aggregated.  Each  granule  is  the  contents  of 
an  air-cell.  The  bronchial  tubes  connecting  with  the  inflamed  lobule  contain 
muco-pus,  fibrin,  and  epithelium,  and  the  pleura  covering  the  inflamed  lobe  is 
coated  with  fibrin. 

The  substance  which  fills  the  air-vesicles  and  gives  the  torn  or  incised 
surface  of  the  inflamed  lobe  its  granular  appearance  consists  of  epithelial 
cells,  pus-cells,  red  blood-globules,  and  fibrin.  The  blood-vessels  are  dis- 
tended with  non-coagulated  blood.  The  fibrin  usually  occurs  in  a  network. 
The  epithelial  cells  are  abundant,  and  they  are  frequently  enlarged  and 
granular.  The  pus-cells  are  abundant ;  the  red  corpuscles  are  few,  or  they 
may  be  so  abundant  that  they  fill  some  of  the  air-vesicles.  When  the 
second  stage,  or  that  of  red  hepatization,  is  completed,  the  air-vesicles  are 
entirely  filled  with  the  inflammatory  products,  so  that  in  the  cadaver  they 
cannot  be  inflated.  The  third  stage,  or  that  of  gray  hepatization,  gradually 
supervenes  after  a  few  days  upon  the  stage  of  red  hepatization,  a  gray  mottling 
first  occurring  ;  subsequently  the  gray  color  becomes  complete.  In  this  stage 
the  same  elements  remain,  but  the  congestion  diminishes,  the  red  corpuscles 
lose  their  color,  and  the  inflammatory  products  gradually  undergo  granular 
degeneration.  When  they  are  fllled  with  granules  the  red  color  is  entirely 
replaced  by  the  gray.  Dr.  Delafield  states  that  the  inflamed  lung  was  found 
in  this  state  in  one-fourth  of  the  cases  examined  by  him.  Death  occurred  in 
these  cases  between  the  fourth  and  twenty-fifth  days.  The  stage  of  resolu- 
tion succeeds  in  favorable  cases,  in  which  the  inflammatory  products  soften, 
liquefy,  and  are  absorbed  or  expectorated.  The  hepatized  lung,  instead  of 
resolving,  may  undergo  a  change  identical  with  or  closely  resembling  cheesy 
degeneration.  It  becomes  dry  and  firm  and  of  a  white  cheesy  color.  Epi- 
thelium, pus,  and  fibrin  can  be  detected  in  some  of  the  alveoli,  while  in  others 
they  are  replaced  by  a  granular  mass.     Again,  in  severe  cases  portions  of  the 


PNEUMONIA.  869 

lung  may  undergo  necrosis  in  consequence  of  arrest  of  circulation.  Delafield 
has  observed  in  these  cases  the  presence  of  a  large  amount  of  fibrin,  and  but 
little  pus  and  epithelium.     At  a  later  stage  the  cavities  formed  contained  pus. 

Fig.  242. 


Fig.  242  represents  an  air-vesicle  from  the  lung  of  a  patient  who  died  forty-eight  hours  after 
the  commencement  of  croupous  pneumonia.  The  vesicle  is  only  partially  filled  with  in- 
flammatory products,  on  account  of  the  brief  duration  of  the  inflammation.  From  Dela- 
field's  Pathological  Anatomy. 

This  is  a  serious  state,  which  is  likely  to  eventuate  in  cheesy  degeneration  of 
the  bronchial  glands  and  tuberculosis. 

Septic  or  embolismal  pneumonia  sometimes  occurs  in  infancy  and  child- 
hood, as  it  more  frequently  does  in  the  adult,  from  an  embolus  detached  from 
a  clot  which  had  formed  in  some  remote  vein,  in  consequence  of  arrest  of  cir- 
culation in  it,  by  inflammation  of  the  contiguous  tissues.  This  is  described 
by  writers  as  a  distinct  form  of  pneumonia,  designated  embolic  or  embolismal. 
A  specimen  showing  this  mode  of  causation  was  exhibited  by  me  at  the  New 
York  Pathological  Society  in  February,  1868.  An  infant,  born  January  22, 
1868,  of  strumous  parents  had  been  fretful,  but  without  appreciable  ailment 
till  February  3d,  when  inflammation  of  the  connective  tissue  occurred  on  the 
anterior  aspect  of  the  left  leg,  a  little  below 
the  knee.  This  extended  downward,  sup- 
purated, and  the  pus  was  evacuated  February 
5th.     In  the  mean  time  three  other  similar 

inflammations    occurred — two    on   the    right  ^/^  ^  ^f  i   ^^^ 

foot  and  leg,  and  the  other  over  the  parietes  ["^     <■       -;)X\^^  l\>s. 

of  the  chest  in  the  right  inframammary  re-  ^   '^      /tV  \^f,    >  >?    '¥ 

gion.     Suppuration  occurred  in  all  of  these.  ^5^,  f  '^^<J:A\        ^AS-'--?^ 

On  February  8th  this  infant  was  suddenly       ^.     V^''''^^^-    -^ -^^  '^0^M 
seized  with  extreme  dyspnoea,  and  died  in  a         ^1'  «?  ,l^^^  'K%,::^»t*  . 
few  hours.     Numerous  minute  puriform  col-       5s%,|  i*'/^^%}    ^  ^^^     % 
lections  (formerly  called  metastatic  abscesses)        ^|ri     ^K<^^f  fe'   'f!^^  ^ 
were  discovered  in  each  lung,  most  of  them  '  "^^^  f^* -^^ -^ 

scarcely  larger  than  a  pin's  head.     One   of 
them,  on  the  right  side  in  the  middle  lobe,  connecting  with  a  bronchial  tube, 


870  LOCAL  DISEASES. 

had  ruptured  into  the  pleural  cavity,  causing  pneumothorax,  collapse,  and 
incipient  pleuritis. 

Fig.  2-13  exhibits  the  microscopic  appearance  of  this  softened  fibrin,  which 
to  the  naked  eye  so  closely  resembled  pus. 

On  account  of  the  speedy  death  the  emboli  had  produced  in  the  lobules 
where  they  had  lodged  little  more  than  congestion  or  the  first  stage  of  pneu- 
monia around  them.  Had  the  infant  lived  longer,  doubtless  the  microbes 
and  ptomaines  would  have  caused  a  greater  amount  and  more  advanced  stage 
of  pneumonia. 

Cheesy  degeneration  of  the  inflammatory  product  occasionally  occurs  in 
the  croupous  form  of  inflammation,  but  it  is  more  common  in  the  catarrhal. 
I  have  most  frequently  observed  it  in  New  York  during  epidemics  of  measles 
when  this  form  of  pneumonia  supervened  upon  the  catarrhal  bronchitis  of 
that  disease.  Cheesy  pneumonia  is  in  its  nature  chronic  and  attended  with 
great  reduction  of  the  vital  powers. 

Cheesy  degeneration  of  the  exudate  consists  essentially  in  the  absorption 
of  the  liquid  portion  and  fatty  degeneration  of  the  solid.  The  obstruction 
of  the  circulation  in  the  capillaries  and  the  accumulation  of  cells  in  the 
alveoli  and  bronchioles  which  cannot  be  expectorated  are  conditions  which 
favor  cheesy  metamorphosis.  The  appearance  and  consistence  of  the  lung 
when  it  has  undergone  this  change  are  well  expressed  by  the  term  which  is 
employed  to  designate  it.  The  cheesy  mass  consists  of  fatty,  shrivelled,  and 
fragmentary  cells,  and  amorphous  matter  in  which  can  be  traced  the  fibres 
of  connective  tissue  and  larger  vessels  of  the  parenchyma,  the  other  histo- 
logical elements  having  disappeared. 

The  caseous  mass  after  a  time  softens,  attracting  moisture  from  the  sur- 
rounding tissues.  The  molecular  detritus  and  the  shrivelled  cells  are  now 
suspended  in  a  liquid,  and,  like  any  dead  matter,  they  are  irritant  to  the  sur- 
rounding lung-substance.  The  bronchial  tube  which  supplies  the  afi'ected 
lobule,  and  which  in  many  instances  was  the  starting-point  of  the  disease, 
again  becomes  pervious,  either  by  softening  of  the  plug  or  by  ulceration  at 
a  higher  point  upon  its  walls  and  air  is  admitted,  which  promotes  the  putre- 
factive process  and  chemical  changes  of  the  caseous  substance. 

The  presence  of  softening  caseous  m'atter  in  the  lungs  very  frequently 
leads  to  the  development  of  tubercles  (see  chapter  on  Tuberculosis),  and 
accordingly  before  the  case  ends  clusters  of  tubercles  may  appear  in  the 
connective  tissue  and  walls  of  the  vessels  of  the  lungs  and  in  other  organs. 

The  SYMPTOMS  of  acute  pneumonia,  whether  catarrhal  or  croupous,  are 
the  following :  Anorexia,  thirst,  restlessness,  elevation  of  temperature,  accel- 
eration of  pulse  according  to  the  intensity  of  the  inflammation  and  the  fee- 
bleness of  the  patient,  flushed  face,  a  countenance  expressive  of  suffering, 
accelerated  respiration,  with  an  expiratory  moan.  These  symptoms  are  con- 
stant in  the  acute  inflammation  unless  of  the  mildest  form.  Those  which 
are  important  I  shall  explain  more  fully. 

The  expiratory  moan  is  described  by  writers  as  a  pathognomonic  sign 
of  pneumonia  or  of  pleurisy.  It  is  due  to  the  pain  experienced  from  the 
movement  of  the  inflamed  part.  As  a  rule,  the  expiratory  moan  indicates 
either  pneumonia  or  simple  pleuritis ;  but  there  are  exceptions.  It  may 
occur,  for  example,  from  indigestible  substances  in  the  stomach  and  intes- 
tines, giving  rise  to  acute  dyspepsia,  or  from  certain  forms  of  abdominal 
inflammation  which  render  movements  of  the  diaphragm  painful,  as  dia- 
phragmatic peritonitis. 

The  cough  in  the  first  days  of  pneumonia  is  usually  dry  or  hacking  and 
painful.  It  afterward,  if  the  case  be  favorable,  becomes  looser  and  is  pain- 
less.    "We  very  seldom  observe  in  the  child  the  bloody  sputum,  which  cha- 


PNEUMONIA.  871 

racterizes  pneumonia  in  the  adult,  since  in  catarrhal  inflammation  there  is 
much  less  exudation  of  blood-corpuscles.  The  sputum,  which  in  this  form 
of  the  disease  is  the  product  of  secretion  and  cell-proliferation,  is  at  first  thin 
and  frothy,  but  afterward  thicker  and  less  tenacious  from  the  increased  num- 
ber of  cells.  There  is  often,  in  the  first  period  of  the  inflammation,  pretty 
severe  and  constant  headache,  the  patient  complaining  of  the  head,  if  old 
enough  to  speak,  before  he  does  of  the  chest.  In  a  severe  attack,  the  child 
at  this  period  lies  with  the  eyes  shut,  apparently  in  a  half-conscious  state, 
fretful  if  spoken  to  or  aroused,  so  that  the  physician  may  be  led  to  suspect 
the  presence  of  cerebral  disease.  If  there  be  vomiting  accompanied  with 
sudden  twitching  of  the  muscles  and  convulsions — symptoms  which  some- 
times occur — the  liability  to  error  in  diagnosis  is  greatly  increased.  Cerebral 
symptoms  are  more  prominent  in  the  commencement  of  pneumonia  than  sub- 
sequently. As  the  disease  advances  they  subside,  and  symptoms  referable  to 
the  chest  become  more  conspicuous. 

The  breathing  is,  as  I  have  said,  accelerated.  Thirty  or  forty  respirations 
per  minute  are  common,  and  in  severe  cases  the  number  reaches  sixty  or  even 
eighty.  In  infancy  there  is  greater  frequency  of  respiration  than  in  child- 
hood. In  those  at  the  breast,  if  the  dyspnoea  be  urgent,  nutrition  is  some- 
times seriously  interfered  with,  since  in  these  severe  cases  respiration  is  per- 
formed more  through  the  mouth  than  nostrils,  so  that  if  the  infant  seize  the 
nipple  it  is  forced  to  relinquish  it  in  order  to  breathe.  Dilation  of  the  alae 
nasi  and  depression  of  the  inframammary  region  accompany  in.spiration.  The 
dyspnoea  in  catarrhal  pneumonia  is  often  due  in  great  part  to  accompanying 
bronchitis. 

The  temperature  in  mild  cases  of  pneumonia  is  elevated  to  about  101°  to 
103° ;  in  severe  cases  it  may  reach  105°,  or  even  107°,  the  former  being  the 
highest  observed  by  Mr.  Squire.  In  97  observations  made  by  M.  Roger  the 
average  temperature  was  104°  during  the  active  period  of  the  inflammation. 
The  face  is  therefore  flushed  and  the  heat  of  surface  pungent,  except  in 
weakly  children,  in  whom,  even  in  severe  and  active  inflammation,  the  face 
is  sometimes  pallid  and  the  extremities  of  natural  or  less  than  natural 
temperature. 

The  tongue  is  moist  and  covered  with  a  light  fur ;  the  thirst  is  such  that 
nutriment  may  be  given  in  the  form  of  drinks  when  the  loss  of  appetite  pre- 
vents the  use  of  solid  food.  The  bowels  are  usually  constipated.  The  secre- 
tions in  the  first  and  second  stages  are  diminished.  The  urine  is  more  deeply 
colored  than  in  health,  and  in  vigorous  patients  it  deposits  urates  on  cooling. 
The  chlorides  are  also  deficient  or  absent  from  the  urine  so  long  as  the  inflam- 
mation is  extending. 

In  favorable  cases  in  from  seven  to  ten  days  the  heat  and  thirst  decline  ;. 
the  pulse  and  respiration  gradually  become  less  frequent ;  the  cough  looser  ; 
the  features  have  a  more  placid  or  contented  expression ;  the  appetite 
returns  ;  and  the  patient  is  again  amused  by  playthings.  The  improvement 
is  progres,sive,  but  gradual.  A  slight  cough  is  occasionally  observed  two  or 
three  weeks  after  convalescence  is  fully  established. 

Death  in  the  acute  stage  of  the  inflammation  commonly  occurs  from 
asthenia.  The  pulse  gradually  becomes  more  frequent  and  feeble,  the  respi- 
ration more  oppressed,  and  finally,  near  the  close  of  life,  the  face  and  extrem- 
ities become  cool.  Occasionally  death  results  from  apnoea,  due  in  great  part 
to  coexisting  bronchitis.  In  exceptional  instances  it  occurs  from  convul- 
sions, followed  by  coma,  especially  in  the  first  week.  In  those  protracted 
eases  in  which  the  inflammatory  products  have  undergone  cheesy  degenera- 
tion death  occurs  from  asthenia. 

Such  are  the  symptoms  and  progress  of  ordinary  acute  pneumonia  in 


872  LOCAL  DISEASES. 

children.  When  the  inflammation  is  subacute,  as  in  those  forms  of  the  dis- 
ease which  result  from  collapse  or  hypostasis,  the  symptoms  are  less  pro- 
nounced. The  respiration  in  such  cases  is  but  moderately  accelerated,  is 
attended  by  little  pain,  and  therefore  the  expiratory  moan  is  often  absent. 
An  occasional  short,  dry  cough  occurs,  with  so  little  increase  of  temperature 
and  quickening  of  the  pulse  that  the  pneumonia  is  often  overlooked  by  the 
physician,  the  symptoms  being  refen-ed  to  bronchitis.  Pleuritis  seldom  occurs 
in  connection  with  this  form  of  pneumonia,  except  when  a  small  abscess  or 
gangrene  results  in  an  affected  lobule  directly  under  the  pleura.  A  few 
such  cases  I  have  observed. 

Tubercular  pneumonia  extends  over  much  or  little  of  the  lung  accord- 
ing to  the  amount  of  the  tubercles.  The  symptoms  are  like  those  of 
severe  primary  pneumonia,  superadded  to  such  as  pertain  to  tuberculosis. 
This  inflammation,  when  once  established  in  the  consumptive  child,  com- 
monly continues  till  the  close  of  life.  I  have  sometimes  had  these  cases 
under  observation  several  consecutive  weeks,  even  months,  and  during  the 
whole  time  there  was  not  only  acceleration  of  pulse  and  respiration,  but  the 
expiratory  moan.  As  regards  pneumonia  occurring  in  whooping  cough,  it  is 
an  interesting  fact  that  it  sometimes  modifies  the  symptoms  of  the  primary 
disease,  so  that  dui'ing  the  active  period  of  the  inflammation  the  paroxysmal 
cough  diminishes,  and  a  short,  hacking  cough  and  expiratory  moan  occur  in  its 
place.  As  the  inflammation  abates  the  spasmodic  cough  returns.  Pneumo- 
nia occurring  in  measles  is  more  obstinate,  protracted,  and  dangerous  than 
the  primary  form.  It  usually  commences  about  the  period  of  the  decline  of 
the  eruption,  and  in  favorable  cases  continues  two  or  three  weeks.  It  is 
then  a  sequel  rather  than  a  complication. 

Physical  Signs. — The  physical  signs  of  pneumonia  in  infancy  and 
childhood  are  the  same  as  in  the  adult,  but  in  a  large  proportion  of  cases 
they  are  less  distinct.  In  a  majority  of  patients  under  the  age  of  three 
years  the  crepitant  rale  is  not  observed.  This  is  due  to  the  small  size  of  the 
alveoli  at  this  age.  I  have  now  and  then  detected  it  in  quite  young  children, 
in  whom  it  is  a  finer  rale  than  in  the  adult.  If  observed  it  is  positive  proof 
of  the  existence  of  pneumonia.  The  physical  signs,  therefore,  in  the  first 
stage  of  the  inflammation  are  often  obscure  in  consequence  of  the  absence 
of  the  pathognomonic  rale.  The  vesicular  murmur  is  somewhat  intensified 
through  the  chest,  and  there  is  at  this  stage  slight  dulness  on  percussion 
over  the  seat  of  the  inflammation,  due  to  engorgement  of  the  vessels,  but  it 
is  difficult  to  appreciate  this. 

In  the  second  stage,  which  supervenes  more  or  less  rapidly,  the  physical 
signs  are  more  distinct.  Bronchial  respiration  is  in  most  cases  detected 
higher  in  pitch  than  the  vesicular  murmur,  with  the  sound  of  expiration 
higher  than  that  of  inspiration.  The  voice  of  the  patient  is  transmitted  to 
the  ear  applied  over  the  seat  of  the  disease,  and  often  a  peculiar  vibratory 
sensation  is  communicated  to  the  hand  applied  over  the  part,  so  that  it  is 
possible  to  locate  the  disease  by  palpation  alone.  In  the  second  stage,  and 
sometimes  in  the  first,  coarse  mucous  rales  in  various  parts  of  the  chest  are 
often  observed  occurring  from  coexisting  bronchitis. 

Percussion  in  the  second  stage  elicits  a  dull  sound  as  compared  with  that 
produced  on  the  opposite  side  of  the  chest.  The  dulness  corresponds  in 
extent  with  the  solidification  and  with  the  bronchial  respiration. 

As  the  inflammation  abates  the  dulness  on  percussion  gradually  dimin- 
ishes, and  the  bronchial  respiration  is  succeeded  by  the  subcrepitant  rale. 
Often  for  a  considerable  period  after  convalescence  is  established  moist  rales 
are^  observed  in  the  chest,  and  sometimes  the  dulness  on  percussion  does  not 
entirely  disappear  until  the  health  is  fully  restored. 


PNEUMONIA.  873 

In  catarrhal  pneumonia  these  signs  are  commonly  less  distinct  than  in 
the  croupous  form  of  inflammation.  This  is  due  in  part  to  the  limited 
extent  of  the  inflammation,  in  part,  in  many  cases,  to  its  subacute  character, 
and  in  part  to  the  fact  that  it  is  in  many  patients  double,  so  that  we  lose  the 
aid  of  comparison.  When  it  results  from  hypostatic  congestion  it  is  nearly 
always  bilateral. 

Diagnosis. — It  will  aid  in  diagnosis  to  recollect  that  under  the  age  of 
three  years  pneumonia  is  ordinarily  catarrhal,  and  that  it  is  preceded  by  and 
associated  with  bronchitis.  Coincident  with  it,  and  often  preceding  its  devel- 
opment for  a  few  days,  are  the  usual  symptoms  of  nasal  and  bronchial  catarrh. 
Defluxion  from  the  nostrils  and  other  symptoms  due  to  "  taking  cold  "  help 
us  to  diagnosticate  catarrhal  pneumonia  from  the  essential  fevers,  with 
the  exception  of  measles.  Croupous  pneumonia  begins  more  abruptly,  but 
in  this  form  of  inflammation  the  greater  extent  of  pulmonary  solidification 
soon  gives  us  clear  and  unmistakable  physical  signs.  The  various  forms  of 
so-called  remittent  fever  bear  considerable  resemblance  as  regards  symptoms 
to  certain  cases  of  pneumonic  inflammation,  but  in  the  latter  there  are  more 
acceleration  of  respiration  and  greater  suffering,  especially  when  the  child 
is  disturbed,  than  in  the  former.  The  physical  signs,  however,  afford  decisive 
proof  of  the  nature  of  the  malady — to  wit,  dulness  on  percussion,  bronchial 
respiration  of  a  higher  pitch  and  harsher  than  the  normal  vesicular  respi- 
ratory sound,  bronchophony,  vocal  fremitus,  etc. 

Difficulty  sometimes  attends  the  diagnosis  of  broncho-pneumonia  from 
simple  bronchitis.  The  presence  of  the  expiratory  moan,  if  it  be  pretty 
constant  and  marked,  afi'ords  evidence  that  the  inflammation  has  extended  to 
the  lungs,  but  the  physical  signs  constitute  the  reliable  means  of  exact  diag- 
nosis. They  should  be  carefully  noted,  in  order  to  determine  if  there  be 
some  point  of  solidification. 

Solidification  gives  rise  to  dulness  on  percussion,  bronchial  respiration, 
and  bronchophony.  These  three  signs  coexisting  afford  sufficient  proof  of 
pneumonia,  unless  there  be  tubercular  consolidation  or  possibly  collapse  super- 
vening on  suff"ocative  bronchitis.  The  history  of  the  case  aids  in  determining 
■whether  there  be  either  of  these  diseases.  Moreover,  collapse  occurs  later 
after  the  attack  commences  than  hepatization,  and  does  not  produce  so 
distinct  bronchophony  or  bronchial  respiration  as  is  observed  in  ordinary 
cases  of  pneumonia. 

Pleuritis  with  eff'usion  may  present  physical  signs  which  bear  consider- 
able resemblance  to  those  in  pneumonia;  but  in  pneumonia,  except  when 
associated  with  tubercular  disease,  the  dulness  on  percussion  is  not  so  great 
as  that  from  pleuritic  efi"usion.  In  pleuritic  effusion  in  a  young  child  the 
respiratory  murmur  can  often  be  heard  with  the  ear  applied  over  the  liquid, 
but  it  is  indistinct  and  transmitted  through  the  liquid  from  a  distance.  The 
practised  ear  is  able  to  discover  the  difference  between  it  and  the  bronchial 
respiration  of  pneumonia.  Vocal  fremitus,  which  is  absent  in  pleuritic  effu- 
sions, is  another  reliable  sign  of  pneumonia  in  children  over  the  age  of  three 
or  four  years.  In  younger  children  it  is  indistinct.  Occasionally  the  physical 
signs  indicate  the  coexistence  of  the  pulmonary  and  pleural  inflammations. 

In  catarrahal  pneumonia  it  is  often  difficult  to  determine  certainly  the 
nature  of  the  disease,  since  the  physical  signs,  if  there  be  but  little  extent 
of  inflammation,  are  absent  or  indistinct.  I  have  often,  in  post-mortem 
examinations,  found  so  small  a  part  of  the  lung  hepatized  that  it  could  not 
possibly  have  produced  any  appreciable  dulness  on  percussion,  bronchial 
respiration,  or  bronchophony.  Such  cases  often  pass  for  simple  bronchitis, 
and  practically  this  matters  little,  since  the  treatment  required  by  the  two 
is  not  dissimilar. 


874  LOCAL  DISEASES. 

Prognosis.  —  Primary  pneumonia,  affecting  only  cue  lung,  if  properly 
treated  in  most  instances  terminates  favorably  in  children  and  even  infants. 
If  double,  it  is,  as  in  the  adult,  much  more  serious,  and  is  in  certain  cases 
fatal.  Secondary  pneumonia,  pneumonia  occurring  in  measles,  whooping 
cough,  tuberculosis,  or  resulting  from  hypostatic  congestion  in  the  course 
of  some  exhausting  disease,  is,  on  the  other  hand,  more  frequently  fatal. 
As  death  usually  occurs  from  asthenia,  the  younger  the  child  and  more 
feeble  the  constitution  the  greater  the  danger. 

Unfavorable  symptoms  are  an  increase  of  dyspnoea,  a  pulse  becoming 
more  and  more  frequent  and  feeble,  pallor  of  countenance,  inability  of  the 
patient  to  support  the  head,  total  loss  of  appetite,  refusal  to  notice  or  be 
amused  by  playthings,  absence  of  tears  when  crying — a  symptom  which 
French  writers  have  pointed  out — and  the  appearance  of  pemphigus  on  the 
face  or  elsewhere. 

Indications  on  which  a  favorable  prognosis  may  be  based  are  moderate 
acceleration  of  pulse  and  elevation  of  temperature,  pneumonia  primary  and 
limited  to  one  side,  ability  to  support  the  head  or  sit  erect,  being  amused 
by  playthings,  etc. 

Treatment. — The  treatment  of  the  two  forms  of  pneumonia — namely, 
catarrhal  and  croupous,  the  former  occurring  chiefly  under  the  age  of  three 
years  and  being  secondary,  the  latter  occurring  in  most  patients  over  that 
age — requires  to  be  considered  separately,  as  much  as  do  their  symptoms 
and  anatomical  characters. 

Catarrhal  pneumonia.,  when  developed  from  and  upon  a  bronchitis,  as  it 
so  often  is,  requires  for  the  most  part  the  continuance  of  the  remedies  which 
are  appropriate  for  the  primary  disease.  (See  chapter  on  Bronchitis.)  But 
from  the  fact  that  it  is  secondary  and  in  children  of  tender  age,  and  since 
the  danger  as  regards  the  pneumonia  is  due  to  asthenia,  more  actively  sustain- 
ing measures  are  demanded  than  are  required  for  uncomplicated  bronchitis. 
When  the  pneumonia  has  continued  a  few  days,  and  often  in  its  commence- 
ment, carbonate  of  ammonium  and  alcoholic  stimulants  are  needed,  and  the 
diet  from  the  first  should  be  nutritious.  In  that  form  of  catarrhal  pneumo- 
nia which  is  due  to  passive  congestion  or  hypostasis,  in  the  causation  of 
which  debility  is  an  important  factor,  tonic  and  stimulating  measures  are 
imperatively  required.  Frequent  change  of  position  is  useful  in  such 
cases. 

In  croupous  pneumonia.,  if  seen  at  the  commencement  or  within  a  few 
hours  of  the  commencement,  an  emetic  of  ipecacuanha  may  be  given,  as 
recommended  by  Trousseau.  This  acts  promptly  as  a  cardiac  sedative, 
diminishing  somewhat  the  aflSux  of  blood  to  the  lungs  and  moderating  the 
inflammation.     It  should  not  be  employed  except  at  the  period  mentioned. 

The  abstraction  of  blood  by  leeches  or  otherwise  has  justly  fallen  into 
disrepute  in  the  treatment  of  the  inflammations  of  children,  since  it  is  too 
depressing.  We  have  in  aconite  and  phenacetin  efficient  substitutes  for 
bloodletting,  which  by  their  sedative  effect  on  the  heart  diminish  the 
exaggerated  afflux  of  blood  to  the  inflamed  lung,  and  thus  enable  us  to 
meet  the  indication  of  treatment  in  the  first  stage  of  the  inflammation.  It 
is  important  in  all  severe  cases  to  preserve  the  blood  and  the  strength,  for 
the  danger  in  the  end  is  chiefly  from  asthenia,  and  therefore  the  use  of  one 
of  the  cardiac  sedatives  mentioned  above  is  preferable  to  the  abstraction 
of  blood. 

The  following  prescription  will  be  found  useful  in  the  commencement 
of  pneumonia,  when  the  child  is  restless  and  has  the  expiratory  moan.  It 
is  especially  useful  if,  in  addition  to  the  general  restlessness,  occasional 
twitching  of  the  limbs  occurs,  which  is  a  forewarning  of  eclampsia: 


PNEUMONIA.  875 

B.  Tine,  opii  deodorat.,  gtt.  xvj  ; 

Phenacetin,  gr.  xvj ; 

Potas.  bromidi,  5j  ; 

Syr.  simplic,  Jss ; 

Aquae  anisi,  ^iss. 

Shake  bottle.  Give  one  teaspoonful  every  two  or  three  hours  to  a  child  of  two  to 
three  years.  If  nervous  symptoms  are  not  prominent,  the  bromide  may  be 
omitted. 

If  bronchial  respiration,  bronchophony,  and  dulness  on  percussion  are 
present,  indicating  the  second  stage  of  pneumonia,  it  is  better  to  discontinue 
the  use  of  the  antipyrine  or  other  cardiac  sedative,  unless  the  temperature 
reach  or  exceed  104°.  If  it  do,  one  grain  of  phenacetin  may  still  be  admin- 
istered every  third  hour  to  a  child  of  two  years,  and  two  grains  to  one  of 
three  or  four  years. 

The  remarks  made  in  reference  to  the  use  of  quinia  and  digitalis  for 
bronchitis  apply  with  still  more  force  to  their  use  in  both  the  catarrhal  and 
croupous  forms  of  pneumonia.  In  secondary  pneumonia,  and  in  primary 
occurring  in  feeble  children,  these  agents  are  in  many  instances  preferable  to 
any  other  medicine  for  the  purpose  of  reducing  the  temperature  and  pulse, 
since  they  produce  this  result  without  depression.  They  may  be  administered 
in  such  cases  from  the  first  day. 

In  some  observations  recently  made  (1880-81)  in  the  New  York  Found- 
ling Asylum  it  seemed  to  us  probable  that  quinine,  given  in  one  or  two  large 
doses  at  the  commencement  of  acute  primary  pneumonia,  as  five  grains  to 
a  child  of  three  years,  exerts  some  controlling  efi'ect  on  the  inflammation, 
perhaps  even  aborting  it. 

When  the  inflammation  begins  to  abate  there  is  usually  progressive 
improvement.  Many  now  recover  with  simple  mucilaginous  drinks  or  mild 
expectorants  useful  for  the  accompanying  bronchitis,  as  chloride  of  ammo- 
nium in  the  syrup  of  tolu.  Others  require  more  sustaining  measures,  and  for 
such  carbonate  of  ammonium  is  preferable,  with,  perhaps,  quinia.  In  severe 
pneumonia  it  is  of  the  utmost  importance  to  sustain  the  vital  powers,  even 
from  the  commencement  of  the  inflammation.  There  can  be  no  doubt  that 
the  great  error  in  the  therapeutic  management  of  children  with  this  malady 
has  been  the  employment  of  medicines  which  reduce  the  strength  when 
gentler  measures  or  those  of  a  sustaining  nature  were  needed.  Alcoholic 
stimulants  are  required  sooner  or  later  in  most  cases.  They  should  be  pre- 
scribed from  the  first  in  feeble  children  and  in  secondary  forms  of  the  inflam- 
mation. Infants  may  take  three  or  four  drops  of  Bourbon  whiskey  or  brandy 
for  each  month  of  their  age  every  two  or  three  hours.  The  diet  should  be 
nutritious,  consisting  of  milk,  animal  broths,  and  the  like,  unless  during  the 
first  three  or  four  days  in  robust  children. 

The  bowels  should  be  kept  open  as  an  important  part  of  the  treatment  of 
croupous  pneumonia  in  its  first  stages.  In  robust  children  a  small  dose  of 
castor  oil,  Rochelle  salts,  or  citrate  of  magnesia  should  be  given  if  .there  be 
any  tendency  to  constipation,  and  subsequently  a  daily  evacuation  should  be 
produced  by  a  clyster  or  otherwise.  A  saline  aperient  by  its  derivative  and 
refrigerant  efi'ect  in  some  cases  obviates  the  necessity  of  employing  cardiac 
sedatives.  A  laxative  enema  is  preferable  for  a  feeble  child  and  in  most 
cases   of  secondary  pneumonia. 

Local  treatment  is  required  in  most  instances.  Counter-irritation  should 
be  produced  over  the  chest  by  measures  which  difi"er  according  to  the  age. 
The  following  are  useful  formulae  for  external  treatment : 

K.  Olei  camphorati. 


876  LOCAL  DISEASES. 

For  a  child  of  three  months  muslin  soaked  with  the  oil  should  be  applied 
over  the  chest,  and  then  covered  with  cotton  batting   and  perhaps  oil-silk. 

R.  Olei  carvophylli,  gij  > 

Olei  camphorati,  5iv. — Misce. 

For  external  use  at  the  age  of  six  months,  applied  by  muslin  soaked  with  it  and 
covered  by  oil-silk. 

For  children  over  six  months  the  following : 

R.   Pulv.  sinapis,  ^j  ;  ^ 

Semen,  lini,  5^^- 

For  external  use. 

In  cheesy  pneumonia,  which  is  always  accompanied  by  anaemia  and  great 
reduction  of  the  vital  powers,  the  carbonate  of  ammonium  in  milk  or  a  syrup 
to  prevent  irritation  is  useful,  as  is  also  the  inhalation  of  the  vapor  of  the 
following  from  a  sponge : 

R.  Creasoti  (Morson's  beech  wood),  ,^ij  ; 

Terebene,  Jiij. 

Add  twenty-five  drops  to  the  sponge  of  the  perforated  zinc  inhaler,  and 
employ  several  times  daily.  Creasote  given  internally  in  cod-liver  oil  or 
in  orange-juice  is  also  recommended  for  those  cases  in  which  tuberculosis 
is  likely  to  occur. 


CHAPTER    X. 

PLEUEISY. 


The  term  pleurisy  or  pleuritis  is  employed  in  this  chapter  to  designate 
inflammation  of  the  pleura  when  not  produced  by  extension  of  the  inflamma- 
tory process  from  the  lung  or  by  the  irritation  of  tubercles  upon  or  under  the 
pleura.  Catarrhal  pneumonia,  common  in  infancy ;  croupous  pneumonia, 
common  in  childhood ;  pulmonary  tuberculosis,  not  rare  in  both  periods  in 
wasted  and  cachectic  children, — are  ordinarily  accompanied  by  pleurisy, 
arising  consecutively  to  the  lung  disease,  and  limited  nearly  to  the  portion 
of  the  pleura  which  covers  the  aflFected  lobes  or  lobules.  But  since  in  these 
cases  the  pleuritis  is  subordinate  to  and  dependent  on  the  graver  diseases,  and 
is  comparatively  unimportant,  it  does  not  require  separate  consideration.  It 
is  properly  treated  of  in  our  books  in  connection  with  and  as  a  part  of  those 
diseases.  All  other  cases  of  pleuritic  inflammation,  although  presenting  wide 
diiferences  in  form  and  clinical  history,  are  embraced  under  the  general  term 
jilenrisi/. 

Frequency. — Pleurisy  was  formerly  supposed  to  be  rare  in  young  chil- 
dren. Even  M.  Barrier  of  Lyons,  the  author  of  a  creditable  treatise  on  dis- 
eases of  children,  wrote  as  late  as  1860 :  "  Ainsi  done,  en  generalisant  les 
faits  de  Vallieux  et  les  notres,  nous  pouvons  dire  :  que  la  pleurisie,  depuis  la 
naissance  jusqu'a  I'age  de  six  ans  environs,  ne  constitue  presque  jamais  une 
afiection  simple,  unique,  et  independante  de  la  pneumonic."  But  greater 
precision  in  the  examination  of  cases,  more  accurate  means  of  diagnosis,  more 
knowledge  of  the  nature  of  diseases,  and  more  frequent  autopsies  have 
enabled  the  profession  to  correct  this  as  well  as  many  other  errors,  and  it 


PLEURISY.  877 

is  now  known  that  primary  pleurisy  is  not  infrequent  in  young  children, 
even  in  infants.  In  asylums  and  hospitals  for  children,  in  which  institutions 
the  nature  of  diseases  is  more  accurately  ascertained  than  in  private  prac- 
tice— for  autopsies  are  made  in  the  fatal  cases — the  frequency  of  pleurisy  in 
its  various  forms,  latent,  semi-fibrinous,  and  purulent,  is  surprising  to  those 
whose  knowledge  of  the  disease  has  been  acquired  only  through  private  prac- 
tice. Thus,  in  the  New  York  Foundling  Asylum  in  the  seven  months  from 
April  1  to  November  1,  1879,  while  there  were  35  cases  of  bronchitis,  21  of 
pneumonia,  and  3  of  tuberculosis,  there  were  11  clearly-ascertained  cases  of 
pleurisy.  There  can  be  no  doubt  that  many  cases  of  this  malady  in  young 
children  are  mistaken  by  good  practitioners  for  other  diseases,  especially  for 
pneumonia,  or,  if  the  pleurisy  be  to  a  certain  extent  latent,  for  remittent  or 
malarial  fever  or  fever  due  to  intestinal  irritation.  I  have  records  of  several 
cases  occurring  in  family  and  hospital  or  asylum  practice  in  which  children 
perished  with  a  wrong  diagnosis  or  without  diagnosis,  when  the  post-mortem 
examination  revealed  pleurisy,  sometimes  of  long  standing.  Thus  in  one 
case  of  fatal  empyema,  commencing  at  the  age  of  six  months  and  continuing 
several  months,  chronic  pneumonia  had  been  diagnosticated  by  physicians 
known  to  be  thorough  in  their  examination  and  usually  accurate.  In  another 
case,  which  proved  fatal  at  about  the  age  of  one  year,  the  child,  who  lived  in 
a  malarial  locality,  had  been  for  weeks  under  treatment  for  supposed  malarial 
disease  ;  but  in  this  case  diagnosis  was  easy,  for  at  my  first  visit,  which  was 
when  the  child  was  dying,  there  was  decided  dulness  on  percussion  over 
the  right  side  of  the  chest.  In  this  case  the  right  lung  was  adherent  to 
the  ribs  anteriorly  and  laterally,  while  posteriorly  it  was  separated  by  pus, 
■which  crowded  forward  the  organ  so  that  its  posterior  surface  was  concave. 

In  wards  of  institutions  and  in  the  crowded  quarters  of  the  poor  pleurisy 
appears  to  be  more  frequent  than  in  families  in  comfortable  circumstances. 
Its  frequency  varies  also  in  difierent  years  according  to  the  presence  and 
prevalence  of  its  causes.  Thus  during  epidemics  of  scarlet  fever  it  is  more 
common  than  at  other  times. 

During  several  weeks  immediately  preceding  May,  1874,  when  there  was 
no  unusual  prevalence  of  the  causes  or  conditions  which  give  rise  to  pleurisy, 
I  noted  carefully  the  character  of  the  sickness  in  404  consecutive  cases  under 
the  age  of  twelve  years  in  private  practice,  and  of  these  2  had  primary 
pleurisy,  or  J  per  cent.  This  is  probably  about  the  usual  proportion  of 
pleurisies  in  children  in  family  practice,  except  when  scarlet  fever  is 
prevalent. 

I  have  preserved  the  records  of  56  cases  of  pleurisy  in  children  under 
the  age  of  twelve  years,  most  of  them  occurring  in  the  institutions  which  I 
am  attending  or  have  attended  as  physician,  and  the  remainder  in  private 
practice.  The  statistics  of  these  cases,  embraced  in  the  following  table,  are 
interesting,  as  showing  the  frequency  of  pleurisy,  and  pleurisy  of  the  suppura- 
tive form,  in  young  children.  The  large  number  of  empyemas  seen  in  the 
table  does  not,  however,  indicate  the  true  proportion  of  suppurative  to  sero- 
fibrinous pleurisies,  since  protracted  and  stubborn  cases,  which  are  largely 
empyemas,  are  more  frequently  brought  to  institutions  for  treatment  than  are 
those  of  a  milder  and  more  manageable  type.  Thus,  in  the  class  of  children's 
diseases  in  the  Bureau  for  the  Relief  of  the  Out-door  Poor  a  large  percentage 
of  the  cases  are  empyemas  which  have  resisted  treatment  elsewhere.  Besides, 
pleurisy  with  little  exudation  is  sometimes  latent  or  so  mild  that  it  is  over- 
looked or  not  diagnosticated  even  by  physicians  who  are  thorough  and  careful 
in  their  examinations,  and  I  do  not  doubt  that  such  cases  have  occurred  in  the 
institutions  and  in  my  private  practice  during  the  time  in  which  my  statistics 
were  collected : 


LOCAL  DISEASES. 
Age  {Jjd  Cases). 


Under  two 

Frora  two  to  six 

From  six  to 

From  one  year 

From  three     ' 

months. 

months. 

twelve  months. 

to  three  years. 

years. 

3  ;  aU  empv- 

15  ;  9  at  least 

2 ;  both  em- 

13; 8  right. 

10;    7  right, 

6  ;  5  right,  1 

emas ;      1 

empyemas — 7 

pyemas — 1 

5  left. 

3  left. 

left  ;  1  em- 

double. 

on  ri.a^ht  side, 

right,    the 

Exudation  in 

Exudation  in 

pyema. 

4  on  left  side. 

other  left. 

some  sero- 

some   sero- 

4 double. 

fibrinous  ; 
in  others, 
purulent. 

fibrinous  ; 
in  others, 
purulent. 

Causes. — Primary  pleurisy  in  the  child  lias  heretofore  been  attributed 
to  that  common  cause  of  inflammations,  "  taking  cold."  It  is  often  most 
common  in  times  of  changeable  temperature.  Cachexia  is  an  acknowledged 
predisposing  cause,  so  that  children  whose  blood  is  impoverished,  whether 
from  previous  disease  or  from  antihygienic  influences,  are  more  liable  to  this 
inflammation  than  those  who  possess  a  sound  and  vigorous  constitution. 
From  the  operation  of  this  cause  a  larger  proportion  of  cases  occur  among 
the  children  of  the  city  poor  than  among  those  who  are  well  nourished  and 
who  live  in  comfortable  circumstances,  since  the  cachectic  and  ill-cared-for 
are  not  only  more  exposed,  but  are  less  able  to  resist  noxious  agencies. 

Pleurisy  is  not  rare  in  new-born  infants,  and  its  cause  when  thus  occur- 
ring is  not  always  apparent.  It  may  sometimes  be  heedless  exposure  to  cold 
or  to  currents  of  air  by  the  nurse,  but  the  common  cause  at  this  age  is 
believed  to  be  the  absorption  of  septic  matter. 

Billard,  whose  observations  were  made  among  foundlings  in  the  Hospice 
des  Enfants  Trouves,  says :  "  Pleurisy  is  more  common  among  young  infants 
than  is  generally  supposed ;  it  often  appears  without  the  lungs  participating 
in  the  inflammation.  I  have  seen  several  infants  die  immediately  after  birth 
from  this  aff'ection."  He  relates  two  cases  of  double  idiopathic  pleuritis  end- 
ing fatally  at  the  ages  of  two  and  ten  days  (^Diseases  of  Infants,  page  419). 
Mignot.  whose  observations  were  made  in  the  same  institution,  also  records 
16  pleurisies,  5  of  which  were  idiopathic,  in  119  dissections  of  new-born 
infants  (Maladies  jJendant  le  Premier  Age). 

Cases  like  the  following  are  not  infrequent : 

In  1867,  I  made  the  post-mortem  examination  of  a  foundling  who  died  in 
the  New  York  Infant  Asylum  at  the  age  of  about  one  month.  On  each  side 
of  the  thorax,  the  pleura,  costal  and  pulmonary,  was  uniformly  injected,  and 
a  small  amount  of  pus,  not  more  than  one  drachm,  was  found  in  one  pleural 
cavity,  and  a  still  less  quantity  of  pus  in  the  other,  with  little  or  no  sero- 
fibrinous exudation.  There  was  also  pus  at  the  root  of  each  lung,  lying  not 
entirely  upon  the  free  surface  of  the  pleura,  but  partly  underneath  it. 

The  fact  of  a  double  pleurisy  without  disease  of  the  lungs,  which  might 
produce  it,  indicated  a  constitutional  cause.  Its  system  had  probably  become 
infected  by  the  absorption  of  septic  matter  from  the  umbilical  vessels. 

One  of  the  eruptive  fevers,  scarlatina,  not  infrequently  produces  pleurisy, 
occurring  as  a  complication  or  sequel.  This  result  seems  to  be  sometimes 
due  to  septic  matter  in  the  blood  resulting  from  the  action  of  the  scar- 
latinous virus.  In  other  instances  it  is  possibly  the  result  of  retained  urea 
consequent  on  scarlatinous  nephritis,  for  pleurisy  is  a  common  complication 
of  Bright's  disease,  due,  it  is  supposed,  to  the  irritating  property  of  urea, 
which  is  excreted  upon  the  pleural  surface.  Pleurisy  in  young  children  is 
sometimes  also  caused  by  the  discharge  into  the  pleural  cavity  of  some  mor- 


PLEVEISY.  879 

l^id  product,  as  pus.  softened  tubercle,  or  decomposed  luug-tissue.  wliieti  from 
its  highly  irritating  effect  causes  intense  and  general  inflammation  of  the 
pleura.     I  have  observed  several  such  cases. 

Thus,  in  Xovember,  1866,  an  infant  of  three  and  a  half  months  died  of 
pleurisy  occurring  upon  the  left  side.  The  left  lung  was  firmly  bound  down 
by  adhesions,  so  as  to  be  reduced  to  about  one-sixth  its  normal  size.  On 
attempting  inflation  of  this  organ  when  it  was  removed  from  the  body,  air 
escaped  from  a  small  opening  in  the  middle  of  the  upper  lobe,  and  around 
this  opening  the  lung-substance  was  of  a  dark  reddish  color,  softened  and 
disintegrated.  It  seemed  probable  from  the  appearance  that  there  had  been 
hypostatic  congestion,  or  perhaps  pneumonia,  in  the  posterior  part  of  the 
lung,  and  that  the  loss  of  vitality  and  softening  had  occurred  from  the  slug- 
gish or  suspended  circulation  in  the  part,  and  that  the  fatal  pleurisy  had 
resulted  from  a  little  of  this  decomposed  tissue  entering  the  pleural  cavity. 

A  case  having  apparently  a  similar  origin  occurred  in  the  Xew  York 
Foundling  Asylum  in  October,  1879  : 

An  infant  aged  flve  months  and  a  half  became  suddenly  and  severely 
sick  with  pleurisy  on  the  right  side,  and  died  in  five  days.  On  opening  the 
pleural  cavity,  air  escaped.  The  record  of  the  examination  states :  ••  In 
about  the  middle  of  the  posterior  surface  of  the  lower  lobe  was  an  opening 
which  admitted  the  tip  of  the  little  finger  to  the  depth  of  one-fourth  to  one- 
third  inch.  The  lung-tissue  was  disorganized  and  of  pultaceous  consist- 
ence around  the  cavity.  Through  this  cavity,  which  communicated  with  a 
bronchial  tube,  the  air  had  escaped,  which  was  noticed  on  opening  the 
chest." 

Occasionally  we  meet  cases,  especially  in  foundling  asylums,  in  which 
the  cause  is  different  from  the  foregoing,  but  in  some  respects  similar.  An 
indolent  pneumonia  occurs  over  a  circumscribed  area  in  the  posterior  part 
of  the  lung,  either  from  hypostasis  or  exposure  to  cold.  Minute  abscesses 
form  in  the  inflamed  parenchyma,  not  larger  than  pins'  heads  or  small  shot. 
Perhaps  they  are  located  in  bronchioles,  and  are  produced  by  the  accumula- 
tion of  muco-puS;  which  collects  in  these  tubes,  and  is  not  expectorated  on 
account  of  the  low  vitality  and  feeble  functional  activity  of  the  tissues  con- 
cerned. These  abscesses  approaching  the  pleural  surface  produce  a  circum- 
scribed pleurisy  of  small  extent ;  and  finally  one.  probably  in  some  sudden 
movement  of  the  lungs,  as  in  crying  or  coughing,  breaks  into  the  pleural 
cavity,  causing  general  purulent  inflammation.  The  following  was  such  a 
case : 

In  May.  1859,  a  male  infant  aged  two  months  was  admitted  into  the 
Nursery  and  Child's  Hospital.  He  was  delicate,  and  had  what  was  diag- 
nosticated a  mild  bronchial  catarrh,  but  by  wet-nursing  his  general  condition 
gradually  improved.  In  July,  however,  he  had  repeated  attacks  of  diarrhoea, 
and  progressively  lost  flesh  and  strength.  On  August  3d  his  respiration 
became  suddenly  accelerated  and  painful,  and  death  occurred  from  dyspnoea 
and  exhaustion.  Xo  cough  or  other  symptom  referable  to  the  respiratory 
apparatus  had  been  observed  previously  to  the  day  of  death. 

At  the  autopsy  the  intestines  were  found  to  present  the  usual  lesions  of 
intestinal  catarrh  of  the  summer  season.  The  right  lung  was  compressed  b}" 
a  sero-fibrinous  exudation,  though,  from  the  small  size  of  the  pleural  cavity, 
the  quantity  of  exuded  liquid  was  not  more  than  two  ounces.  Nearly  the 
entire  right  pleura,  visceral  and  parietal,  was  covered  with  fibrin  of  a  creamy 
appearance,  and  there  were  loose  flocculi  in  depending  portions  of  the  cavity. 
This  lung  could  be  inflated,  except  a  little  of  the  lower  lobe,  which  was  hepa- 
tized.  The  left  lung  also  occupied  a  very  small  space,  being  partially  col- 
lapsed.    It  could  be  readily  inflated,  when  it  appeared  normal,  except  a  small 


880  LOCAL  DISEASES. 

portion  in  the  posterior  aspect  of  the  lower  lobe,  which  was  partially  covered 
with  lymph,  and  was  found  to  contain  two  abscesses,  one  closed  and  the  other 
opening  externally  on  the  surface  of  the  lung  and  connecting  internally  with 
the  bronchial  tube.  On  attempting  inflation  air  passed  directly  through  this 
opening.  The  closed  abscess  contained  from  one-third  to  one-half  a  drachm 
of  pus  and  disintegrated  lung-tissue,  as  shown  by  the  microscope. 

Another  case,  showing  a  similar  cause  of  pleurisy,  occurred  in  a  female 
infant  of  about  four  months,  in  the  same  institution,  in  Xovember.  1869 : 

She  was  admitted  in  October,  somewhat  reduced  from  diarrhoea,  but  her 
health  improved  partially,  though  she  remained  feeble,  and  the  records  state 
that  she  was  much  troubled  with  meteorism  and  occasional  pain.  On  Novem- 
ber 2d  she  was  suddenly  seized  with  great  dyspnoea,  and  died  in  about  fifteen 
minutes.  No  cough  had  been  noticed  or  other  symptom  referable  to  the 
chest,  but  there  can  be  little  doubt  that  the  occasional  symptoms  of  pain 
referred  to  in  the  notes  were  due  to  the  pleurisy.  The  body  was  much 
emaciated,  and  depending  portions  showed  hypostatic  congestion  ;  right  lung 
adherent  to  diaphragm  and  to  a  considerable  part  of  the  costal  pleura  by 
fibrinous  exudation ;  this  lung  was  somewhat  compressed  and  non-crepitant ; 
its  upper  lobe  floated  in  water,  while  its  middle  and  lower  lobes  sank  and 
could  be  only  partially  inflated ;  this  portion  of  the  lung  contained  a  few 
small  superficial  abscesses,  each  holding  scarcely  more  than  one  drop  of  pus ; 
two  of  these  were  empty,  and  air  passed  through  them  on  attempting  infla- 
tion. They  probably,  one  or  both,  opened  into  the  pleural  cavity  during  life, 
but  possibly  they  were  opened  in  separating  the  adhesions  which  united  the 
two  pleural  surfaces  at  this  point ;  the  pleural  cavity  contained  from  two  to 
three  ounces  of  liquid,  consisting  mainly  of  pus  and  fibrinous  shreds. 

A  similar  case  occurred  in  the  New  York  Foundling  Asylum  in  October, 
1879 : 

The  patient,  aged  four  months,  began  to  be  sick  October  11th,  having 
the  characteristic  symptoms,  and  died  October  15th.  The  right  pleural 
cavity  contained  about  ^iij  of  sero-purulent  liquid,  pressing  the  lung  forward 
and  toward  the  median  line.  In  the  posterior  surface  of  the  right  lower  lobe, 
near  its  base  and  immediately  under  the  pleura,  were  three  or  four  small 
abscesses,  each  not  larger  than  a  small  drop  of  pus,  and  two  or  perhaps  three 
of  these  had  ruptured,  so  that  air  escaped  from  them  on  attempting  inflation, 
while  one  was  closed,  the  pus  in  it  being  visible  under  the  pleura. 

This  cause  of  pleurisy — namely,  the  bursting  of  a  minute  abscess  in  the 
lung — and  that  in  which  a  portion  of  the  lung  loses  its  vitality,  disintegrates, 
and  enters  the  pleural  cavity,  are  probably  not  frequent,  except  in  the  first 
months  of  infancy  in  wasted  and  ill-conditioned  infants  in  families  of  the  city 
poor  and  in  the  asylums. 

A  peripharyngeal  abscess,  descending  along  the  oesophagus,  has  been 
known  to  cause  fatal  pleuritis  by  bursting  into  the  pleural  cavity,  and  pus 
from  carious  vertebrae  has  produced  the  same  result.  In  January,  1864,  I 
presented  to  the  New  York  Pathological  Society  the  lungs  of  an  infant  whose 
history  was  as  follows  : 

R ,  aged  nine  months,  of  strumous  parentage,  and  whose  only  sister 

had  sufiered  severely  from  strumous  ophthalmia  and  periostitis,  was  taken 
sick  about  December  19,  1863,  with  febrile  symptoms,  attended  by  restless- 
ness, but  apparently  without  any  serious  indisposition.  On  the  22d  the 
mother  called  my  attention  to  a  prominence  just  below  the  right  clavicle, 
which  proved  to  be  an  abscess,  and  a  poultice  was  applied  over  it.  On  the 
24th  the  prominence  suddenly  subsided,  and  immediately  the  symptoms  were 
greatly  aggravated.  The  pulse  rose  to  160  per  minute,  the  respiration  from 
60  to  80,  and  expiration  was  accompanied  by  a  moan,  indicating  acute  pleu- 


PLEURISY.  881 

ritic  inflammation.  Within  forty-eight  hours  after  the  disappearance  of  the 
swelling  and  the  exacerbation  of  symptoms  dulness  on  'percussion  over  the 
right  side  of  the  chest  was  observed,  and  this  increased  till  it  was  complete 
from  the  clavicle  to  the  base  of  the  thorax.  The  acceleration  of  pulse  and 
respiration  continued,  the  patient  grew  more  and  more  feeble,  and  death 
occurred  December  31st. 

On  dissecting  away  the  integument  from  the  right  side  of  the  chest  an 
abscess  was  opened  containing  nearly  one  ounce  of  pus,  located  at  the  point 
where  the  tumor  had  been  observed.  At  the  base  of  this  abscess,  between 
two  of  the  ribs,  was  a  small  round  opening,  not  much  larger  than  a  knitting- 
needle,  leading  directly  into  the  cavity  of  the  chest,  so  that  on  depressing 
the  ribs  liquid  flowed  from  the  pleural  cavity.  On  removing  the  sternum 
the  liquid  was  found  to  be  sero-fibrinous,  with  considerable  pus  in  depending 
portions  of  the  pleural  cavity. 

I  have  met  one  other,  apparently  almost  identical,  case,  occurring  in  an 
infant  of  seven  months. 

Pleurisy  in  the  adult  is  sometimes  the  result  of  violence.  The  most 
notable  and  unequivocal  cases  having  this  origin  are  those  in  which  the  ribs 
are  fractured.  It  rarely  happens  that  we  can  attribtxte  the  pleurisy  of  chil- 
dren to  this  cause.  I  can  recollect  only  one  case  in  which  the  inflammation 
seemed  to  be  due  to  violence : 

In  September.  1867,  an  infant  of  twenty-two  months  in  the  almshouse 
on  BlackwelUs  Island,  having  had  a  cough  half  a  year  and  being  some- 
what reduced,  fell  from  bed,  striking  against  the  left  side  of  the  thorax. 
Severe  pleuritic  symptoms  supervened,  and  the  child  died  of  empyema  in 
three  and  a  half  weeks.  More  than  a  pint  of  pus  was  found  in  the  left 
pleural  cavity,  pressing  the  heart  beyond  the  median  line  and  the  diaphragm 
downward,  so  that  it  was  convex  toward  the  abdomen.  The  bronchial  glands 
were  hyperplastic  and  slightly  cheesy,  and  a  caseous  nodule  lay  in  the  anterior 
surface  of  the  right  lung,  which  seemed  otherwise  healthy.  The  left  lung, 
bound  down  by  adhesions,  could  be  partially  inflated.  Whether  or  not  it  con- 
tained small  tubercles  is  not  stated  in  the  records. 

The  occurrence  of  the  injury  just  before  the  commencement  of  the  pleu- 
risy may  indeed  have  been  a  coincidence,  but  the  mother  constantly  believed 
that  the  fall  caused  the  inflammation,  and  there  was  no  other  assignable 
cause. 

It  is  probable,  from  the  history  of  this  case  and  the  lesions,  that  the 
cheesy  degenerations  antedated  the  fall,  and  that  the  pleura  was  in  an  abnor- 
mal state  and  prone  to  inflammation  when  the  injury  was  received. 

The  etiology  of  pleurisy  in  children  diff"ers.  therefore,  from  that  in  adults. 
Certain  causes  are  the  same ;  but  others,  as  scarlet  fever  and  irritating 
products  generated  in  the  walls  of  the  chest  and  bursting  into  the  pleural 
cavity,  are  not  rare  in  infancy  and  childhood,  while  they  seldom  occur  in 
adults. 

Histories  of  cases  like  the  above  strengthen  the  belief  that  pleurisy  in 
children  frequently,  and  perhaps  usually,  has  a  microbic  origin.  This  belief 
also  receives  support  from  the  researches  of  Dr.  Henry  Koplik  of  New  York. 
An  interesting  and  instructive  paper  detailing  his  investigations  was  read 
before  the  American  Paediatric  Society,  June  4,  1890.  He  has  kindly  fur- 
nished me  the  following  resume  of  this  paper : 

"  My  methods  of  investigation  were  strictly  in  accord  with  those  of  the 
Koch  school,  and  the  results  attained  in  the  above  cases  correspond  closely 
to  those  of  the  above  authors  in  the  adult  subject.  The  twelve  cases  could 
be  divided  from  a  bacteriological  standpoint  into  four  groups.  The  first  group 
includes  those  cases  in  which  the  examination  of  the  pus  of  the  empyema 
56 


882  LOCAL  DISEASES. 

yielded  either  the  streptococcus  pyogenes  or  the  staphylococcus  pyogenes 
aureus.  The  etiology  of  this  set  of  cases  is  still  obscure.  The  exact  source 
of  these  micro-organisms  is  still  a  matter  of  speculation.  Whether  we  agree 
with  Weichselbaum,  and  assume  that  the  empyemas  may  follow  a  pneu- 
monia (?),  or  that  these  organisms,  being  present  in  the  subpleural  tissues, 
may  be  enabled  to  become  potent  through  such  a  predisposing  agent  as  cold 
or  a  slight  traumatism,  the  etiology  for  the  present  is  veiled  in  doubt.  The 
micro-organisms  found  are  not  characteristic.  The  second  group  of  cases 
includes  the  empyemas  of  pneumonic  character.  They  are  those  in  which 
the  diplococcus  pneumoniae  (Frank el  and  Weichselbaum)  is  found  in  the 
purulent  exudate.  In  seven  cases  of  the  above  series  this  micro-organism 
alone  was  found  in  the  pus  withdrawn  from  the  chest.  It  was  in  uncontami- 
nated  form,  and  when  cultivated  in  pure  culture  and  inoculated  upon  animals 
results  were  attained  identical  with  those  of  Frankel  and  Weichselbaum. 
The  isolated  presence  of  such  a  virulent  micro-organism  in  a  pure  state  in 
the  pus  of  an  empyema  must  lead  to  the  inevitable  conclusion  that  a  pneu- 
monia in  the  lung  had  preceded  or  complicated  the  empyema.  In  two  cases 
of  the  above  seven  the  pleural  exudate,  though  at  first  quite  serous  in  cha- 
racter, contained  the  diplococcus  pneumoniae.  These  cases  subsequently 
developed  into  well-marked  empyemas.  The  pus  in  the  empyemas  also  con- 
tained only  the  diplococcus  of  Frankel  and  Weichselbaum. 

"  The  third  group  includes  those  cases  in  which  the  processes  are  of  a 
tubercular  nature.  There  is  only  one  case  of  this  group  to  report — a  boy 
aet.  eight  years.  The  tubercle  bacilli  were  found  in  the  pus  by  cover-glass 
stain  only.  Experiments  upon  animals  have  thus  far  proved  negative.  The 
pus  in  this  case  was  contaminated  with  streptococcus  pyogenes.  The  patient 
is  still  living  at  the  time  of  writing,  but  the  lung  has  not  expanded  on  the 
affected  side.  There  are  no  physical  signs  in  this  case  of  lung  tuberculosis 
in  the  lung  of  the  healthy  or  affected  side  of  the  chest. 

"  The  fourth  group  of  empyemas  includes  those  cases  in  which  a  focus  of 
suppuration  outside  of  the  chest  can  with  probability  be  fixed  upon  as  a 
source  of  infection  and  as  a  direct  cause  of  the  empyema.  In  the  above 
twelve  cases  only  one,  an  infant  aet.  four  months,  could  be  classed  in  this 
group.  For  two  weeks  preceding  the  chest  trouble  the  patient  had  suffered 
from  a  deep  burrowing  abscess  of  one  foot.  The  study  of  the  pus  from  the 
chest  yielded  a  pure  culture  of  streptococcus  pyogenes.  A  pure  culture  of 
this  injected  into  animals  proved  very  virulent  and  fatal.  The  little  patient 
died  quickly,  even  in  spite  of  operation  for  the  relief  of  the  empyema." 

Anatomical  Characters. — In  the  commencement  of  pleurisy  the  sub- 
pleural blood-vessels,  lying  in  the  connective  tissue,  and  the  capillaries  of 
the  pleura  are  engorged  with  blood,  producing  vascular  points  and  arbor- 
escence,  seen  through  a  magnifying-glass  of  low  power.  Frequently  in  chil- 
dren, as  in  adults,  minute  extravasations  of  blood,  resulting  from  extreme 
congestion,  occur  under  the  endothelial  layer,  scarcely  perceived  by  the 
naked  eye,  but  readily  seen  under  the  glass.  Immediately  exudation  of 
liquid  holding  numerous  cells  begins  in  the  connective  tissue  which  sur- 
rounds the  capillaries ;  the  pleura  becomes  dry  and  lustreless,  while  the  pro- 
duction and  exfoliation  of  its  endothelial  cells  are  greatly  increased.  These 
no  longer  present  their  normal  appearance,  but  are  swollen  and  granular  in 
consequence  of  the  inflammation. 

Immediately  after  these  parenchymatous  changes  occur,  serum,  fibrin- 
ogenic  substance,  and  leucocytes  begin  to  exude  upon  the  free  surface  of  the 
pleura.  The  term  fibrinogenic  substance,  instead  of  fibrin,  is  employed, 
because  it  is  now  believed  that  fibrin  itself  is  not  exuded,  but  a  substance 
which  becomes  fibrin  through  the  presence  and  action  of  certain  agents  with 


PLEURISY.  883 

which  it  comes  in  contact,  among  which  may  be  mentioned  air,  red  blood-cor- 
puscles, and  even  serum,  from  which  fibrin  has  been  precipitated  (Virchow, 
Cornil,  Eanvier,  and  others). 

In  the  exuded  liquid,  even  if  it  have  the  appearance  to  the  naked  eye  of 
ordinary  serum,  the  microscope  always  reveals  the  presence  of  pus-cells  or 
leucocytes  and  red  blood-cells,  however  small  their  quantity  may  be.  The 
minute  rootlets  of  the  lymphatic  system,  which  are  interspaces  or  lacunae  in 
the  subpleural  connective  tissue,  and  which  here  and  there  open  by  stomata 
upon  the  pleural  surface,  are  clogged  by  inflammatory  products  and  their 
walls  swollen  at  an  early  stage  (E.  Wagner  and  others).  In  these  lymphatic 
channels  both  pus-cells  and  coagulated  fibrin  are  seen  by  the  microscope. 
That  pneumonia,  whether  catarrhal  or  croupous,  seldom  occurs  in  super- 
ficial parts  of  the  lungs  without  causing  inflammation  of  that  portion  of  the 
pleura  which  covers  the  afi"ected  lobules  is  universally  known ;  but  the 
reverse  is  also  true,  that  pleurisy  seldom  occurs  without  causing  inflamma- 
tion of  the  alveoli  which  are  adjacent  to  the  inflamed  membrane.  The  pneu- 
monia thus  caused  is  so  superficial  that  it  is  very  liable  to  be  overlooked  at 
the  post-mortem  examination  in  the  presence  of  the  graver  lesions  of  the 
pleura ;  but  a  knowledge  of  its  occurrence  is  important  in  diagnosis,  for, 
though  it  may  have  no  greater  depth  than  a  line,  it  is  sufficient  to  produce 
crepitant  rales  like  those  in  ordinary  pneumonia.  Therefore,  if  we  hear 
these  rales,  we  may  mistake  the  disease  for  pulmonary  inflammation  and 
overlook  the  pleurisy — an  error  not  unusual  in  the  treatment  of"  children. 
Trousseau,  who  surpassed  most  of  his  contemporaries  as  a  clinical  observer, 
wrote  :  "  This  sound,  which  is  met  with  in  the  great  majority  of  cases  of 
pleurisy,  is  in  fact  a  crepitant  rale,  and  I  have  called  it  a  crepitant  rale  of 
pleurisy.  My  interpretation  is  very  simple.  Just  as  we  never  have  erysip- 
elas without  engorgement  of  the  cellular  tissue,  there  cannot  be  erysipelas 
of  the  pleura  or  pleurisy  without  an  irritative  engorgement  of  the  subpleural 
cellular  tissue  or  of  the  peripheric  pulmonary  parenchyma.  This  fluxion 
naturally  carries  with  it  into  the  pulmonary  vesicles  a  serous  exudation. 
....  We  also  meet  with  a  fine  subcrepitant  rale,  which  is  very  often  heard 
quite  at  the  beginning  of  pleurisy,  and  which  likewise  nearly  always  con- 
tinues for  some  weeks."  More  recent  observers  and  writers  fully  agree  with 
the  statement  of  Trousseau,  except  that  what  he  designates  irritative  engorge- 
ment, the  microscope  shows  to  be  a  true  inflammation  of  the  pulmonary 
alveoli. 

There  are  four  constituents  of  every  pleuritic  exudation — to  wit,  serum, 
fibrin,  red  blood-corpuscles,  and  leucocytes  or  pus-cells ;  which  last  are  iden- 
tical in  appearance  with  the  white  blood-corpuscles  and  the  lymph-corpuscles, 
and  the  origin  of  which  has  been  investigated  by  many  microscopists.  It  is 
convenient  to  classify  cases  of  pleuritis  according  to  the  quantity  and  rela- 
tive proportion  of  these  constituents,  as  follows:  1st.  The  plastic,  sometimes 
designated  dry  or  adhesive  ;  2d.  The  sero-fibrinous  ;  3d.  The  purulent ;  4th. 
The  hemorrhagic. 

1.  Plastic  Pleurisy. — In  cases  which  pertain  to  this  group  the  inflam- 
mation is  chiefly  parenchymatous,  either  no  exudation  occurring  upon  the 
free  surface  of  the  pleura,  or  if  any,  whether  fibrin,  pus,  or  serum,  it  is  so 
slight  that  it  possesses  no  clinical  importance.  The  essential  anatomical 
changes  in  this  form  of  pleurisy,  as  regards  the  pleural  surface,  are  rapid 
proliferation,  retrogressive  change  or  decay  and  exfoliation  of  the  endothe- 
lial cells,  and  the  sprouting  out  of  granulations  which  develop  into  connec- 
tive tissue.  In  plastic  pleurisy  there  is  no  compression  of  the  lungs,  and 
the  pleural  surfaces  are  separated  from  each  other  only  by  the  granulations, 
which  soon  unite  with  those  of  the  opposite  surface.     This  form  of  pleurisy 


884  LOCAL  DISEASES. 

is  not  infrequently  latent  in  children,  for  at  the  autopsies  of  those  who  have 
died  of  various  diseases  we  often  observe  bands  of  connective  tissue  uniting 
the  opposite  pleural  surfaces,  when  the  parents  or  nurses  cannot  recall  to 
mind  any  sickness  or  symptoms  such  as  pleurisy  commonly  causes.  It  is 
certain  also  that  plastic  pleurisy  is  often  overlooked  when  not  latent,  the 
fever  and  other  symptoms  being  attributed  to  causes  quite  distinct  from 
the  true  one.  The  symptoms  and  physical  signs  are  obviously  less  pro- 
nounced in  this  than  in  other  forms  of  pleurisy. 

2.  Sero-fibrinous  Pleurisy This  is  the  most  frequent  of  all.     It  is  the 

pleurisy  which  is  usually  thought  to  result  from  catching  cold.  The  serum 
exudes  from  the  capillaries  of  the  inflamed  pleura  in  very  variable  quantity  in 
different  cases,  and  the  pleural  surface  is  soon  covered  with  a  fibrinous  layer. 
This  may  be  a  mere  film  or  it  may  attain  the  thickness  of  half  an  inch  or 
more.  It  is  usually  at  first  slightly  attached,  but  afterward,  from  being 
blended  with  the  granulations,  it  may  be  firmly  adherent.  In  some  cases  it 
is  quite  compact,  while  in  others  it  has  a  loose  areolar  texture,  containing  in 
its  interstices  serum  and  pus-cells.  The  fibrin  is  for  the  most  part  deposited 
on  the  pleura,  but  shreds  and  flakes  of  it  also  float  in  the  serum.  In  the 
serum,  as  well  as  entangled  in  the  fibrin,  we  find  not  only  red  blood-cells  and 
leucocytes,  but  endothelial  cells  thrown  off  from  the  pleura,  which,  as  well 
as  those  still  adherent,  are  almost  always  in  process  of  degeneration  and 
decay. 

If  a  perpendicular  section  be  made  through  the  pleura,  in  this  as  well  as 
in  the  other  forms  of  pleurisy  many  newly-formed  cells,  the  lymph-corpuscles, 
are  observed  in  the  meshes  of  the  subpleural  connective  tissue,  and,  as  we 
examine  the  section  nearer  to  the  surface  of  the  pleura,  these  cells  are  seen 
to  be  aggregated  in  masses  and  held  together  by  a  structureless,  homogeneous 
matrix.  The  lymph-corpuscles  appear  to  be  the  active  agents  in  the  forma- 
tion of  granulations.  They  are  observed  in  various  stages  of  transformation 
from  the  round  to  the  spindle-shaped.  The  prolongations  of  the  spindle- 
shaped  cells  unite  with  each  other,  so  as  to  form  the  connective  tissues, 
capillaries,  and  other  elements  of  the  granulating  surface.  That  the 
endothelial  cells  take  no  part  in  the  production  of  the  new  tissue  is  inferred 
from  the  fact  that  most  of  them  present  the  appearance  of  retrogressive 
change  and  decay.  The  granulations,  as  they  sprout  out  from  the  pleura, 
become  intimately  blended  with  the  fibrinous  exudation,  and  when  the  eff"used 
liquid  is  absorbed  they  unite  with  those  of  the  opposite  pleural  surface, 
forming  an  organic  union,  by  blood-vessels  and  nerves,  between  the  lung  and 
parietes,  the  lung  and  pericardium,  or  different  lobes  of  the  same  lung,  as  the 
case  may  be.  They  pass  in  two  or  three  weeks  from  embryonic  to  perfect 
tissue,  vessels  and  nerves  grow  in  them,  and  they  possess  henceforth  all  the 
properties  of  living  tissues :  they  are  able  to  absorb ;  they  are  liable  to 
inflammation  and  hemorrhage ;  and  may,  in  fine,  participate  in  all  the  altera- 
tions of  the  organism  of  which  they  are  a  part  (Jaccoud). 

3.  Purulent  Pleurisy. — Although,  as  stated  above,  pus-cells  are  always 
present  in  the  pleuritic  exudation,  we  designate  the  disease  purulent  pleurisy 
or  empyema  when  the  cells  are  so  numerous  as  to  render  the  liquid  turbid. 
If  there  be  cloudiness  appreciable  to  the  naked  eye  and  due  to  the  pus-cells, 
the  case  is  regarded  as  one  of  this  form  of  pleurisy.  Purulent  pleurisy  is 
at  first,  in  a  large  proportion  of  cases,  sero-fibrinous,  becoming  purulent  after 
some  days  or  weeks — a  fact  readily  ascertained  by  the  use  of  the  hypodermic 
syringe  at  diff"erent  periods.  In  other  instances  the  pleurisy  is  purulent  from 
the  first.  Pleurisy  is  in  family  and  in  hospital  practice  more  frequently 
purulent  in  children  than  in  adults,  and  in  ill-conditioned  children  than  in 
those  who  are  robust.   .  It  is  therefore  apt  to  be  purulent  in  one  who  has  had 


PLEURISY.  885 

an  exhausting  disease,  as  scarlet  fever,  and  in  the  cachectic  children  who 
reside  in  or  are  brought  to  institutions  for  treatment.  Thus,  in  the  New  York 
Foundling  Asylum  in  1879  an  infant  aged  two  months  and  three  days  became 
feverish,  and  had  the  expiratory  moan  and  hurried  respiration  characteristic 
of  pleurisy.  On  the  fourth  day  Dr.  Reynolds,  who  was  in  attendance, 
inserted  the  hypodermic  syringe  and  filled  it  with  thin  pus.  This  was, 
apparently,  a  case  of  primax'y  idiopathic  empyema.  Pleurisy  is  purulent 
when  it  is  produced  by  the  entrance  of  some  irritating  substance  into  the 
pleural  cavity,  as  pus  or  decomposed  lung-tissue. 

The  production  of  pus  in  the  pleural  cavity  is  often  surprisingly  rapid, 
for,  when  many  ounces  have  been  removed  by  the  aspirator,  nearly  the 
original  quantity  is  sometimes  restored  within  two  or  three  days.  As 
Frantzel  says,  it  does  not  seem  possible  that  so  many  pus-cells,  which  must 
surpass  in  numbers  the  aggregate  of  the  white  blood-corpuscles,  could  wan- 
der from  the  blood-vessel  in  so  short  a  time,  so  that  we  must  look  for  some 
other  source  of  the  immense  production  of  leucocytes,  in  addition  to  that  dis- 
covered by  Cohnheim.  A  large  part  of  the  pus-cells  is,  in  all  probability, 
produced  by  rapid  segmentation  of  the  lymph-corpuscles.  In  two  cases  of 
purulent  pleurisy,  occurring  in  infancy,  I  found  pus  underlying  the  pleura 
near  the  hilus,  without  apparently  any  loss  of  integrity  in  the  pleura,  in  such 
quantity  that  it  was  immediately  recognized  by  the  naked  eye.  Pus  under 
the  pleura,  as  well  as  in  the  pleural  cavity,  was  apparently  due  to  unusual 
violence  in  the  inflammation  and  rapid  production  of  leucocytes. 

4.  Hemorrhagic  Pleurisy. — This  is  not  common.  I  recall  but  one  case, 
a  child,  in  whom  the  pleurisy  occurred  as  a  sequel  of  scarlet  fever.  The 
fluid  several  times  removed  by  the  aspirator  had  a  deep  reddish-brown  color. 
I  was  apprehensive  that  the  point  of  the  aspirator,  by  wounding  the  granu- 
lations, had  caused  the  hemorrhage  which  stained  the  pus  removed  at  each 
subsequent  operation.  But  with  the  care  exercised  and  the  great  amount  of 
blood-stained  exudation,  it  seems  almost  certain  that  this  was  not  the  true 
explanation,  and  that  it  was  a  genuine  case  of  hemorrhagic  pleurisy. 

Hemorrhagic  exudation  in  the  pleurisy  of  children  is  sometimes  due  to 
purpura  haemorrhagica,  being  like  the  other  hemorrhages  a  symptom  of  the 
general  disease.  In  other  cases  it  signalizes  the  commencement  of  a  new 
inflammation  in  the  vascular  granulations  of  a  previous  pleurisy.  Occurring 
under  such  circumstances,  it  is  due  to  the  increased  fluxion  in  the  numerous 
delicate  capillaries  of  the  granulations.  Pleurisy  due  to  cancerous  or  tuber- 
cular formations  in  or  upon  the  pleura  is  sometimes  hemorrhagic.  Jaccoud 
says :  "  A  sei'o-fibrinous  or  purulent  exudation  may  be  red  by  the  transuda- 
tion of  haematin,  without  true  hemorrhage  ;  .  .  .  .  the  red  exudations  which 
have  been  observed  in  scorbutus  and  marsh  cachexia  are  really  due  to  these 
pseudo-hemorrhages."  In  those  cases  in  which  there  is  true  hemorrhage  it  is 
still  uncertain  whether  rupture  of  the  capillaries  or  a  transudation  ordinarily 
occurs,  or  whether  the  blood-cells  may  not  escape  in  both  modes. 

A  liquid  pleuritic  exudation,  whether  sero-fibrinous  or  purulent,  obviously 
produces  an  important  mechanical  eff"ect  from  its  location.  In  young  children, 
especially  those  enfeebled  by  sickness,  the  expansive  power  of  the  lung  is 
slight,  so  that  it  readily  yields  to  pressure  applied  to  its  surface,  and  becomes 
more  and  more  compressed  as  the  liquid  accumulates.  Except  when  retained 
by  adhesions,  the  lung  is  pressed  toward  the  mediastinum,  and  at  the  same 
time  carried  forward  and  upward.  Patients  with  pleurisy  usually  lie  on  the 
back  and  affected  side,  so  that  gravitation  determines  to  a  considerable  extent 
in  what  part  of  the  pleural  cavity  the  liquid  will  collect.  In  the  considerable 
number  of  post-mortem  examinations  which  I  have  witnessed  of  children  who 
perished  from  pleurisy,  chiefly  empyema,  the  lung  was  usually  attached  ante- 


886  LOCAL  DISEASES. 

riorly  to  the  thorax  from  the  mediastinum  outward,  as  far  as  the  costo-chondral 
articulations,  or  farther,  except  in  the  lower  part  of  the  cavity,  where  there 
were  no  adhesions  or  adhesions  only  in  the  mediastinum.  There  were  also 
attachments  along  the  mediastinum,  and  attachments  more  or  less  firm  on  all 
sides,  anteriorly,  laterally,  and  posteriorly,  in  the  upper  part  of  the  pleural 
cavity,  toward  which  the  lung  was  compressed.  Many  variations  occur, 
depending  on  the  amount  of  liquid  and  the  extent  of  the  adhesions ;  but, 
judging  from  autopsies  which  I  have  seen,  I  would  say  that  in  the  average 
in  cases  so  severe  that  the  question  of  operative  interference  arises,  if  we 
draw  a  line  from  the  axilla  downward  and  forward  to  the  epigastrium,  the 
lung  is  adherent  to  the  thorax  over  the  space  anterior  and  internal  to  this 
line,  while  external  and  posterior  to  it  the  liquid  separates  the  lung  from  the 
ribs.  This  fact  is  important,  as  indicating  the  proper  point  for  puncturing 
the  chest — namely,  below  the  lower  angle  of  the  scapula  and  between  the 
eighth  and  ninth  ribs.  One  reason  why  the  earlier  performers  of  thoracen- 
tesis were  so  unsuccessful  was  that  they  selected  the  anterior  wall  of  the 
chest  as  the  point  of  operation.  Now-a-days,  however,  no  one  would  be  jus- 
tified in  performing  thoracentesis  unless  he  first  employed  the  hypodermic 
syringe  and  removed  fluid  at  the  point  which  he  selects  for  the  puncture. 
The  statistics  of  Mohr  relating  to  lung  displacement  in  empyema,  chiefly 
statistics  of  adult  cases,  are  somewhat  difierent  from  my  general  recollection 
of  cases  occurring  in  infancy  and  childhood,  as  stated  above.  In  23  cases  he 
found  the  lung  free  from  adhesions  and  compressed  against  the  vertebral 
column  and  the  mediastinum  ;  in  13  cases  the  organ  was  compressed  from 
below  upward ;  in  1  from  above  downward ;  in  4  from  within  outward ;  in  4 
from  behind  forward ;  and  in  4  from  before  backward.  These  variations 
depend  on  the  adhesions  which  the  lung  happens  to  contract.  Perhaps  a 
point  a  little  external  to  the  perpendicular,  passing  through  the  angle  of  the 
scapula,  is  preferable  for  puncture,  as  I  have  known  the  lung  to  be  adherent 
to  the  posterior  wall  of  the  chest  near  the  mediastinum  when  the  portion 
farther  removed,  say  two  inches  from  the  median  line,  was  separated  by 
interposed  liquid. 

Sometimes  the  liquid  is  collected  in  multilocular  cavities  formed  by  the 
connective  tissue,  and  these  frequently  intercommunicate.  Exceptionally  in 
children,  as  in  the  adult  cases  observed  by  Mohr,  when  there  has  been  a 
large  and  rapid  liquid  exudation  or  when  the  disease  has  been  violent  and 
of  short  duration,  adhesions  do  not  occur. 

On  account  of  the  great  difference  in  the  size  of  the  pleural  cavity  at 
difierent  ages  during  infancy  and  childhood,  the  amount  of  liquid  which 
produces  that  degree  of  compression  of  the  lung  which  materially  impairs 
its  function  varies  greatly.  At  the  age  of  four  months  three  ounces  produce 
complete  collapse  of  the  lung,  so  that  it  resembles  a  fleshy  mass  (carnification). 
The  largest  amount  of  liquid  relatively  to  the  size  of  the  chest  in  any  of  the 
cases  which  I  have  observed  was  about  one  and  a  half  pints  in  the  left  pleural 
cavity  in  an  infant  that  died  at  the  age  of  twenty-two  months  in  September, 
1867.  The  heart  lay  chiefly  to  the  right  of  the  median  line,  and  the  diaphragm 
was  convex  toward  the  abdominal  cavity.  The  case  occurred  in  the  almshouse 
on  Blackwell's  Island,  and  might  in  all  probability  have  been  relieved  had 
attention  been  directed  to  it  sufficiently  early. 

Liquid  in  the  left  pleural  cavity,  when  considerable,  presses  the  heart 
toward  the  mediastinum,  so  that  the  apex-beat,  instead  of  being  a  little 
internal  to  the  linea  mammalis,  approaches  the  sternum.  As  the  heart  is 
carried  to  the  right,  the  beat  is  felt  under  the  lower  end  of  the  sternum, 
and  with  still  greater  increase  in  the  efi'usion  the  pulsation  is  detected  by  the 
finger  to  the  right  of  the  sternum.     If  the  exudation  be  on  the  right  side,  the 


PLEURISY.  887 

displacement  of  the  heart  toward  the  left  is,  for  obvious  reasons,  less  than 
the  displacement  toward  the  right  in  pleurisy  of  the  left  side.  Much  external 
pressure  upon  the  heart  embarrasses  its  movements  and  prevents  proper  filling 
of  its  cavities,  while  the  action  of  the  organ  is  accelerated  so  as  to  compensate 
the  deficiency.     Therefore,  the  pulse  is  quick  and  feeble. 

In  one  instance  in  my  practice  the  lower  extremities  and  the  portion 
of  the  trunk  below  the  thorax  became  oedematous  from  compression  of  the 
ascending  vena  cava,  and  writers  allude  to  cases  in  which  other  vessels  and 
ducts,  as  the  thoracic,  were  compressed  so  as  seriously  to  embarrass  their 
functions.  The  patient  with  the  oedema  was  a  boy  of  about  four  years, 
with  empyema  of  the  left  side. 

In  large  eflFusion  the  mediastinum  is  pressed  against  the  healthy  lung  so 
as  to  diminish  its  transverse  diameter,  and  Traube  has  shown  that  the  effect 
of  this  is  to  increase  the  length  of  the  lung  or  its  vertical  measurement. 
Consequently,  as  the  lung  on  the  healthy  side  extends  lower  than  in  the 
normal  state,  the  convexity  of  the  diaphragm  on  this  side  is  diminished,  as 
well  as  on  the  affected  side,  where  it  is  depressed  by  the  efi"usion. 

The  pleura  in  protracted  cases  of  empyema  becomes  much  infiltrated,  and, 
from  the  growth  of  connective  tissue  which  blends  with  it,  is  thickened,  some- 
times to  the  extent  of  one  or  two  lines.  A  few  months  since,  in  removing  the 
lungs  from  the  body  of  a  young  infant  that  perished  of  empyema  in  the  New 
York  Foundling  Asylum,  a  portion  of  the  costal  pleura,  two  or  three  inches 
in  diameter,  being  adherent  to  the  lungs,  was  detached  from  the  ribs.  It  had 
a  thickness  of  fully  two  lines  and  its  free  surface  was  rough. 

Occasionally  the  inflammation  extends  from  the  pleura  to  the  pericar- 
dium, producing  general  pericarditis.  I  recall  to  mind  4  cases  with  this 
complication  in  which  the  diagnosis  was  verified  by  post-mortem  examina- 
tions. All  had  empyema,  3  on  the  left,  and  1  on  the  right  side.  Pericar- 
ditis, always  a  grave  disease,  is  almost  necessarily  fatal  when  thus  occurring 
as  a  complication  of  empyema.  More  rarely  the  inflammation  extends  from 
the  pleura  to  the  peritoneum.  One  such  case  occurred  in  my  practice,  the 
child  dying  of  empyema  on  the  right  side,  and  at  the  autopsy  we  found  the 
lesions  of  a  localized  diaphragmatic  peritonitis  of  the  right  side,  with  a 
fibrinous  exudation  of  small  extent  on  the  convex  surface  of  the  liver 
directly  opposite  to  that  on  the  diaphragm.  We  are  indebted  to  Von  Reck- 
linghausen for  knowledge  of  the  mode  in  which  inflammation  is  propagated 
from  the  pleura  to  the  peritoneum,  and  the  same  explanation  probably 
applies  to  its  propagation  to  the  pericardium.  In  the  serous  covering  of  the 
diaphragm,  pleural  and  peritoneal,  minute  stomata  have  been  discovered 
which  pertain  to  the  lymphatic  system.  They  open  upon  the  surface  of  the 
diaphragm,  and  underneath  in  the  substance  of  the  diaphragm  connect  with 
lacvmae  or  interspaces  from  which  the  minute  lymphatic  vessels  originate. 
These  stomata  and  lymphatic  spaces,  pervious  in  their  normal  state,  are  usually 
clogged,  as  has  been  stated  above,  by  inflammatory  products  when  the  serous 
membrane  is  inflamed.  Occasionally  the  inflammation  traverses  these  lym- 
phatic channels  from  one  surface  to  the  other,  from  the  pleura  to  the  peri- 
toneum, thus  causing  by  extension  a  circumscribed  peritonitis. 

The  changes  which  the  inflammatory  products  undergo  are  the  following : 
With  the  abatement  of  the  inflammation  the  liquid  portion  begins  to  be 
absorbed,  though  absorption  is  much  more  tardy  than  in  non-inflammatory 
efiusions,  since  the  absorbents  are  to  a  great  extent  covered  and  clogged  by 
fibrin  and  pus.  The  serum  is  first  absorbed,  and  the  flocculi  of  fibrin  sink 
into  depending  portions  of  the  cavity  or  become  attached  to  the  fibrinous 
layers  or  the  granulations  upon  the  pleural  surface.  The  pus-cells  and  the 
fibrin,  whether  in  flocculi  or  layers,  begin  to  undergo  retrogressive  change. 


LOCAL  DISEASES. 

They  become  granular  from  fatty  degeneration,  liquefy,  and  are  absorbed. 
Sometimes  portions  of  these  degenerated  products  which  are  not  absorbed 
form  inert  caseous  masses  in  recesses  of  the  cavity  or  between  the  bands  of 
connective  tissue,  where  they  remain  unchanged  for  years.  With  few  excep- 
tions, those  who  recover  from  an  attack  of  pleurisy  experience  no  subsequent 
ill-eflPect,  though  the  bands  and  patches  of  connective  tissue  are  permanent. 

Pus  always  possesses  irritating  properties.  Decomposed  and  putrid  pus 
(ichor)  is  very  irritating.  Empyemic  pus,  therefore,  like  pus  in  other  situa- 
tions, now  and  then  produces  ulceration  or  necrosis  of  the  pleural  surface  by 
which  it  is  confined,  and  in  consequence  of  its  destructive  action  it  sometimes 
establishes  an  outlet  by  which  it  escapes,  with  relief  to  the  patient  and  cure 
of  the  disease.  The  chest-wall  is  thinnest  anteriorly  in  the  inframammary 
region,  and  at  this  point  the  pus,  when  it  makes  its  way  through  the  thoracic 
wall,  usually  points  and  discharges.  The  fistulous  opening  thus  produced 
continues  many  months,  until  the  pleural  cavity  is  gradually  obliterated  by 
the  adhesions  and  the  patient  recovers. 

By  a  similar  destructive  process  in  the  pulmonary  pleura  pus  occasionally 
escapes  into  the  bronchioles  and  is  expectorated.  This  mode  of  cure  appears 
to  be  common  in  children,  for  my  attention  has  not  infrequently  been  called 
to  the  fact  that  children,  during  the  progressive  but  slow  convalescence  from 
empyema,  expectorated  large  quantities  of  muco-pus,  although  in  some  of 
the  cases  pus  had  been  removed  by  the  aspirator  or  trocar.  Frantzel  makes 
the  remark — which  is  fully  sustained  by  clinical  experience  in  this  country — 
that  although  an  opening  is  made  in  the  lung  by  the  necrotic  or  ulcerative 
process,  so  that  pus  escapes  into  the  bronchioles,  air  does  not  pass  from  them 
into  the  pleural  cavity.  Pyopneumothorax  is  very  rare  in  the  empyema  of 
children,  except  as  air  is  admitted  in  the  operation  of  thoracentesis. 

As  the  liquid  is  absorbed  the  compressed  lung  ordinarily  expands  in  pro- 
portion to  the  absorption,  so  that  more  and  more  air  enters  its  alveoli.  But 
frequently,  in  cases  of  long  duration,  the  absorption  proceeds  faster  than  the 
expansion,  so  that  the  ribs  on  the  afi"ected  side  sink  below  their  normal  level. 
As  a  consequence,  the  intercostal  spaces  are  narrowed,  the  shoulder  is  depressed, 
and  the  dorsal  portion  of  the  spinal  column  bends  to  accommodate  the  ribs, 
so  as  to  be  concave  toward  the  aff"ected  side.  It  is  very  rarely  that  the 
deformity  thus  produced  is  permanent.  Though  the  newly-formed  bands  and 
patches  of  connective  tissue  may  so  bind  the  lung  that  its  return  to  the  nor- 
mal state  is  tardy,  yet  with  few  exceptions  the  alveoli  one  after  another  open 
to  admit  air,  and  when  full  inflation  is  attained  the  symmetry  of  the  chest  is 
restored.  But  there  are  rare  cases  in  which  the  newly-formed  connective 
tissue  is  firm  and  unyielding  almost  as  cartilage,  and  lime  salts  are  some- 
times deposited  in  it,  forming  a  calcareous  plaque  which  invests  the  lung  like 
a  cuirass.  An  unexpanded  lung  with  such  a  covering  obviously  can  never 
afterward  be  fully  inflated.  I  can  recall  to  mind,  however,  only  one  case  of 
permanent  complete  collapse  or  carnification  of  lung  resulting  from  pleurisy. 
The  inflammation,  which  was  treated  by  the  late  Dr.  Cammann,  occurred  in 
childhood,  and  several  years  afterward,  whea  the  patient  reached  womanhood, 
although  the  general  health  was  good,  there  were  physical  signs  of  an 
unaerated  lung  and  the  consequent  deformity  (depressed  shoulder  and  ribs 
and  bent  spinal  column).  Pleurisy  with  its  granulations  and  retrogressive 
products  afi'ords  one  of  the  conditions  in  which  tubercles  are  developed,  so 
that  we  sometimes  find,  at  the  post-mortem  examination  of  cases  which  have 
been  protracted,  "  miliary  tubercles  in  the  pleura,  while  chronic  phthisis  and 
general  tuberculosis  are  absent  "  (Delafield). 

From  the  intimate  relation  of  the  heart  to  the  lungs  this  organ  obviously 
suffers  severely  in  every  large  pleuritic  exudation.     Total  compression  of  a 


PLEURISY.  889 

lung  arrests  one-half  of  the  circulation  through  the  pulmonary  artery,  except 
as  the  increased  flow  in  the  opposite  lung  serves  for  compensation.  Hence  in 
cases  of  large  effusion  which  end  fatally  we  commonly  find  the  pulmonary 
artery  and  the  right  cavities  of  the  heart  distended  with  blood  and  clots, 
while  the  left  cavities,  having  received  a  diminished  quantity  of  blood,  are 
probably  empty. 

Symptoms. — As  has  been  stated  above,  pleurisy  in  children  is  sometimes 
latent  or  attended  by  symptoms  so  mild  as  to  attract  little  attention  even 
when  there  has  been  general  inflammation  of  the  pleural  surface  with  much 
effusion.  Both  primary  and  secondary  pleurisy  may  present  this  form, 
latency  being  more  frequent  the  younger  the  patient.  In  feeble,  cachectic 
children,  with  blood  thin  and  impoverished,  pleuritic  symptoms,  as  pain, 
dyspnoea,  and  fever,  are  less  pronounced  than  in  the  robust,  and  hence 
latency  is  more  common  in  the  tenement-house  population  of  the  cities  and 
in  institutions  than  in  the  better  walks  of  life.  The  following  is  a  not  infre- 
quent example  of  latency :  A  feeble  infant,  aged  five  months  and  twenty- 
eight  days,  died  suddenly  in  the  Nursery  and  Child's  Hospital  in  December, 
1870.  The  attention  of  the  resident  physician  had  not  been  called  to  it,  as 
it  was  not  supposed  to  be  sick,  except  that  it  was  ill-nourished  and  its  general 
condition  bad.  The  nurse  who  had  charge  of  the  ward  stated  that  it  pre- 
sented no  symptom  of  acute  disease,  unless  a  slight  cough  during  the  three 
or  four  days  preceding  its  death.  Percussion  over  the  right  side  of  the  chest 
of  the  corpse  gave  a  flat  resonance,  and  at  the  autopsy  the  right  lung  was 
found  compressed,  nearly  or  quite  destitute  of  air,  and  covered  by  a  loose 
fibrinous  layer  three-fourths  of  an  inch  thick  in  places,  and  a  moderate  serous 
exudation. 

Ordinarily,  acute  idiopathic  pleurisy  in  children  begins  quite  abruptly, 
and  with  symptoms  which  attract  attention  from  the  first.  Probably  in  most 
instances  it  is  preceded  by  I'igors  or  a  chilly  sensation,  but  this  usually  escapes 
notice,  if  it  be  present,  in  patients  under  the  age  of  five  or  six  years.  Fever, 
fretfulness,  and  a  physiognomy  indicative  of  pain  are  the  common  initial 
symptoms.  If  the  patient  be  an  infant,  the  fretfulness  closely  resembles 
that  produced  by  colic,  for  which  I  have  on  several  occasions  known  it  to 
be  mistaken  by  the  attending  physician. 

The  symptoms  of  pleurisy  are  twofold — namely,  the  constitutional,  or 
such  as  are  common  to  all  inflammations,  and  the  local,  or  those  referable 
to  the  chest.  Various  observers  have  noted  the  position  in  which  patients 
lie  in  bed  as  indicating  the  seat  of  the  inflammation.  It  has  been  stated  that 
adults,  in  the  commencement  of  pleurisy,  ordinarily  obtain  most  relief  with 
a  decubitus  on  the  sound  side,  but  when  effusion  has  occurred  they  lie  on  the 
affected  side,  unless  there  be  marked  dyspnoea,  which  is  most  relieved  by  a 
semi-erect  position,  which  allows  greater  descent  of  the  diaphragm.  I  have 
not  noticed  that  children  with  pleurisy  prefer  any  fixed  or  uniform  position, 
except  there  be  marked  dyspnoea,  which  may  prompt  them  to  elevate  the 
shoulders.  The  patient  in  the  acute  stage  is  commonly  quiet  when  he  lies  in 
the  position  which  he  selects,  and  if  disturbed  from  it  becomes  more  fretful, 
his  cough  more  frequent,  and  his  suffering  apparently  increased. 

In  ordinary  cases  the  temperature  rises  on  the  first  day  to  102°  or  103°. 
If  it  be  more  elevated  than  this,  there  is  usually  a  complication.  The  tem- 
perature begins  to  abate  when  the  exudation  has.  occurred.  In  suppurative 
pleurisy  the  fever  is  more  protracted,  often  continuing  for  weeks  or  months, 
presenting,  after  the  acute  stage  has  passed,  the  characters  of  hectic  fever, 
with  morning  abatement  and  evening  recrudescence.  In  weakly  and  anaemic 
children,  even  when  the  pleurisy  is  pretty  severe  and  most  of  the  usual  symp- 
toms are  present,  the  temperature  may  be  but  slightly  elevated.     Thus  in  one 


890  LOCAL  DISEASES. 

of  the  institutions  with  which  I  am  connected,  in  a  young  infant  whose  fret- 
fulness  was  during  the  first  twenty-four  hours  ascribed  to  colic,  the  axillary 
temperature  during  the  first  three  days  never  rose  above  100°. 

The  pulse  in  the  acute  stage  is  usually  between  100  and  130  per  minute, 
but  in  young  children  who  are  restless  it  is  often  more  frequent  than  this 
during  the  first  week.  It  is  accelerated  as  long  as  the  temperature  is  elevated, 
but  in  sero-fibrinous  pleuritis  after  exudation  has  occurred  its  frequency 
diminishes  unless  the  heart  be  compressed.  Compression  and  imperfect  or 
partial  filling  of  the  cavities  of  the  heart  produce  a  feeble  and  rapid  pulse. 
In  empyema  the  pulse  is  accelerated  as  long  as  pus  is  confined  in  the  pleural 
cavity,  unless  its  quantity  be  small. 

Headache,  usually  frontal,  is  frequent  dui'ing  the  febrile  stage.  Convul- 
sions, which  occasionally  occur  in  the  beginning  of  pneumonia,  are  rare. 
Pain  in  the  chest  on  the  affected  side  is  common,  and  is  therefore  a  valuable 
diagnostic  symptom,  but  it  is  often  so  slight  as  to  be  overlooked  in  infants 
and  feeble  children.  It  is  increased  by  movements  of  the  chest-walls,  as  in 
full  inspiration,  by  coughing,  and  when  pressure  is  made  by  the  fingers  in 
the  examination.  Its  common  seat  is  between  the  fifth  and  eighth  ribs,  exter- 
nal to  the  linea  mammalis,  but  there  are  many  cases  in  which  the  pain  is 
referred  to  some  other  part,  as  the  infraclavicular,  mammary,  inframammary, 
or  even  the  scapular  or  infrascapular,  region.  Rarely,  it  is  referred  to  the  epi- 
gastric or  umbilical  region,  or  even,  it  is  said,  to  some  point  upon  the  sound 
side  of  the  thorax.  This  location  of  the  pain  at  a  point  distant  from  the  seat 
of  the  inflammation  is  attributable  to  the  anastomosis  of  the  intercostal  nerves 
with  those  of  the  opposite  side  of  the  chest  or  with  those  which  ramify  in  the 
abdominal  walls. 

The  pain  of  pleurisy,  as  it  ordinarily  occurs,  has  received  different  explana- 
tions. It  has  been  attributed  to  tension  of  the  pleura,  to  friction  of  the  pleural 
surfaces  on  each  other,  and  to  extension  of  the  inflammation  to  the  neuri- 
lemma of  the  minute  nervous  branches  of  the  pleura.  All  these  causes 
apparently  act  in  producing  it,  but  the  persistent  pain  in  the  first  days  of 
pleurisy,  though  increased  by  motion,  is  probably  due  in  great  part  to  that 
last  mentioned.  Pleuritic  pain  is  sharp  or  stitch-like.  It  begins  to  abate  in 
a  few  days,  and  in  a  large  proportion  of  cases  ceases  by  the  fifth  or  sixth 
day,  or  is  no  longer  noticed  except  in  coughing  or  during  sudden  movement 
of  the  chest. 

The  respiration  is  accelerated,  as  in  all  febrile  diseases,  but  it  is  more  rapid 
than  in  inflammatory  ailments  which  do  not  involve  the  thoracic  organs,  on 
account  of  the  pain  experienced  on  full  respiration.  The  patient  instinctively 
avoids  full  inflation  of  the  lungs,  and  the  breathing  is  consequently  rapid,  to 
compensate  for  incompleteness  of  the  inspiratory  act. 

In  ordinary  attacks  of  pleurisy  painful  and  hurried  respiration  is  of  short 
duration.  It  becomes  easier  and  more  natural  toward  the  close  of  the  first 
week.  In  subacute  and  chronic  cases  the  rhythm  and  frequency  of  respira- 
tion differ  but  little  from  the  normal. 

A  cough,  whatever  the  form  of  pleurisy,  is  one  of  the  earliest  symptoms. 
It  is  short,  frequent,  and  dry,  and  in  the  most  favorable  cases  begins  to  dimin- 
ish in  the  second  week.  A  loose  cough  is  due  to  accompanying  bronchitis  or 
broncho-pneumonia,  or,  at  a  late  stage  of  the  disease,  to  escape  of  pus  from 
the  pleural  cavity  into  the  bronchial  tubes. 

Little  need  be  said  in  regard  to  symptoms  referable  to  the  digestive  appa- 
ratus. Vomiting  is  common  on  the  first  and  second  days.  Thirst,  loss  of 
appetite,  and  consequent  loss  of  flesh  and  strength,  are  uniformly  present. 
In  empyema,  which  from  its  nature  is  protracted,  nutrition  is  always  greatly 


PLEURISY.  891 

impaired.     The  surface  presents  an  anaemic  appearance,  the  flesh  is  soft  and 
flabby,  and  the  emaciation  is  progressive  till  the  pus  is  evacuated. 

Physical  Signs. — In  children  above  the  age  of  three  or  four  years  the 
physical  signs  difi"er  but  little  from  those  in  adult  cases,  but  under  this  age 
there  are  certain  diiferences  which  the  practitioner  should  know.  We  may, 
in  the  commencement  of  the  attack,  notice  diminution  in  the  movement  of 
the  chest-walls  on  the  aff"ected  side,  since  the  patient  instinctively  endeavors 
to  repress  respiration  on  that  side  in  order  to  lessen  the  pain.  In  severe 
cases  the  epigastrium  and  hypochondria  are  sometimes  depressed  during 
inspiration  (the  so-called  abdominal  respiration),  but  this  sign  is  less  common 
and  less  marked  than  in  severe  bronchitis,  and  when  present  it  may  be  largely 
due  to  accompanying  bronchitis.  After  efi'usion  has  occurred  and  the  pain 
has  abated  or  is  slight,  the  respiration  is  less  accelerated  than  at  first,  and  it 
may  be  nearly  or  quite  normal. 

Inequality  of  the  two  sides  produced  by  the  liquid  is  more  common  in 
children  of  an  advanced  age  than  in  those  under  the  age  of  three  or  four 
years.  In  infants,  even  when  there  is  a  large  liquid  exudation,  the  bulging 
is  often  so  slight  that  it  is  scarcely  appreciable  either  by  sight  or  measure- 
ment, and  in  not  a  few  there  is  no  apparent  difference  in  the  circumference 
of  the  healthy  and  aff"ected  sides.  I  have  made  measurements  in  infantile 
pleurisy  during  the  stage  of  efi'usion,  and  been  unable  to  convince  myself 
that  there  was  any  diff"erence,  although  other  signs  indicated  the  presence  of 
an  efiusion  which  filled  at  least  one-half  the  pleural  cavity.  I  explain  this 
fact  in  this  way :  The  lungs  of  an  infant,  especially  of  one  reduced  by  sick- 
ness, are  very  liable  to  a  state  of  semi-collapse  or  partial  inflation  in  their 
whole  extent  and  of  complete  collapse  of  their  thin  borders,  as  of  the  tongue- 
like process  of  the  left  upper  lobe,  which  lies  over  the  pericardium,  and  of 
the  margins  of  the  lower  lobes,  which  lie  in  the  angle  made  by  the  thorax 
or  diaphragm.  This  occurs  in  the  weakly  infant  even  when  there  is  no  ob- 
struction to  the  entrance  of  air,  and  the  liability  to  it  is  greatly  increased  by 
external  pressure  applied  to  the  lung,  as  from  a  pleuritic  effusion,  so  that  the 
lung  recedes,  becomes  compressed,  and  unaerated  before  the  ribs  yield  to  the 
pressure.  If  the  exudation  cease  as  soon  as  the  lung  is  collapsed,  there  is 
little  or  no  outward  displacement  of  the  ribs  and  the  intercostal  spaces  are 
not  elevated.  It  is  obviously  very  important  to  know  this  diff"erence  between 
infantile  and  adult  cases,  as  it  has  a  bearing  upon  the  diagnosis  between 
pleurisy  with  effusion  and  pneumonia. 

Palpation. — In   adults   and  in   children   with  strong  voices,  if  the  lung 

deprived  of  air,  either  by  compression  or  an  exudation  within  its  alveoli,  lie 

against  the  chest-wall,  speaking  or  moaning  produces  a  vibratory  sensation 

which  is  communicated  to  the  hand  placed  upon  the  chest.     The  fremitus  is 

feeble   or   not   appreciable  when  the  voice  is  feeble.     Therefore,  in  infants 

whose  vocal  cords  are  small,  and  particularly  in  infants  reduced  by  sickness, 

this  sign  is  ordinarily  absent  or  so  slight  that  it  is  detected  with  difficulty, 

while  in  older  and  robust  children  it  is  distinctly  perceived.     If  the  condition 

^  be  otherwise  favorable  for  the  production  of  fremitus,  but  the  lung  be  pressed 

I  away  from  the  ribs  by  an  intervening  liquid,  no  vibration  is  felt  when  the 

I  patient  speaks  or  cries.     But  if,  in  the  same  case,  the  fingers  be  removed  to 

I  the  suprascapular,  axillary,  infraclavicular,  or  mammary  region,  where  the 

compressed  lung  comes  in  contact  with  the  walls  of  the  chest,  fremitus  may 

I  be  perceived.     Palpation  also  enables  us  to  ascertain  the  point  of  apex-beat 

of  the  heart,  the  variation  of  which  from  the  normal  size  is  one  of  the  most 

conclusive  proofs  of  a  pleuritic  efi'usion. 

Percussion. — In  the  first  hours  of  pleurisy  there  is  either  no  perceptible 
change  in  the  percussion  sound,  or  the  resonance  is  slightly  diminished  from 


892     ■  LOCAL  DISEASES. 

tlie  fact  that  inspiration  on  the  affected  side  is  resisted  by  the  patient  and  the 
lung  is  only  partially  inflated.  When  exudation  occurs,  if  there  be  a  thin 
layer  of  liquid  over  the  lung,  the  percussion  sound  is  tympanitic.  It  has, 
therefore,  this  quality  at  an  early  stage  in  the  inframammary,  mammary,  and 
perhaps  infrascapular  regions  when  the  amount  of  liquid  is  small,  and  at  a 
later  stage,  when  the  quantity  of  liquid  is  greater,  the  percussion  sound  over 
the  lower  part  of  the  chest  is  dull,  while  that  over  the  central  or  upper  part 
is  tympanitic.  Entire  filling  of  the  pleural  cavity  with  liquid,  and  total 
exclusion  of  air  from  the  lung,  give  rise  to  a  dull  or  flat  percussion  sound 
over  every  part  from  the  apex  to  the  base.  It  may  be  stated  as  a  rule  in  the 
pleurisy  of  children  that  at  a  certain  stage  of  the  effusion  percussion  pro- 
duces a  sound  which  is  either  decidedly  tympanitic  or  which  partakes  of  the 
tympanitic  character.  Skoda  attributed  the  occurrence  of  tympanism  to  the 
fact  that  a  lung  still  aerated  vibrates  better  if  surrounded  by  a  thin  layer  of 
liquid,  and  consequently  gives  better  resonance  than  when  it  lies  against  the 
chest-walls. 

When  the  exudation  is  so  great  that  the  lung  is  totally  compressed  and 
removed  to  a  distance  from  the  chest-walls,  the  finger  in  percussing  experi- 
ences a  sensation  of  solidity  or  resistance,  and  there  is  no  longer  any  vibra- 
tion of  the  ribs.  Consequently,  the  percussion  sound  is  dull  or  flat,  as  over 
any  solid  body,  differing  from  that  in  pneumonia,  in  which  there  is  still  some 
vibration  of  the  chest-walls  and  the  dulness  is  not  absolute.  In  pleurisy, 
therefore,  there  is,  according  to  the  amount  of  exudation,  either  nearly  the 
normal  percussion  sound,  as  at  the  beginning  of  the  attack  and  in  any  stage 
of  plastic  pleurisy  (pleuresie  seche),  or  a  zone  of  dull  sound  below  and 
another  of  tympanitic  sound  above,  or  a  zone  of  normal  resonance  above 
and  one  of  dull  resonance  at  the  base,  with  an  intervening  one  of  tympan- 
ism ;  or.  finally,  there  is  absolute  dulness  from  the  clavicle  to  the  base  of  the 
chest. 

It  very  rarely  happens  in  the  child  that  the  level  of  the  fluid  changes  by 
changing  the  position,  on  account  of  the  adhesions,  so  that  this  sign,  described 
in  the  books  as  one  of  great  importance  in  diagnosis,  affords  very  little  assist- 
ance to  diagnosis  in  children. 

Auscultation. — In  the  beginning  of  pleurisy  auscultation  affords  but  slight 
information,  except  that  the  practised  ear  may  detect  a  little  diminution  in 
the  fulness  of  the  respiratory  act  in  the  lung  whose  pleura  is  inflamed,  and 
perhaps  a  slightly  exaggerated  respiration  in  the  other  lung.  But  after 
twelve  or  fifteen  hours,  when  exudation  begins  to  occur  upon  the  pleural 
surface,  we  may  hear  the  dry  friction  sound,  which  can  be  imitated  by  push- 
ing the  finger  strongly  across  the  dry  palm  of  the  hand.  It  is  only  heard  in 
occasional  cases,  since  the  physician  may  not  make  his  visit  at  the  proper 
time  for  hearing  it  or  he  does  not  apply  the  ear  over  the  proper  place. 
Frantzel  says :  "  We  shall  scarcely  ever  fail  to  find  the  friction  sound  in 
recent  pleuritis  if  we  look  for  it  early  and  diligently  in  some  circumscribed 
spot."  I  do  not  think  that  this  remark,  however  true  it  may  be  of  adult 
cases,  is  entirely  correct  as  regards  children,  for  it  is  only  in  exceptional 
instances  that  it  can  be  heard  in  them.  It  occurs  both  during  inspiration 
and  expiration,  and  it  does  not  disappear  after  coughing.  Being  produced 
upon  the  surface  of  the  lung,  it  seems  near  the  ear  of  the  auscultator.  Per- 
haps it  is  not  observed  during  several  consecutive  respirations,  and  then  a 
deeper  inspiration  causes  the  pleural  surfaces  to  glide  upon  each  other,  and 
it  is  detected.  The  friction  sound  as  sometimes  heard  is  well  described  by 
the  term  "  scraping,"  and  in  other  eases  by  the  term  "  creaking,"  as  was 
noticed  by  Hippocrates,  who  compared  it  to  the  creaking  of  leather. 

In  some  patients  it  is  heard  for  a  brief  period,  and  does  not  recur,  and  it 


PLEURISY.  893 

may  be  detected  only  during  strong  and  deep  respiration  or  in  coughing.  It 
disappears  entirely  when  the  accumulation  of  liquid  prevents  contact  of  the 
surfaces.  After  absorption  of  the  liquid  the  friction  sound  may  reappear, 
and  in  certain  patients  it  is  heard  only  at  this  time — to  wit,  in  the  third 
stage. 

An  interesting  and  common  sound  heard  on  inspiration  is  the  so-called 
crepitant  rale  q/' j:)?e(f?7'sy,  produced  in  the  superficial  alveoli.  The  remarks 
made  by  Trousseau  upon  it  have  been  already  given.  As  stated  above,  the 
inflammation  extends  from  the  pleura  to  the  pulmonary  vesicles  which  lie 
directly  underneath,  and  as  soon  as  exudation  occurs  within  them  the  ana- 
tomical conditions  are  present  in  which  the  crepitant  rale  is  produced,  as  in 
the  ordinary  form  of  pneumonia.  This  rale  may  obviously  be  heard  before 
any  eflFusion  takes  place  upon  the  free  surface  of  the  pleura,  and  it  continues 
until  the  alveoli  are  so  compressed  by  the  pleuritic  exudation  that  they  no 
longer  admit  air. 

The  exudation  in  the  pleural  cavity  changes  the  character  of  the  respira- 
tory sound.  A  thin  layer  of  liquid  over  the  lung  causes  diminution  in  the 
force  of  the  vesicular  murmur,  and  soon  an  expiratory  as  well  as  an  inspira- 
tory sound  begins  to  be  heard.  This  modified  vesicular  murmur  is  weak, 
and  more  distant  from  the  ear  than  the  respiratory  sound  of  health.  When 
the  exudation  is  sufiicient  to  close  the  alveoli,  while  the  air  still  traverses  the 
medium-sized  bronchial  tubes,  we  notice  a  tubular  or  bronchial  hruit.  If  the 
small  and  medium-sized  tubes  are  compressed  while  the  air  enters  the  large 
tubes,  the  respiratory  bruit  may  be  amphoric.  Total  absence  of  respiratory 
sound  results  from  complete  collapse  of  the  alveoli  and  consequent  exclusion 
of  air  from  them,  and  arrest  of  the  movements  of  the  air  in  the  tubes  of  the 
afiiected  side.  Jaccoud  says :  "  Regarded  as  a  sign  of  the  quantity  of  the 
eflFusion,  the  modifications  of  the  respiratory  hruit  and  of  the  respiration  may 
then  be  arranged  in  an  increasing  series,  as  follows :  diminution  of  the  vesic- 
ular murmur ;  feeble  respiration  (souffle  cloux)  ;  no  sound  and  feeble  respira- 
tion ;  bronchial  respiration ;  no  sound  and  bronchial  respiration ;  no  sound 
and  cavernous  respiration  ;  general  absence  of  sound  (silence  general).  The 
replacement  of  an  inferior  term  of  the  series  by  a  superior  term  implies  an 
augmentation  in  the  quantity  of  liquid,  and  in  general  the  passage  of  a 
superior  term  to  an  inferior  term  denotes  a  diminution  of  the  effusion."  But 
this  statement  relating  to  the  effect  upon  the  auscultatory  sounds  of  the 
increase  and  decrease  of  the  liquid  must  be  modified  as  regards  patients 
under  the  age  of  five  years.  In  such  patients  it  is  rare,  however  great  the 
effusion,  that  respiration  is  not  heard  when  the  ear  is  placed  over  the  liquid. 
This  is  due  to  the  small  size  of  the  pleural  cavity,  and  the  consequent  ready 
transmission  of  sound  from  the  centre  of  the  thorax  to  its  periphery.  Accord- 
ing to  the  amount  of  exudation  and  the  degree  of  compression,  the  respira- 
tory sound  is  a  faint  and  distant  vesicular,  or  broncho-vesicular,  or  bronchial 
murmur,  and  its  character  is  found  to  vary  from  one  to  the  other  of  these 
sounds  as  we  apply  the  ear  over  different  parts  of  the  chest. 

When  the  inflammation  is  active  and  the  exudation  occurs  rapidly,  bron- 
chial respiration  may  be  heard  as  early  as  the  second  or  third  day,  or  even  by 
the  close  of  the  first  day,  in  the  infrascapular  region.  If,  on  the  other  hand, 
the  inflammation  be  chiefly  plastic  or  the  exudation  of  liquid  be  slow  and  its 
quantity  small,  the  respiratory  murmur  may  be  vesicular,  though  faint  and 
distant,  during  the  whole  course  of  the  attack.  Sometimes  when  the  mur- 
mur is  vesicular  in  the  greater  part  of  the  lung,  broncho-vesicular  or  bron- 
chial respiration  is  heard  over  a  limited  area,  where  the  effusion  happens  to 
be  sufficient  to  produce  requisite  compression  of  the  lung. 

The  voice  of  the  patient  when  auscultated  over  the  affected  side  has  a 


894  LOCAL  DISEASES. 

character  which  corresponds  with  and  varies  according  to  the  respiratory 
murmur.  Vocal  resonance  is  feeble  or  absent  if  the  respiratory  murmur  be 
vesicular.  If  it  be  bronchial,  the  auscultated  voice  is  more  distinct,  having 
the  character  known  as  bronchophony,  or  when  there  is  a  moderate  quantity 
of  liquid  over  the  lung,  so  that  this  organ  vibrates,  it  may  have  that  modifi- 
cation of  bronchophony  known  as  aegophony.  Occasionally  we  can  hear  the 
voice  as  a  confused  and  distant  sound  when  the  quantity  of  liquid  is  so 
great  that  respiration  is  inaudible.  The  signs  derived  from  the  auscultated 
voice  are  not,  as  is  well  known,  pathognomonic  of  liquid  efi'usion.  Bronchoph- 
ony is  more  common  and  distinct  in  pneumonic  or  tubercular  solidification 
of  lung  than  in  pleurisy,  and  even  aegophony  may  be  produced  without  the 
presence  of  a  liquid  by  "  pleural  membranes  realizing  certain  physical  con- 
ditions "  (Jaccoud).  But  since  the  auscultated  voice  is  weaker  in  children 
than  in  adults,  we  often  do  not  hear  it  in  infants  and  ill-conditioned  children, 
even  when  the  anatomical  conditions  as  regard  the  lungs  and  pleural  cavity 
are  favorable  to  its  transmission. 

In  children,  as  in  adults,  bronchial  rales  are  common  in  pleurisy,  dry  or 
moist ;  coarse  when  produced  in  the  larger  tubes,  or  fine  when  occurring  in 
the  finer  tubes. 

Diagnosis. — Ordinarily,  a  careful  observance  of  the  history,  symptoms, 
and  physical  signs  enables  the  physician  to  make  a  positive  diagnosis.  Obscure 
or  doubtful  cases  occur  chiefly  in  infancy.  Circumscribed  pleurisy  or  pleurisy 
attended  with  little  or  no  liquid  exudation  is  obviously  likely  to  be  overlooked 
and  its  symptoms  mistaken  for  those  of  another  disease. 

Pleurisy  before  the  stage  of  exudation  may  be  mistaken  for  pneumonia, 
since  the  prominent  symptoms  in  the  commencement  of  the  two  diseases  are 
similar.  But  in  pleurisy  there  are  commonly  greater  acceleration  of  pulse 
and  respiration,  greater  suffering  as  evinced  by  the  features,  greater  tender- 
ness on  percussion  or  on  pressing  the  chest-wall,  and  a  more  decided  expira- 
tory moan,  while  the  patient  probably  endeavors  to  repress  respiration  on  the 
aff"ected  side,  so  that  inflation  of  the  lungs  is  partial  and  shallow.  It  will  aid 
in  the  diagnosis  to  recollect  that  in  children  under  the  age  of  five  years  acute 
pneumonia  is  in  most  instances  catarrhal,  and  not  croupous,  and  is  preceded 
and  accompanied  by  severe  bronchitis,  being  due  to  downward  extension  of 
the  inflammation  from  the  bronchial  tubes.  It  therefore  does  not  begin  with 
the  abruptness  of  pleurisy. 

Pleurisy  with  efi'usion  may  be  mistaken  for  pneumonia  in  the  stage  of 
solidification,  for  hydrothorax,  or.  on  the  left  side,  for  pericardial  efi'usion,  or 
vice  versa.  But  the  percussion  sound  over  a  pleuritic  exudation  is  either 
tympanitic  or  flat,  while  over  a  lung  solidified  by  infiammation  it  has  some 
resonance,  though  dull.  There  is  also  a  sensation  of  greater  resistance  and 
solidity  in  percussing  over  a  pleuritic  exudation  than  over  an  infiamed  lung. 
Moreover,  the  respiratory  murmur,  whether  vesicular,  broncho-vesicular,  or 
bronchial,  is  more  distant  and  less  distinct  to  the  ear  of  the  auscultator 
when  applied  over  a  liquid  than  over  a  solidified  lung. 

A  pleuritic  exudation,  unless  slight,  also  changes  the  apex-beat  of  the 
heart,  pressing  it  toward  the  median  line  in  left  pleurisy,  and  away  from 
the  median  line  in  right  pleurisy,  as  has  been  stated  above — a  change  not 
observed  in  pneumonia.  Bulging  of  the  intercostal  spaces,  expansion  of 
the  chest-walls,  change  in  height  of  the  fluid  by  change  in  the  position  of 
the  child — important  signs  in  the  diagnosis  of  adult  pleurisy — are,  as  we 
have  seen,  commonly  absent  in  young  children,  even  when  there  is  abundant 
liquid  effusion,  but  they  are  sometimes  observed  in  children  of  a  more 
advanced  age.  Bronchophony  and  vocal  fremitus,  signs  of  pneumonic  solid- 
ification, are  absent  or  so  feeble  in  the  pneumonia  of  young  children  that 


PLEURISY.  895 

their  absence  cannot  be  regarded  as  indicative  of  the  presence  of  pleuritic 
eflPusion,  except  in  children  over  the  age  of  four  or  five  years.  Moreover, 
these  signs,  when  present,  do  not  necessarily  indicate  pneumonia,  for  if  in 
pleuritic  efi"usion  the  ear  or  hand  be  placed  over  a  part  of  the  chest  where 
adhesions  have  united  the  lung  to  the  ribs,  and  the  child  be  of  such  an  age 
that  the  vocal  cords  have  sufficient  vibration,  both  bronchophony  and  the  frem- 
itus may  be  perceived.  The  absence  or  presence,  therefore,  of  vocal  fremitus 
and  bronchophony  affords  only  limited  assistance  in  the  differential  diagnosis 
of  pleurisy  and  pneumonia  in  young  children.  In  those  of  an  advanced 
age,  whose  vocal  cords  have  greater  vibration,  it  aids  in  the  discrimination 
of  doubtful  cases,  especially  if  the  examination  be  made  in  the  infrascap- 
ular  region,  which  corresponds  with  the  location  of  the  liquid  if  any  be 
present. 

A  pleuritic  effusion  is  distinguished  from  hydrothorax  by  the  fact  that 
the  latter  is  usually  bilateral  and  of  slow  increase,  without  symptoms  refer- 
able to  the  chest,  except  when  there  is  considerable  effusion,  which  causes 
more  or  less  dyspnoea.  Pleurisy,  unlike  hydrothorax,  causes  fever  and  other 
constitutional  symptoms,  and  also  a  cough,  pain  in  the  chest,  and  early 
embarrassment  of  respiration.  Moreover,  hydrothorax  seldom  occurs,  except 
from  cardiac  or  renal  disease  or  scarlet  fever. 

A  greatly  distended  pericardial  sac  simulates  in  some  degree  a  pleuritic 
effusion  on  the  left  side,  but  the  absence  of  symptoms  which  pertain  to 
pleurisy,  as  the  cough,  stitch-like  pain  in  the  chest,  the  localization  or  greater 
distinctness  of  the  dull  sound  on  percussion  in  the  cardiac  region,  absence  or 
feebleness  of  the  apex-beat,  and  indistinctness  or  distance  of  the  heart-sounds, 
will  preserve  the  observant  physician  from  error  of  diagnosis. 

Prognosis. — In  mild  cases  attended  with  little  exudation  the  inflammation 
soon  begins  to  abate,  and  by  the  close  of  the  second  week  the  symptoms  have 
nearly  disappeared.  In  plastic  and  sero-fibrinous  pleurisies  recovery  may  be 
confidently  expected,  unless  there  be  some  grave  complication,  or  perchance 
syncope  should  occur  from  large  and  rapid  efiusion.  .  A  large  effusion,  what- 
ever its  character,  especially  if  located  on  the  left  side,  often  causes  such  a 
twist  in  the  great  vessels  within  the  thorax  as  seriously  to  retard  the  circula- 
tion of  blood  and  endanger  life.  In  effusions  of  the  left  side  the  heart  is  often 
carried  so  far  toward  the  right  that  the  ascending  vena  cava,  where  it  emerges 
from  the  central  tendon  of  the  diaphragm,  is  bent  at  an  angle  so  as  seriously 
to  obstruct  the  return  of  blood  from  the  lower  half  of  the  body,  and  conse- 
quently a  reduced  quantity  of  blood  reaches  the  right  cavities  and  the 
pulmonary  artery.  The  result  is  a  diminished  flow  of  blood  in  the  systemic 
circulation,  with  anaemia  of  important  organs,  as  the  brain.  The  great  arteries 
connected  with  the  heart  are  also  more  or  less  bent  in  cases  attended  by  dis- 
placement of  this  organ.  In  effusions  on  the  right  side  the  right  auricle  and 
ventricle  sometimes  do  not  expand  to  the  normal  extent  during  the  diastole, 
on  account  of  the  pressure  of  the  liquid,  and  the  result  is  similar  to  that 
in  effusions  on  the  left  side  as  regards  obstructed  cii'culation  and  angemia  of 
important  organs.  Therefore,  patients  with  large  pleuritic  effusions,  whether 
left  or  right,  are  liable  to  sudden  fainting  and  even  to  fatal  syncope.  For- 
tunately, with  our  present  improved  methods  of  thoracentesis  children  need 
not  perish  in  this  way  if  the  operation  be  resorted  to  at  the  proper  moment. 
There  is  another  danger.  When,  in  consequence  of  the  exudation,  the  lung  is 
so  compressed  that  its  function  is  nearly  or  quite  lost,  the  sound  lung  obviously 
receives  an  augmented  supply  of  blood.  It  is  therefore  very  liable  to  sudden 
congestions  and  transudation  of  serum  (oedema).  If  this  occur,  the  dyspnoea 
is  augmented  and  the  condition  is  one  of  utmost  peril.  Death  may  result 
from  this  state. 


896  LOCAL  DISEASES. 

The  prognosis  obviously  varies  according  to  the  cause  of  the  inflammation 
and  the  quantity  and  natui'e  of  the  exudation.  Idiopathic  pleurisies  do  better, 
as  a  rule,  than  those  which  occur  as  a  complication  or  sequel  of  some  other 
disease.  Absorption  is  more  rapid  in  the  beginning  of  convalescence,  when 
the  fluid  is  thin,  than  at  a  later  period,  when  it  has  greater  consistence. 
Fibrin,  whether  flocculent  or  laminated,  is  necessarily  slowly  absorbed,  first 
undergoing  fatty  degeneration  and  liquefaction.  Empyema,  if  not  relieved 
by  operative  measures,  continues  many  months ;  even  after  pus  is  let  out 
convalescence  is  slow.  In  the  very  considerable  number  of  empyemic  cases 
which  have  from  time  to  time  been  brought  to  the  class  of  children's  diseases 
in  the  Bureau  for  the  Relief  of  the  Out-door  Poor  the  histories  commonly 
showed  that  the  disease  had  continued  from  three  to  six  months,  with  pro- 
gressive loss  of  flesh  and  strength.  Nevertheless,  after  proper  evacuation 
of  the  pus  and  the  establishment  of  a  fistulous  opening  the  majority  have 
gradually  recovered,  death  in  the  unfavorable  cases  being  commonly  due 
to  extreme  prostration,  with  perhaps  fatal  organic  changes,  as  amyloid 
degeneration  and  tuberculosis. 

Secondary  pleurisy  occurring  in  a  reduced  state  of  the  system,  as  after 
scarlet  fever,  and  pleurisy  complicated  by  a  grave  disease,  as  pericarditis  or 
pneumonia,  are  always  dangerous  to  life. 

It  is  the  common  belief  that  pleuritic  eff"usions  involve  greater  danger  on 
the  left  than  on  the  right  side,  from  the  fact  that  the  exudation  in  the  left 
pleural  cavity  produces  more  immediate  and  direct  pressure  on  the  heart  and 
causes  a  greater  twist  in  the  vessels  than  is  produced  by  that  in  the  right 
cavity,  but  Leichtenstern  ^  states  that  in  52  cases  of  sudden  death  from 
pleuritic  efi'usions,  31  were  right  and  20  left  pleurisies.  The  walls  of  the 
cavities  of  the  heart,  upon  which  the  liquid  in  the  right  pleural  cavity  directly 
presses  are  thinner,  and  therefore  more  yielding,  than  the  walls  of  the  left 
cavities.  The  records  of  the  cases  collected  by  Leichtenstern  show  that 
sudden  death  sometimes  results  from  extensive  and  far-reaching  thrombi  in 
the  right  cavities  of  the  heart  and  in  the  superior  vena  cava,  or  from  emboli 
detached  from  the  thrombi  and  intercepted  in  the  pulmonary  artery.  In  grave 
cases  attended  by  large  efi"usion  sudden  death  sometimes  occurs  after  some 
exertion  on  the  part  of  the  patient,  as  after  vomiting,  severe  coughing,  or 
hurried  rising  to  the  erect  position  or  lifting  a  heavy  weight.  It  is  believed 
that  under  such  circumstances  there  is  a  retarded  flow  of  blood  through  the 
lungs  and  into  the  left  cavities  of  the  heart  and  the  aorta,  so  that  sudden 
and  fatal  anaemia  of  the  brain  is  produced. 

As  already  stated,  death  may  occur  in  protracted  cases  from  amyloid 
degeneration  of  important  organs,  as  the  kidneys  and  liver.  This  can  some- 
times be  detected  by  enlargement  of  liver  and  spleen  and  the  occurrence  of 
albuminuria. 

It  is  evident  that  the  prognosis  varies  greatly  according  to  the  degree 
of  dyserasia.  In  profound  blood-poisoning,  whether  scarlatinous,  ursemic, 
or  septic£emic,  pleurisy  is  always  grave.  Septic  pleurisy,  which  occurs  for 
the  most  part  in  new-born  infants  during  epidemics  of  puerperal  fever,  is 
especially  so.  When  it  has  continued  a  few  hours  the  pinched  features  and 
rapid  sinking  show  that  we  have  to  deal  with  something  more  than  an 
ordinary  attack.^ 

^  Deutsches  Arehiv  fur  Jclin.  Med.,  Band  iv. 

^  The  following  case,  which  occurred  in  my  practice  during  the  epidemic  of  puer- 
peral fever  in  1881,  may  be  adduced  as  an  example :   Mrs.  D ,  a  primipara,  was 

delivered  by  the  forceps,  after  a  tedious  labor,  at  9  p.  m.  ,  April  6th.  On  the  following 
morning  her  temperature,  without  the  occurrence  of  a  chill,  had  risen  to  105J°,  and  her 
pulse  varied  between  125  and  134.     She  was  in  a  critical  state  for  several  days  with  a 


PLEURISY.  897 

Pleurisy  is  also  very  severe,  and  ordinarily  fatal,  when  it  is  caused  by  the 
entrance  of  some  pathological  product  into  the  pleural  cavity,  as  pus  or  decay- 
ing lung-substance. 

Treatment. — It  will  be  proper,  in  considering  the  treatment,  to  describe 
that  which  is  appropriate  for  each  of  the  three  stages  into  which  writers 
have  for  convenience  divided  pleurisy :  First,  the  stage  preceding  effusion ; 
secondly,  that  of  eflfusion ;  and  thirdly,  that  of  absorption  and  convalescence. 
In  the  beginning  of  the  inflammation  appropriate  measures  should  be  promptly 
employed  for  the  purpose  of  reducing  the  inflammation  and  preventing  or 
diminishing,  so  far  as  possible,  the  exudation  that  soon  follows.  The  abstrac- 
tion of  blood  is  now  properly  discarded  in  the  treatment  of  most  inflammations 
of  infancy  and  childhood,  but  in  certain  cases  of  pleurisy  occurring  in  robust 
children  over  the  age  of  four  or  five,  or  even  three  years,  the  early  and  judi- 
cious employment  of  one  or  two  leeches  diminishes  the  pain  and  temperature, 
and  apparently  also,  to  a  certain  extent,  the  inflammation.  But  it  may  be 
stated  as  a  rule  that  the  loss  of  blood  is  not  only  not  required,  but  is  inju- 
rious, in  all  secondary  pleurisies  and  in  the  primary  form  after  exudation  has 
occurred.  It  is  injurious  in  all  forms  of  pleurisy  in  pallid  and  cachectic 
children,  and  therefore  in  a  large  proportion  of  the  cases  occurring  in  the 
tenement-houses  and  institutions  of  the  cities.  The  flow  of  blood  from  the 
bites  if  leeches  are  employed  should  ordinarily  be  arrested  after  two  or  three 
hours,  but  if  slight  it  may  continue  longer  in  vigorous  children  of  eight  or 
ten  years. 

At  the  first  visit  of  the  physician  an   emollient  and  slightly  irritating 

temperature  varying  between  103°  and  105J°,  and  without  any  local  symptoms  either 
of  meti'itis  or  cellulitis,  but  finally  recovered.  The  baby,  healthy  and  vigorous  at  birth, 
had  been  allowed  to  obtain  what  nutriment  it  could  from  the  breast,  but  the  nurse 
remarked  that  she  "never  saw  a  child  sleep  so  much,"  and  I  gave  very  little  attention 
to  it,  as  my  time  was  devoted  wholly  to  the  mother.  On  the  10th,  when  four  days  old, 
its  sleepiness  ceased,  and  it  became  constantly  fretful,  as  from  colic,  and  it  refused  to 
draw  the  nipple.  Early  in  the  morning  of  the  11th  I  was  summoned  to  it,  and  was 
astonished  at  its  altered  appearance,  its  shrunken  features,  and  its  evidently  dying  state. 
Percussion  upon  the  right  side  gave  a  flat  resonance  from  the  clavicle  to  the  diaphragm, 
and  there  was  some  meteorism  in  the  abdomen.  The  thermometer  introduced  into  the 
rectum  showed  no  elevation  of  temperature,  and  no  unusual  heat  of  surface  or  cough  had 
been  noticed  by  the  nurse.  By  active  stimulation  the  infant  lived  till  the  middle  of  the 
afternoon.  The  autopsy  revealed  a  sero-fibrinous  exudation  filling  the  right  pleural 
cavity,  producing  complete  carnification  of  the  lung,  so  that  it  resembled  that  of  the 
foetal  state,  and  soft  patches  or  flakes  of  fibrin  upon  the  lungs.  By  an  oversight  the 
peritoneum  was  not  examined.  Cases  like  this,  of  pleuritis  in  the  new-born,  produced, 
it  is  thought,  by  the  wandering  micrococci  of  the  septic  state,  occur  chiefly  during  epi- 
demics of  childbed  fever.  Some  years  ago  I  saw  a  new-born  infant  in  one  of  the  insti- 
tutions, whose  mother  had  puerperal  fever,  die  in  a  similar  manner,  and  the  autopsy 
showed  that  the  cause  was  peritonitis.  The  following  example  from  Trousseau' s  clinical 
lecture  on  erysipelas  of  new-born  infants  will  aid  in  understanding  such  cases.  Sj^eaking 
of  Dr.  P.  Lorain,  he  says  :  "  During  the  epidemic  at  the  Maternite,  where  this  able  and 
laborious  observer  was  resident  pupil,  he  collected  the  information  of  which  the  follow- 
ing is  a  summary  :  Of  106  stillborn  infants,  10  were  found  to  have  died  from  peritonitis, 
and  3  of  the  mothers  of  these  10  infants  were  carried  ofi'by  puerperal  fever  after  delivery. 
Of  193  infants  born  alive,  50  died  of  the  very  same  atFections  which  proved  fatal  to  the 
lying-in  women.  The  most  frequent  causes  of  death  were  peritonitis,  numerous  abscesses, 
purulent  infection,  phlegmonous  swellings,  erysipelas,  gangrene  of  the  limbs,  putrid 
infection,  or  some  other  remarkable  septic  condition."  ....  "  Mother  and  child,  then, 
are  subject  to  the  same  morbific  influence."  Farther  on  Trousseau  says  of  the  infant 
affected  by  this  puerperal  poison  :  "It  will  cry  incessantly  from  pain.  A  state  of  rest- 
lessness will  be  succeeded  by  collapse,  which  will  close  the  scene  on  the  fifth,  sixth,  or 
seventh  day.  On  examining  the  body  after  death  pus  will  be  found  in  the  cellular 
tissue,  sometimes  suppurative  pleurisy,  more  frequently  phlebitis  of  the  umbilical  vein 
or  of  the  vena  porta,  or  peritonitis."  An  interesting  incidental  fact  shown  by  these 
statistics  is  that  the  cause  of  this  puerperal  disease  of  the  new-bom  is  sometimes  operative 
in  the  fatal  state. 

57 


89S  LOCAL  DISEASES. 

poultice  should  be  ordered,  enveloping  the  entire  chest,  to  be  constantly 
worn,  except  as  it  is  temporarily  removed  during  the  application  of  the  leech 
and  the  subsequent  flow  of  blood.  The  poultice  should  be  so  mildly  irritat- 
ing that  it  causes  constant  redness  of  the  skin  without  pain,  and  it  should 
not  be  removed  except  when  a  fresh  poultice  is  prepared  to  replace  it.  Thus 
employed,  it  produces  constant  dilatation  of  the  capillaries  of  the  skin,  and  by 
the  fluxion  caused  diminishes  the  engorgement  of  the  capillaries  of  the  costal 
pleura.  A  poultice  of  common  mustard,  with  flaxseed  in  powder,  one  part  to 
sixteen,  between  two  pieces  of  muslin,  and  so  wet  that  it  moistens  the  hand 
in  holding  it,  produces  this  eff"ect.  Applied  morning  and  evening,  it  can  be 
constantly  worn  without  complaint  of  pain  produced  by  its  irritating  action. 
For  infants  under  the  age  of  eight  months  I  prefer  the  use  of  plain  flaxseed, 
with  camphorated  oil  smeared  upon  its  under  surface.  The  oil  may  be 
applied  several  times  daily,  while  the  morning  and  evening  application  of  the 
poultice  is  sufiicient.  Spongiopilin  or  compresses  of  flannel  wrung  out  of 
hot  water  and  covered  with  oil-silk  meet  the  indication,  and  possess  the 
advantage  of  being  lighter  and  cleaner  and  more  readily  applied  than  the 
poultice.  Redness  may  be  produced  by  applying  under  the  spongiopilin  a 
single  thickness  of  muslin  soaked  with  camphorated  oil,  or  for  children  of  a 
more  advanced  age  with  camphorated  oil  and  one-fourth  part  of  turpentine. 

Vesication,  formerly  much  employed,  has  properly  nearly  fallen  into  dis- 
use in  the  treatment  of  the  pleurisy  of  children.  While  it  is  liable  to 
increase  the  sufi"ering,  it  has  apparently  no  tendency  to  diminish  the  inflam- 
mation in  whichever  stage  employed,  and  there  is  no  certainty  that  it  stimu- 
lates the  absorbents  and  expedites  the  removal  of  the  liquid,  according  to  the 
old  theory.  A  case  is  reported  in  the  practice  of  one  of  the  New  York  phy- 
sicians in  which  a  blister  had  been  applied  when  the  inflammation  was  still 
active,  and  at  the  autopsy  the  portion  of  the  costal  pleura  which  lay  directly 
underneath  the  surface  that  had  been  vesicated  was  covered  by  a  thicker 
fibrinous  exudation  than  that  upon  the  contiguous  surface.  The  increased 
aflHux  of  blood  caused  by  the  blister  had,  to  appearance,  extended  to  the 
costal  pleura  and  increased  the  pleurisy.  The  application  of  cold  bandages 
around  the  chest,  which  is  recommended  by  some,  seems  to  aggravate  the 
cough  in  certain  patients,  and  does  not  ordinarily  give  the  relief  of  moist  and 
warm  applications. 

Internal  Remedies. — The  indications  are  to  employ  such  medicines  as 
diminish  the  frequent  action  of  the  heart,  and  thus  retard  in  a  measure  the 
flow  of  blood  to  the  pleura,  and  such  as  diminish  the  pain  and  frequency  of 
the  cough,  which  by  increasing  the  friction  of  the  pleural  surfaces  tends  to 
increase  the  inflammation.  For  robust  children  over  the  age  of  three  years 
in  the  first  stage  of  primary  pleurisy  the  tincture  of  aconite  may  be  pre- 
scribed, half  a  drop  for  a  patient  of  three  years,  and  one  drop  for  one  of  six 
years,  ^very  third  hour  for  two  or  three  days  or  until  the  required  eff'ect  be 
produced  upon  the  pulse,  when  it  should  be  discontinued.  It  is,  as  a  rule, 
too  depressing  for  younger  patients.  Digitalis  is  a  better  and  safer  remedy 
for  children  under  the  age  of  three  years  for  all  secondary  pleurisies  and  for 
all  cachectic  cases.  Benefit  results  from  continuing  the  use  of  digitalis  in 
the  stage  of  exudation,  when  aconite  would  be  inadmissible.  A  child  of  two 
years  can  take  two  drops  of  the  officinal  tincture,  and  one  of  five  years  four 
drops,  every  two  or  three  hours. 

Antipyrine  is  an  eff"ectual  antipyretic.  One  or  two  doses  reduce  tempera- 
ture two  or  three  degrees.  It  therefore  promises  to  be  a  useful  remedy  in 
the  first  stage  of  pleuritis  as  well  as  in  other  acute  diseases,  when  the  tem- 
perature is  so  high  as  to  involve  danger.  It  is  not  a  tonic,  and  it  seems  to 
impair  the  digestive  function.     It  is  therefore  most  useful  in  those  diseases 


PLEURISY.  899 

which  are  not  attended  by  any  marked  prostration,  but  in  which  the  fever, 
from  its  intensity,  exhausts  the  strength.  If,  therefore,  in  the  commence- 
ment of  pleurisy  the  temperature  rises  above  103°,  it  may  properly  be  pre- 
scribed in  doses  of  four  grains  to  a  child  of  five  years,  and  be  repeated,  if 
necessary,  in  three  hours.  It  is  soluble  in  water,  and  it  may  be  employed 
as  an  enema  if  the  stomach  be  irritable.  Phenacetin  or  antifebrin  may  be 
employed  as  a  substitute  for  antipyrine. 

The  use  of  quinia  is  suggested,  since  it  is  an  antipyretic  and  tonic,  but  in 
my  practice  it  has  been  much  less  useful  in  pleurisy  than  in  pneumonia. 
This  agent,  in  whatever  form  given,  does  not  appear  to  exert  any  notable 
controlling  effect  either  on  the  fever  or  gravity  of  pleurisy.  Nevertheless,  I 
have  often  employed  it,  especially  in  secondary  pleurisies,  with  or  without 
digitalis,  and  it  probably  does  some  good  as  a  tonic.  The  salts  of  quinia,  as 
ordinarily  given  in  solution  to  young  children,  are  frequently  vomited.  When 
vomited,  a  soluble  salt,  as  the  bisulphate,  may  be  given  as  a  suppository,  or 
Squibb's  oleate  of  quinia  may  be  employed  by  inunction.  I  should,  however, 
add  that,  though  I  have  used  inunctions  of  the  oleate  in  pleurisy  during  the 
last  year,  ten  grains  of  the  alkaloid  at  a  time,  I  have  not  seen  any  marked 
beneficial  effect.  To  meet  the  second  indication  in  the  treatment  of  the  first 
stage — namely,  to  relieve  the  pain  and  restlessness  and  to  diminish  the  cough, 
so  that  there  is  less  friction  of  the  pleural  surfaces — our  chief  reliance  must 
be  on  hyoscyamus  or  one  of  the  opiate  preparations.  The  following  formulae 
will  be  found  useful : 

R.  Tinct.  opii  deodorat.,  gtt.  xx  ; 

Tinct.  digitalis,  gtt.  xl ; 

Syr.  pruni  Virginiani,  ^j  ; 

Aquis,  ^iss. — Misce. 

Dose :  One  teaspoonfnl  (one  drachm)  every  three  hours  for  an  infant  of  eighteen 
months.  The  tincture  of  hyoscjamus  may  be  employed  in  place  of  the  opiate 
in  double  the  dose. 

For  a  child  of  three  years : 

R.  Tinct.  ipecac,  comp. 

(Squibb's  liquid  Dover's  powder), 
Tinct.  digitalis,  da.  gtt.  xxxij  ; 

Syr.  pruni  Virginiani,  ^ij. — iMisce. 

Dose  :  One  teaspoonful  every  two  or  three  hours. 

For  a  robust  child  of  eight  years  with  primary  pleurisy  : 

R.  Morph.  sulphat.,  gr.  j  ; 

Tine.  rad.  aconit.,      _  gtt.  sx  ; 

Syr.  prrmi  Virginiani,  ^iiss. — Misce. 
Dose :  One  teaspoonful  every  three  hours. 

The  diet  in  the  first  stage  should  consist  of  milk  and  farinaceous  food, 
given  liberally.  The  meat  teas  or  the  expressed  juice  of  meat  may  be  added, 
and  in  secondary  pleurisies,  as  after  scarlet  fever,  it  is  often  proper  to  give  a 
moderate  amount  of  alcoholic  stimulants  from  the  first. 

Second  Stage. — Measures  employed  in  the  first  stage  have  been  designed 
to  diminish  the  inflammation  and  relieve  suffering.  The  duty  of  the  physician 
in  the  treatment  of  the  second  stage  is  chiefly  to  aid  in  the  removal  of  the 
inflammatory  product,  and  prevent,  so  far  as  possible,  its  further  formation. 
If  this  be  sero-fibrinous  and  its  quantity  be  small,  so  as  to  fill  only  the  lower 
portion  of  the  cavity,  little  aid  may  be  needed  from  therapeutics  ;  but  a  larger 
effusion,  compressing  the  lung  and  displacing  the  heart,  requires  medicinal 


900  LOCAL  BISEASES. 

and  often  surgical  measures.  The  recommendations  of  Niemeyer,  that  the 
patient's  food  contain  little  liquid  and  that  his  drinks  be  restricted  as  a  means 
of  increasing  absorption  from  the  pleural  surface,  is  not  applicable  to  young 
children,  whose  diet  must  of  necessity  be  largely  liquid,  and  that  of  infants 
chiefly  milk. 

Attempts  to  stimulate  the  absorbents  by  external  treatment  of  the  chest 
are  of  doubtful  efficacy,  whether  by  the  application  of  small  blisters,  can- 
tharidal  collodion,  the  iodine  ointment  or  tincture,  or  a  stimulating  liniment. 
The  common  practice  of  treating  glandular  swellings  by  iodine  applications 
suggests  their  use  for  pleuritic  effusions,  and  of  the  agents  employed  locally 
to  hasten  absorption  they  are  probably  the  best,  but  they  should  not  be  used 
so  often  or  in  such  quantity  as  to  cause  pain  or  restlessness*  from  their  irri- 
tating effect.     The  following  ointment  may  be  used : 

R.  Potas.  iodidi,  .^ij  ; 

Lanolin,  ^ij. — Misce. 

To  be  rubbed  freely  over  the  side  of  the  chest  which  is  the  seat  of  the  sero-fibrin- 
ous  exudation  three  or  four  times  daily. 

It  is  an  established  principle  in  therapeutics  that  the  removal  of  a  serous 
liquid  in  either  of  the  larger  cavities  of  the  body  is  hastened  by  such  rem- 
edies as  produce  an  abundant  liquid  secretion  or  transudation  from  any  of  the 
organs  or  surfaces.  Hence  in  the  treatment  of  pleuritic  effusions  those  med- 
icines which  act  on  the  skin,  causing  diaphoresis,  upon  the  intestines,  causing 
watery  stools,  and  upon  the  kidneys,  causing  diuresis,  are  at  once  suggested 
as  most  likely  to  be  efficacious.  But  sudorifics,  though  useful  for  dropsies 
having  a  renal  origin,  have  not  been  much  used  of  late  years  for  the  removal 
of  exudations  in  the  pleural  cavity,  experience  having  shown  that  they  are 
inadequate  for  this  purpose.  Recently,  however,  the  discovery  of  a  very 
active  agent  of  this  class,  jaborandi,  has  revived  in  a  measure  the  sudorific 
treatment  of  the  second  stage,  so  that  in  the  National  Dispensatory  of  Stille 
and  Maisch  this  diaphoretic  is  one  of  the  recommended  remedies.  But  the 
heart,  crippled  in  its  action  by  the  pressure  of  the  liquid,  badly  tolerates 
agents  of  a  depressing  nature,  and  jaborandi,  or  its  active  principle  pilocarpine, 
exerts  a  weakening  effect  on  this  organ.  It  therefore  should  be  used  with 
caution  in  this  disease.  It  is  probably  best  in  most  instances  not  to  employ 
it,  inasmuch  as  we  possess  other  and  efficient  remedies. 

The  fact  that  sero-fibrinous  exudations  have  been  known  to  diminish  rap- 
idly during  attacks  of  diarrhoea  suggests  the  use  of  purgatives  ;  but,  although 
an  open  state  of  the  bowels,  as  two  or  three  daily  stools,  aids  in  absorption, 
free  purgation  is  badly  borne  by  young  or  feeble  children,  as  it  reduces  the 
strength,  and  therefore  is  not  to  be  recommended  as  a  therapeutic  measure. 
Moreover,  there  is  not  the  need  of  employing  severe  or  exhausting  medicines 
for  the  removal  of  the  liquid  which  existed  in  former  times,  since  we  are  able 
to  accomplish  this  quickly,  easily,  and  safely  by  the  excellent  asj)irating 
instruments  now  in  common  use. 

Diuretics,  on  the  other  hand,  are  apparently  more  useful,  while  they  are 
less  exhausting,  than  sudorifics  or  cathartics.  Digitalis,  combined  with  the 
citrate  or  acetate  of  potassium,  has  stood  the  test  of  experience,  and  is  now 
more  widely  used  than  any  other  agent  of  this  class.  Being  both  a  diuretic 
and  heart-tonic,  it  possesses  properties  which  render  it  especially  serviceable 
in  the  ti-eatment  of  pleuritic  effusions.  The  following  is  a  useful  prescription 
for  a  child  of  five  years  : 

R.  Potassii  acetatis,  ^ij  ; 

Infus.  digitalis,  ^iij. — Misce. 

Give  one  teaspoonful  every  three  hours. 


PLEURISY.  901 

It  is  a  matter  of  observation  that  absorption  occurs  more  rapidly,  and  a 
sero-fibrinous  is  less  likely  to  become  a  purulent  effusion,  if  the  bodily  con- 
dition be  good.  Hence  tonics,  especially  the  bitter  vegetables,  are  sometimes 
useful,  and  a  diuretic  in  combination  with  a  tonic,  as  the  acetate  of  potassium 
in  decoction  of  cinchona,  may  often  be  prescribed  with  advantage. 

Still,   however  judicious   the   treatment,   hygienic   and   medicinal,  manyi 
cases  require  surgical  interference,  and  the  number  of  such  is  larger  in  the 
city  than  in  the  country,  and  in  tenement-houses  than  in  the  better  walks  of 
life,  since  the  cachexia  so  common  in  city  children   increases  the  liability  to 
purulent  exudations. 

Thoracentesis. — The  indications  for  the  operation  are  the  following : 

1st.  Dyspnoea  due  to  the  presence  of  the  liquid,  whether  it  be  sero- 
fibrinous, purulent,  or  hemorrhagic.  Usually  when  dyspnoea  occurs  the 
pleural  cavity  is  full,  and  if  there  be  parenchymatous  disease  of  either  lung, 
a  moderate  quantity  of  liquid  may  cause  such  embarrassment  of  respiration 
that  thoracentesis  is  indicated. 

2d.  A  flat  percussion  sound  over  the  entire  affected  side,  with  displace- 
ment of  the  heart,  even  if  there  be  no  present  dyspnoea,  is  also  an  indication 
for  the  operation,  for  dyspnoea  may  occur  suddenly  with  other  alarming  symp- 
toms between  the  visits  of  the  physician.  Moreover,  experience  has  shown 
that  absorption  from  a  distended  pleural  cavity  is  very  tardy,  in  consequence 
of  compression  of  the  absorbents,  whereas  if  a  portion  of  the  liquid  be 
removed  absorption  of  the  remainder  is  more  rapid.  The  patient  with  full 
pleural  cavity  and  lung  totally  compressed  lies  on  the  affected  side,  and  is 
usually  uncomfortable  in  any  other  position,  and  the  withdrawal  of  a  portion 
of  the  liquid — as,  for  example,  one  half — the  operation  being  discontinued 
when  the  patient  begins  to  cough  or  evince  distress,  produces  no  ill  effect  and 
increases  the  comfort. 

3d.  A  moderate  effusion,  without  material  decrease  in  quantity  after  some 
weeks  of  observation,  also  indicates  the  need  of  surgical  interference,  since 
long  compression  of  a  lung  involves  risks.  There  is  danger  that  catarrhal 
ending  in  cheesy  pneumonia  and  tubercles  may  occur  in  a  lung  whose  func- 
tion is  long  suspended  ;  besides,  the  longer  compression  has  existed  the  more 
tardy,  difficult,  and  incomplete  will  be  the  inflation  when  the  liquid  is  removed, 
on  account  of  the  altered  state  of  the  alveoli  and  the  presence  of  fibrinous 
bands  over  the  lung.  Thus,  in  a  case  recently  under  observation  only  partial 
infiation  of  the  lung  occurred  after  letting  out  the  liquid,  so  that  the  ribs  and 
shoulder  on  the  affected  side  are  permanently  depressed  and  unequivocal 
symptoms  of  tuberculosis  are  now  present. 

4th.  If  the  inflammation  extend  to  the  pericardium,  so  as  to  cripple  the 
heart's  action,  or  if  there  be  any  serious  pre-existing  heart  disease,  the  liquid, 
even  in  moderate  quantity,  may  by  pressure  so  embarrass  and  retard  the 
heart's  action  that  its  cavities  are  not  properly  filled,  so  that  passive  conges- 
tion of  certain  organs  and  dangerous  anaemia  of  others,  especially  of  the 
brain,  may  result.  Under  such  circumstances  an  early  performance  of  tho- 
racentesis is  indicated. 

5th.  Empyema. — The  presence  of  pus  in  the  pleural  cavity  affords  in  itself, 
in  a  large  proportion  of  cases,  sufficient  indication  of  the  need  of  thoracente- 
sis. In  recent  cases  with  only  moderate  constitutional  disturbance  and  embar- 
rassment of  respiration,  if  we  ascertain  by  the  hypodermic  syringe  that  the 
liquid  is  only  slightly  clouded  by  leucocytes,  surgical  interference  may  be 
postponed  while  the  acute  inflammation  is  treated.  Thvis,  in  case  of  an 
infant  of  two  months  thin  pus  was  withdrawn  on  the  fourth  day  of  acute 
pleuritis,  and,  although  thoracentesis  was  early  performed,  it  appeared  prob- 
able, from  the  subsecjuent  course  of  the  case,  that  it  would  have  been  as  well 


902  LOCAL  DISEASES. 

had  the  operation  been  deferred.  If  spontaneous  evacuations  of  pus  have 
occurred  through  one  of  the  intercostal  spaces,  producing  a  fistula  from 
which  there  is  a  daily  oozing,  or  if  it  be  probable,  from  the  symptoms  and 
signs,  that  pus  is  escaping  from  the  pleural  cavity  into  a  bronchial  tube,  and 
is  being  gradually  expectorated — a  mode  of  cure  which  is  not  infrequent  in 
children — thoracentesis  may  be  deferred.  In  the  case  of  an  infant  aged  six 
months  recently  under  treatment  for  empyema  of  the  left  side  we  removed 
four  ounces  of  pus  and  washed  out  the  pleural  cavity.  The  opening  having 
closed,  and  the  physical  signs  indicating  the  reaccumulation  of  a  considerable 
quantity  of  liquid,  we  were  preparing  for  a  second  operation  when  the  parents 
and  nurse  called  our  attention  to  the  fact  that  there  were  occasional  severe 
attacks  of  coughing,  during  which  the  breath  presented  a  very  decidedly 
purulent  odor.  Although  there  was  no  external  expectoration,  as  the  sputum 
was  swallowed,  thoracentesis  was  postponed,  and  the  result  justified  the 
decision,  for  the  patient  gradually  convalesced.  Except  under  circumstances 
like  the  above,  empyema,  when  clearly  diagnosticated  by  the  employment 
of  the  hypodermic  syringe,  should  be  promptly  treated  by  evacuation  of 
the  pus. 

Instruments  to  he  Used,  and  Mode  of  Operating. — Ingenious  instruments 
for  tapping  the  chest  have  been  invented  by  Dr.  Chadbourne  of  New  York, 
Dr.  A.  M.  Phelps  of  Chateaugay,  Franklin  co.,  N.  Y.,  and  others,  which  by 
India-rubber  packing  totally  exclude  air,  while  the  operation  is  performed 
with  facility  and  little  pain.  That  devised  by  Dr.  Chadbourne  has  a  cannula 
with  two  arms — one  for  attachment  by  means  of  tubing  to  the  exhausting 
receiver,  and  the  other  is  designed  to  facilitate  irrigation  of  the  pleural 
cavity. 

Phelps's  apparatus  has  a  third  tube,  entering  the  bottle  through  the 
stopple,  and  a  glass  tube  passes  from  the  stopple  to  nearly  the  bottom  of  the 
bottle.  With  this  apparatus,  by  reversing  the  movement  of  the  syringe,  the 
liquid  can  be  withdrawn  from  the  chest,  the  bottle  emptied  of  it,  the  water 
used  for  irrigation  be  conveyed  into  the  bottle,  from  the  bottle  to  the  chest, 
and  back  into  the  bottle,  without  changing  the  position  of  the  bottle  or 
removing  the  stopple.  The  use  of  the  trocar  and  cannula  instead  of  the 
sliding  aspirator  point,  which  plays  outside  the  cannula,  is  an  improvement 
in  this  instrument. 

The  instrument  to  be  preferred  is  of  simpler  construction.  The  cannula 
is  about  the  size  of  the  smallest  needle  of  Dieulafoy's  aspirator — the  proper 
size,  in  my  opinion,  for  thoracentesis  for  both  sero-fibrinous  and  purulent 
exudations.  I  greatly  prefer  the  use  of  the  exhausting-bottle  rather  than  the 
exhausting-pump  without  the  bottle,  as  it  is  more  convenient  and  produces 
greater  suction  from  its  greater  size.  The  cannula  is  provided  with  an  arm 
which  connects  it  by  tubing  with  the  exhausting-bottle.  Beyond  this  arm 
the  body  of  the  cannula,  sufficiently  expanded  to  contain  India-rubber  pack- 
ing, extends  about  one  and  a  half  inches  and  is  provided  with  a  stopcock. 
Through  this  packing  the  trocar  is  introduced,  and  after  the  puncture  it  is 
withdrawn  to  the  stopcock,  which  is  then  turned  to  prevent  the  admission  of 
air.  Then  the  obturator  is  introduced  in  place  of  the  trocar,  so  as  to  remove 
any  obstruction  which  may  enter  the  cannula. 

The  tubing  which  extends  from  the  arm  of  the  cannula  to  the  bottle  should 
be  firm,  with  a  somewhat  larger  bore  than  that  of  the  cannula,  and  its  point 
of  attachment  to  the  bottle  should  also  be  provided  with  a  stopcock.  A  short 
glass  tube  introduced  into  this  tubing  near  the  cannula  is  convenient  for 
noticing  the  character  of  the  fluid,  which,  if  it  be  thick  pus,  may  flow  with 
difficulty  and  not  reach  the  bottle.  A  bottle  of  sufficient  capacity  to  hold 
two  quarts  obviously  produces  more  suction  power  than  one  of  less  size,  and 


PLEURISY.  903 

is  therefore  preferable  for  certain  cases,  and  its  sides  should  be  marked  to 
indicate  ounces  and  drachms.  The  tube  which  connects  the  cannula  with  the 
bottle  enters  through  the  stopple,  and  proceeding  from  the  stopple  is  another 
tube  similar  to  the  first,  to  which  the  syringe  is  attached.  The  syringe  has 
two  points  for  attachment  to  the  tube  and  a  double  action  in  its  interior,  so 
that  attached  by  one  point  it  exhausts  the  air  from  the  bottle,  and  attached 
by  the  other  point  it  condenses  air  in  the  bottle.  The  stopcock  between  the 
cannula  and  the  bottle  should  always  be  closed  when  the  syringe  is  used, 
whether  for  exhaustion  or  condensing.  It  is  very  important  that  this  should 
be  constantly  borne  in  mind  when  working  the  syringe,  or  air  may  be  thrown 
into  the  pleural  cavity  and  much  harm  done. 

Mode  of  Operating  for  Sero-fibrinous  Exudations. — In  the  following 
remarks  I  shall  state  what  I  consider  the  best  method  for  performing 
thoracentesis,  having  formed  my  opinion  from  the  cases  which  I  have 
witnessed  and  been  able  to  follow  in  institutions  and  in  family  practice. 
A  mode  of  treatment  which  may  be  safe  and  proper  for  the  adult  is  not 
always  the  best  for  the  child,  and,  as  there  are  different  opinions  and  differ- 
ent modes  of  procedure,  and  as  many  who  are  familiar  with  adult  cases 
recommend  similar  treatment  for  the  child  to  that  which  they  have  employed 
with  success  for  the  older  and  more  robust  cases,  I  shall  advise  the  abandon- 
ment of  certain  measures  which  are  in  common  use  and  the  substitution  of 
others.  The  hypodermic  syringe  should  be  first  used  at  the  point  where  it 
is  proposed  to  perform  the  operation,  the  disinfected  needle  being  inserted 
about  one  inch,  for  I  hold  it  unjustifiable  to  tap  the  chest  without  first  ascer- 
taining that  there  are  no  adhesions  at  the  site  selected  for  puncture,  and  at 
the  same  time  ascertaining  the  character  of  the  liquid.  Incision  of  the  skin 
with  the  knife  and  spraying  the  surface  with  ether  are  not  required  as  pre- 
liminary treatment,  since  the  puncture  is  quickly  and  easily  performed  with 
a  small  trocar  and  with  very  little  pain.  The  rule  is  established  by  many 
observations  that  the  operation  should  be  performed  in  or  near  the  vertical 
line  passing  through  the  angle  of  the  scapula  and  between  the  eighth  and 
ninth  ribs  or  one  of  the  adjacent  intercostal  spaces.  I  have  elsewhere  stated 
that  a  point  a  little  external  to  this  line  is  preferable,  as  the  lung  is  less  liable 
to  be  injured.  The  instrument  should  obviously  be  inserted  no  farther  than 
will  be  sufficient  to  reach  the  liquid,  and,  since  from  measurements  which  I 
have  made  the  thickness  of  the  thoracic  wall  in  rather  fleshy  children  is  about 
half  an  inch,  penetration  to  the  depth  of  one  inch  will  ordinarily  be  sufficient 
to  pass  the  fibrinous  layer.  We  are  liable  to  puncture  more  deeply  than  is 
necessary  without  some  safeguard,  and  incur  the  risk  of  wounding  the  lung. 
India-rubber  tubing  may  cover  the  instrument  to  within  one  inch  of  the  end, 
or  a  cord  may  be  tied  snugly  around  the  instrument  at  one  inch  from  the  tip. 
The  sensation  communicated  to  the  fingers  will,  however,  be  the  best  guide 
to  the  careful  operator  as  regards  the  exact  depth  to  which  the  instrument 
should  be  carried.  The  trocar  should  now  be  withdrawn,  the  obturator  intro- 
duced in  its  place,  the  air  exhausted  fi'om  the  bottle,  and  then  the  stopcock 
turned  to  allow  the  liquid  to  escape. 

It  should  flow  slowly,  as  it  probably  will  through  so  small  a  cannula,  but 
the  flow  can  be  regulated  by  the  stopcock.  The  qtiantity  to  be  removed 
depends  upon  the  age  and  condition  of  the  child,  the  size  of  the  cavity,  and 
the  quantity  of  the  liquid,  but  if  the  patient  begin  to  cough  or  feel  uncom- 
fortable after  the  removal  of  one-half,  or  even  one-third,  of  the  liquid  the 
cannula  should  be  withdrawn.  The  sensation  of  insufficient  breath  is  no 
longer  experienced,  and  the  remaining  liquid  is  progressively  absorbed.  This 
operation  is  one  of  the  easiest  in  svirgery,  while,  with  the  precautions  men- 
tioned above,  no  ill  effect  need  be  apprehended.     One  operation  is,  in  most 


904  LOCAL  DISEASES. 

instances,  all  that  is  required,  tliougli  if  need  be  it  can  be  repeated  after  some 
days,  and  it  is  very  seldom  that  the  lung  does  not  fully  expand  to  fill  the 
chest  if  the  operation  be  performed  at  the  proper  time. 

Mode  of  Operating  for  Empyema. — It  will  aid  in  understanding  this  part 
of  our  subject  to  remember  that  all  pleuritic  exudations  contain  pus-cells,  and 
that  the  only  anatomical  difi"erence  between  sero-fibrinous  exudations  and 
empyema  is  in  the  proportion  of  these  cells.  There  is,  therefore,  a  fixed 
and  definite  boundary-line  between  the  two  kinds  of  exudation.  The  term 
''  empyema  "  is,  as  all  know,  applied  by  common  usage  to  the  liquid  when  it 
contains  so  many  leucocytes  or  pus-cells  that  a  turbid  appearance  is  imparted 
to  it.  Absorption  is  slow  and  difficult  or  impossible  if  the  liquid  contain  a 
large  amount  of  solid  ingredients — to  wit,  fibrin  and  pus-cells— while  liquid 
containing  only  a  small  proportion  of  these  constituents  more  readily  enters 
the  absorbents.  In  other  words,  thin  pus  may  be  absorbed  and  removed  from 
the  system  by  natural  methods,  or  by  the  same  instrument  and  operation 
which  we  have  recommended  for  sero-fibrinous  exudations,  while  a  thick 
liquid  adherent  to  the  pleura  or  sinking  heavily  in  dependent  portions  of  the 
cavity  disappears  very  slowly,  losing  by  absorption  only  a  little  of  the  liquor 
puris,  while  the  bulk  of  it  cannot  be  absorbed,  so  that  the  only  relief  is  by 
evacuation  through  an  opening.  Often  in  practice,  after  the  acute  symptoms 
of  an  empyema  have  in  a  measure  abated,  the  physical  signs  indicate  some 
diminution  of  liquid  in  successive  weeks,  but  further  removal  soon  (3omes  to 
a  standstill  and  the  resources  of  surgery  must  be  tried. 

The  same  small  trocar  and  cannula,  or  a  little  larger,  should  be  used  for 
tapping  the  chest  of  an  empyemic  child  which  we  have  recommended  for 
sero-fibrinous  exudation,  and  with  the  same  precautions.  If  the  liquid  be  thin 
and  but  slightly  turbid,  if  it  be  but  little  removed  from  sero-fibrin  in  its  cha- 
racter, it  will  flow  through  the  cannula,  even  if  it  be  necessary  to  use  the 
obturator  often  to  remove  obstructions.  Having  withdrawn  all  the  liquid 
which  will  flow  through  the  opening,  unless  severe  coughing  or  some  unpleas- 
ant symptom  occur,  which  is  an  indication  to  discontinue  the  withdrawal,  the 
instrument  is  removed  and  the  aperture  may  be  closed  with  adhesive  plaster. 
In  exceptional  instances,  if  the  pus  be  thin  and  the  pus-cells  few  in  propor- 
tion to  the  amount  of  serum,  one  aspiration  may  be  sufficient  to  elfect  a 
cure ;  but  usually  the  cavity  refills.  If  the  pus  be  thick,  it  will  almost 
inevitably  refill,  and  it  is  better  to  make  a  free  incision  with  a  bistoury  at 
once.  If  the  pus  be  thin  and  the  cavity  after  aspiration  refill  in  a  few  weeks, 
free  incision  is  preferable  to  a  second  aspiration,  for  as  a  rule  the  lung  should 
not  be  compressed  by  pus  more  than  four  to  six  weeks,  as  by  longer  com- 
pression it  might  be  seriously  injured. 

Therefore,  if  the  chest  refill  after  one  or  at  most  two  aspirations,  an  incision 
should  be  made  with  the  knife  at  the  same  point  as  that  selected  for  aspira- 
tion— that  is,  between  the  eighth  and  ninth  ribs  and  in  the  line  passing  per- 
pendicularly through  the  lower  angle  of  the  scapula.  An  incision  should  be 
made  with  a  sharp-pointed  bistoury  a  little  nearer  the  ninth  than  the  eighth 
rib,  sufficiently  large  to  admit  the  blunt-pointed  bistoury,  and  with  this  the 
incision  should  be  extended  to  the  distance  of  one-third  to  one-half  inch, 
which  will  allow  the  pus  to  flow  out  freely.  The  opening  should  then  be 
covered  by  oakum  confined  by  long  strips  of  adhesive  plaster.  Pus  may  or 
may  not  continue  to  flow  into  the  oakum.  If  it  do  not,  the  opening  will 
close,  if  left  to  itself,  within  two  or  three  days.  No  tent  or  drainage-tube  is 
employed,  for  reasons  to  be  mentioned  hereafter.  The  physician  should 
return  after  twelve  or  twenty-four  hours,  not  later,  and  should  introduce 
through  the  opening  the  ordinary  gum-elastic  male  catheter,  warmed  so  as  to 
be  flexible  and  strongly  bent  at  its  middle.     The  point  should  be  directed  to 


PLEUBIST.  905 

the  bottom  of  the  cavity.  Perhaps  the  soft-rubber  catheter  might  be  prefer- 
able, but  I  have  never  used  it,  being  satisfied  with  the  other.  The  catheter 
should  be  attached  by  tubing  to  the  exhausting-syringe  or  bottle,  and  any 
pus  in  the  depending  portions  of  the  cavity  will  be  readily  removed.  I  have 
generally  at  this  visit  removed  from  the  bottom  of  the  cavity  two  or  three 
ounces,  sometimes  very  thick,  and  such  as  would  not  readily  flow  from  the 
opening.  Every  day  or  twice  daily  the  operation  should  be  repeated  ;  which 
will,  I  think,  more  effectually  remove  the  pus  than  washing  out  the  cavity, 
and  the  opening  cannot  close.  This  operation  detains  the  physician  only  a 
few  moments.  The  catheter  should  be  a  No.  10,  and  it  is  the  best  possible 
probe.     By  the  close  of  the  first  week  the  opening  becomes  fistulous. 

After  each  removal  of  the  pus  long  strips  of  adhesive  plaster  firmly 
applied  over  the  ribs,  from  the  sternal  region  downward  and  backward, 
facilitate  approximation  of  the  pleural  surfaces  and  obliteration  of  the  cavity. 
During  convalescence  the  patient,  if  old  enough,  should  be  directed  to  make 
full  inspirations,  which  serve  to  expand  the  lungs. 

That  so  simple  and  important  an  operation  as  thoracentesis  should  have 
been  known  and  practised  by  the  ancients — even,  it  is  said,  by  Hippocrates — 
and  have  fallen  into  disuse  till  it  was  revived  in  our  own  times  by  Bowditch 
and  Trousseau,  seems  remarkable.  This  was  probably  in  part  due  to  the  bad 
instruments  employed,  and  in  part  to  the  fact  that  in  olden  times  the  opera- 
tion was  performed  in  the  anterior  walls  of  the  chest,  where  adhesions  are 
frequently  present.  But  there  are  certain  accidents  and  unfavorable  results 
of  the  operation  which  may  be  profitably  considered,  since  they  can  nearly 
always  be  avoided : 

1st.  The  Admission  of  Air  into  the  Pleural  Cavity. — This  is  unnecessary 
and  can  be  avoided,  but  those  who  have  often  witnessed  the  operation  as 
ordinarily  performed  have  remarked  the  fact  that  the  admission  of  more  or 
less  air  is  common. 

The  entrance  of  a  certain  amount  of  air  into  a  serous  cavity  when  the 
serous  membrane  is  in  its  normal  state  does  not  appear  to  be  productive  of 
harm  with  ordinary  precautions  as  regards  temperature,  etc.,  as  in  ovariotomy, 
in  which  air  is  admitted  into  the  largest  serous  cavity  in  the  body  ;  and  the 
moderate  admission  of  air  into  the  pleural  cavity  when  the  pleura  is  healthy 
does  not,  as  a  rule,  produce  any  ill  effect.  Thus,  a  case  is  related  of  a  man 
who  suffered  from  heart  disease,  and  was  led  to  think  that  the  pressure  of  a 
small  amount  of  air  internally  might  be  substituted  for  external  pressure, 
which  always  gave  relief.^  He  was  his  own  instrument-maker  and  operator. 
He  constructed  a  small  tube  about  as  slender  as  a  common  pin,  to  which  a 
bladder  was  attached  filled  with  air.  The  point  of  this  was  thrust  through 
an  intercostal  space  till  it  penetrated  the  pleural  cavity,  and  air  was  made 
to  enter  by  compressing  the  bladder.  Belief  always  followed  and  the 
patient's  health  improved.  This  treatment  was  continued  two  or  three  years. 
Dr.  Lizars,  who  was  present  at  the  meeting  of  the  medical  society  before 
which  this  case  was  related,  stated  that  he  had  performed  a  similar  operation 
on  four  or  five  patients  affected  with  aneurysms,  with  some  apparent  benefit 
and  in  no  case  with  injury. 

But  the  condition  is  very  different  if  there  be  inflammatory  products  in 
the  cavity.  It  is  a  fact  known  to  all  observers  that  animal  liquids  withdrawn 
from  the  circulation  and  escaped  from  the  vessels  through  injury  or  disease 
remain  in  a  closed  cavity  for  a  lengthened  period  without  putrefactive  change 
— as,  for  example,  a  clot  of  blood  under  the  scalp  or  pericranium  of  a  new- 
born infant — but  if  air  be  admitted  it  becomes  offensive  within  a  few  hours. 
The  admission  of  air  into  the  pleural  cavity  which  contains  exuded  products 
1  London  Lancet,  January  15,  1831. 


906  LOCAL  DISEASES. 

undoubtedly  promotes  putrefactive  changes  in  the  latter,  and  the  admission 
of  even  a  small  amount  of  air,  containing,  as  it  does,  micro-organisms  which 
multiply  rapidly  in  the  animal  fluids,  and  which  appear  to  be  the  active 
agents  in  putrefaction,  suffices  to  convert  sero-fibrin  or  laudable  pus  into  an 
offensive,  irritating,  and  poisonous  liquid,  which  increases  the  constitutional 
disturbance  and  the  gravity  of  the  disease. 

Air  in  the  pleural  cavity,  in  proportion  to  its  quantity,  also  tends  to  pre- 
vent the  approximation  to  each  other  of  the  pleural  surfaces  and  the  oblitera- 
tion of  the  cavity,  which  is  required  in  all  empyemic  cases,  since  this  is  the 
mode  of  cure.  Obviously,  the  entrance  of  air  does  less  harm  if  there  be  a 
fistulous  opening,  and  pus  escape  as  soon  as  it  forms,  than  iii  a  closed  cavity, 
but  it  should  in  all  instances  be  avoided,  as  never  beneficial  and  likely  to  do 
harm  in  the  manner  indicated.  It  is  never  a  necessary  accident  of  thoracen- 
tesis, since  it  can  be  avoided  by  the  use  of  proper  instruments  provided  with 
India-rubber  packing  and  stopcocks.  There  can  be  no  doubt,  also,  that  the 
point  of  the  aspirator  has  often  so  pricked  and  torn  the  lung  that  air  has 
entered  the  cavity  from  this  organ — a  result  avoided  by  judiciously  using  the 
trocar  and  cannula. 

2d.  Injury  to  the  Lung  hy  the  Surgical  Instruments  Used. — The  lung  is 
sometimes  injured  by  the  point  of  the  hypodermic  needle  employed  for 
diagnosis.  Cases  are  reported  in  the  hospitals  of  New  York  of  the  break- 
ing off  and  loss  of  the  needle  in  the  lung  from  sudden  and  strong  move- 
ment of  this  organ,  as  in  coughing.  The  most  severe  injury  is,  however, 
commonly  produced  by  the  aspirator  needle,  and  some  very  serious  cases 
of  this  accident  have  occurred  in  which  the  needle  so  pierced  and  toi'e 
the  lung  that  not  only  air  escaped  from  it,  but  also  a  considerable  quantity 
of  blood.  It  is  obvious  that  the  danger  of  injuring  the  lung  is  greater  in 
recent  than  in  chronic  cases,  and  greater  in  sei'o-fibrinous  than  in  purulent 
pleuritis,  for  a  thickened,  infiltrated,  and  firm  pleura  affords  protection  to  the 
lung.  It  is  very  difficult  to  avoid  injuring  this  organ  if  suction  be  made  and 
the  liquid  be  withdrawn  with  the  unguarded  point  of  the  aspirator  needle 
projecting  into  the  chest.  The  removal  of  the  liquid  necessitates  the 
impinging  of  the  lung  upon  the  point  of  the  instrument  even  if  it  be  held 
very  obliquely,  and  in  recent  cases,  when  there  is  a  little  thickening  and 
infiltration  of  the  pleura,  the  surface  of  this  organ  may  be  pricked  or  torn 
sufficiently  to  allow  air  to  escape  and  hemorrhage  occur,  when  the  operator 
who  holds  the  needle  can  scarcely  believe  that  such  an  accident  were  possi- 
ble, so  slight  has  been  the  sensation  communicated  to  the  fingers.  Thus, 
thoracentesis  was  performed  on  an  infant  of  two  months  which  had  severe 
empyema  of  short  duration.  The  instrument  was  held  by  myself  obliquely, 
and  it  entered  the  pleural  cavity  only  a  short  distance,  and  yet  the  lung  was 
injured  in  three  places,  from  which  it  was  probable,  from  the  signs  and 
symptoms,  that  air  had  escaped.  The  specimen  showing  the  injury  was 
exhibited  to  the  Pathological  Society  in  1879.  Obviously,  to  prevent  this 
injury  aspiration  should  be  performed  through  the  covered  needle,  as  that  of 
Phelps's  or  Potain's,  or  the  trocar  which  I  have  recommended  above  and 
prefer.  I  must  here  repeat  what  has  been  stated  above,  not  to  plunge  the 
trocar  to  a  greater  depth  than  is  needed,  which  is  about  one  inch.  The  end 
of  the  cannula  may  also  injure  the  lung  if  it  be  pressed  in  too  deeply,  since  it 
is  necessarily  rather  sharp  from  its  small  size. 

3d.  Washing  out  the  Pleural  Cavity. — Since  the  aspirator  has  come  into 
general  use  it  is  the  common  practice  to  wash  out  the  pleural  cavity  with 
carbolized  water  in  the  treatment  of  empyema.  The  proportion  of  carbolic 
acid  to  water  commonly  employed  is  about  one  part  to  eighty,  and  at  a  tem- 
perature of  100°.     From  a  discussion  at  the  meeting  of  the  New  York  Sur- 


PLEURISY.  907 

gical  Society,  Oct.  12,  1880,  it  appears  that  the  use  of  carbolized  water 
iavolves  risk  of  carbolic-acid  poisoning  in  case  the  liquid  be  only  partially 
removed  after  it  is  thrown  into  the  pleural  cavity  ;  and  the  late  Prof.  Erskine 
Mason  was  in  the  habit  of  employing  salicylic  acid,  one  part  to  the  hundred 
of  water,  in  place  of  carbolic  acid,  since  it  possesses  all  the  advantages  with 
none  of  the  possible  risks  of  the  latter.  He  stated  that  it  promptly  deodor- 
izes fetid  pus  even  in  the  proportion  of  one  part  to  two  hundred.  The  use 
of  carbolic  acid  would  probably  be  entirely  safe  if  the  liquid  were  removed 
immediately  after  washing  the  cavity,  but  for  some  reason  this  is  not  always 
possible.  In  case  of  an  infant  with  empyema  under  treatment  of  Drs.  Lock- 
row,  Billington,  and  myself,  after  removing  the  pus  by  trocar  and  cannula 
attached  to  the  exhausting-bottle,  and  once  washing  out  the  pleural  cavity, 
the  liquid  was  thrown  a  second  time,  giij,  into  the  left  pleural  cavity  of 
an  infant  of  five  months,  but  not  a  drop  of  it  could  be  removed.  There 
was,  however,  no  symptom  which  we  could  refer  to  the  carbolic  acid.  In 
view  of  these  facts  and  the  possible  danger  of  carbolic-acid  poisoning,  the 
use  of  salicylic  acid  appears  to  be  preferable,  at  least  for  children,  who  are 
less  able  to  resist  the  action  of  poisonous  agents  than  adults. 

In  this  connection  I  must  state  my  conviction  that  washing  out  the 
pleural  cavity  is  unnecessary  if  empyema  be  treated  as  recommended  above, 
and  it  may  be  injurious.  But  it  is  proper  treatment  when  the  pus  has 
undergone  decomposition,  is  offensive  to  the  smell,  and  therefore  poisonous. 
If  it  be  putrid,  its  immediate  disinfection  as  well  as  removal  from  the  pleural 
cavity  appears  to  be  clearly  indicated,  but  in  the  common  form  of  empyema, 
as  the  pus  escapes  through  the  opening  which  has  been  made  and  the  suppu- 
rative cavity  becomes  smaller,  adhesions  of  the  pulmonary  and  costal  surfaces 
occur,  which  the  injection  of  water  may  tear  up  and  destroy,  and  thus  the 
obliteration  of  the  cavity  is  retarded.  Letting  out  the  pus  and  approxima- 
tion of  the  pleural  surfaces  to  each  other  are  the  indications  as  regards  surgical 
measures.  Besides,  washing  out  the  pleural  cavity  is  not  devoid  of  danger. 
Alarming  symptoms  may  be  developed  unexpectedly  and  rapidly,  even  when 
the  operation  is  slowly  and  cautiously  performed.  The  infant  of  five  months 
with  empyema  whose  case  I  have  alluded  to  furnished  a  striking  example 
of  this.  Four  ounces  of  pus  had  been  removed  through  a  small  cannula 
from  the  left  pleural  cavity,  and  without  removing  the  cannula  the  cavity 
had  been  once  washed  out.  It  was  proposed  to  repeat  the  washing,  as  the 
infant  had  thus  far  tolerated  the  operation  and  was  in  an  unusually  favorable 
state  for  a  case  of  empyema.  The  patient  was  in  a  semi-erect  position,  and 
three  ounces  of  water  at  a  temperature  of  100°  had  entered  the  cavity  from 
the  inverted  bottle,  when  he  began  to  cough,  fretted,  and  became  very  rest- 
less. Immediately  Dr.  Lockrow  applied  the  suction-point  of  the  syringe  to 
the  tubing,  and  attempted  to  withdraw  the  liquid,  but  with  no  result.  The 
patient's  face  assumed  a  deadly  pallor  ;  he  frothed  at  the  mouth,  his  lips  were 
compressed,  and  breathing  ceased.  He  was  to  all  appearances  dead.  He  was 
immediately  placed  upon  the  back  by  Dr.  Billington,  and  by  prompt  resort 
to  artificial  respiration  the  terrible  suspense  was  soon  ended  by  the  gasps 
of  the  child  and  the  return  in  a  few  moments  of  consciousness  and  normal 
respiration.  It  seemed  to  me  that  this  untoward  accident  was  due  to  the 
flow  of  water  against  the  heart,  so  that  it  prevented  full  dilatation  of  its 
cavities,  and  consequently  diminished  the  flow  of  blood  into  the  aorta  and 
produced  anaemia  of  the  brain.  Lichtenstern  says :  "  Various  causes  which 
sometimes  quite  interrupt  or  impede  the  flow  of  blood  to  the  left  heart,  such 
as  severe  paroxysms  of  coughing,  vomiting,  lifting  heavy  burdens,  may  give 
rise  to  a  suddenly  fatal  anaemia  of  the  left  heart,  and  secondarily  of  the  brain. 
The  anaemia  of  the  lungs  or  brain  found  in  many  cases  is  only  of  secondary 


908  LOCAL  DISEASES. 

importance.  It  frequently  happens,  after  tlioracentesis  with  aspiration  that 
an  antemia  is  produced  in  the  partially-distended  lung,  and  this  may  lead  to 
death  by  asphyxia.  In  sudden  death  during,  immediately,  or  a  short  time 
after  thoracentesis  by  aspiration  the  cause  is  anaemia,  either  of  the  heart  or 
brain.  In  cases  in  which  severe  syncope  and  sudden  death  are  observed 
during  the  irrigation  of  the  pleural  cavity  the  cause  is  either  direct  mechani- 
cal concussion  of  the  easily-exhausted  heart  by  the  stream  of  water  thrown 
in,  or  shock."  ^ 

4th.  The  Use  of  Tent  and  Drainage-tube  in  Empyema. — With  due.  regard 
for  the  opinions  of  the  experienced  surgeons  who  employ  and  recommend  the 
tent  and  drainage-tube,  but  whose  observations  have  been  largely  upon  adult 
cases  of  empyema,  I  cannot  recommend  their  employment  for  children,  unless 
perhaps  the  tent  for  a  day  or  two  after  the  incision ;  but  the  tent  is  not 
necessary  if  the  catheter  be  daily  introduced  in  the  manner  which  I  have 
advised.  The  drainage-tube  almost  necessarily  admits  air  during  inspiration, 
but  this  is  not  the  most  serious  objection  to  it.  Cachectic  children  with 
poorly-nourished  tissues  badly  tolerate  pressure  upon  an  open  wound  by  a 
hard  substance.  It  is  liable  to  cause  ulceration  and  enlarge  the  opening, 
and  continued  pressure  of  the  tube  may  cause  periostitis  upon  the  edge  of 
the  rib  and  necrosis.  Scrofulous  and  feeble  children  are  very  prone  to  both 
caries  and  necrosis  from  even  slight  pressure  or  bruises  upon  the  surface 
of  the  bone — a  result  to  which  adults  are  much  less  liable.  In  a  paper  pub- 
lished by  Mr.  W.  Thomas'^  on  the  treatment  of  empyema  by  resection  of  one 
or  more  ribs,  9  cases  are  detailed,  in  3  of  which  necrosis  had  occurred  from 
pressure,  it  is  stated,  of  drainage-tubes,  thus  necessitating  the  removal  of  the 
diseased  portion.  During  the  year  1881  a  wasted  empyemic  infant  was 
brought  to  one  of  the  institutions  of  this  city  for  treatment.  After  letting 
out  the  pus  a  drainage-tube  was  introduced  and  secured.  At  the  next  visit 
ulceration  had  so  enlarged  the  opening  that  a  large  amount  of  air  entered 
the  chest,  with  a  whistling  noise  at  each  inspiration,  and  was  expelled  during 
expiration,  and  necrosis  of  the  portion  of  the  rib  against  which  the  tube 
pressed  had  also  occurred.  Air  was  finally  excluded  by  covering  the  opening 
with  a  cloth  smeared  on  each  side  with  a  concentrated  solution  of  gutta- 
percha in  chloroform,  but  the  case  after  some  days  ended  fatally.  The 
escape  of  the  drainage-tube  into  the  pleural  cavity,  which  has  occurred  by 
breaking  of  the  threads  which  secured  it,  is  so  rare  an  accident  that  it  does 
not  constitute  an  objection  to  the  introduction  of  the  tube ;  but  aspiration 
daily  or  twice  daily  through  the  catheter  so  completely  removes  the  pus  that 
drainage  is  not  required,  and  the  risk  of  injury  by  the  pressure  of  the  tube 
is  therefore  avoided. 

5th.  I  have  witnessed  in  a  few  instances  the  burrowing  of  pus  under  the 
skin  at  the  point  where  an  incision  had  been  made  to  let  out  the  pus.  This 
complication  may  lead  to  more  or  less  ulceration  or  sloughing,  and  it  greatly 
increases  the  danger  of  poisoning.  But  infiltration  of  pus  will  almost  never 
occur  if  the  incision  be  direct  through  the  tissues,  and  not  with  the  skin 
pushed  to  one  side,  so  that  it  forms  a  covering  or  valve  when  it  returns,  as 
was  once  recommended  in  the  books  as  a  means  of  excluding  air.  But  air 
does  not  enter  the  cavity  through  a  direct  opening  if  it  be  properly  covered 
after  the  pus  has  escaped.  Burrowing  of  pus  and  pyaemic  poisoning  there- 
from cannot,  then,  be  regarded  as  an  accident  of  the  mode  of  operation  which 
I  have  recommended. 

Paracentesis  thoracis,  tapping  the  pleural  cavity  to  withdraw  fluid  accu- 
mulated in  it,  is  required — (1)  where  fluid  is  so  copious  as  to  fill  one  pleura ; 

^  Leutsches  Archiv  fur  Bin.  Med.,  Band  iv.  4  Heft;  London  Med.  Record,  Dec.  15, 
1880.  '^Birmingham  Med.  Bee,  1880,  N.  S.,  vol.  iii. 


PLEURISY. 


909 


(2)  when,  the  eifusion  being  large,  there  has  been  one  or  more  fits  of  ortho- 
pnoea ;  (3)  when  the  contained  fluid  is  purulent ;  (4)  where  a  pleuritic  effu- 
sion occupies  as  much  as  half  of  one  pleural  cavity ;  and  (5)  when  it  shows 
no  signs  of  progressive  absorption.  The  operation  should  be  preceded  by  an 
exploratory  tapping  with  a  hypodermic  syringe  to  determine  the  kind  of 
fluid. 

Fig.  244. 


Fig.  245. 


Trocar  and  canunla. 

The  instrument  consists  of  a  trocar  and  cannula  (Fig.  244),  the  latter  being 
fitted  to  screw  upon  a  flexible  suction-tube  of  the  syringe ;  the  cannula  should  be 
provided  with  a  stopcock ;  the  trocar  and  cannula  being  introduced  within  the 
chest,  the  trocar  is  withdrawn  and  the  cannula  attached  to  the  syringe  ;  the  liquid 
is  then  removed  by  means  of  the  expansion  of  the  India-rubber  suction  bag  after  its 
compression  with  the  hand.  Any  form  of  aspirator  may  be  used,  or  the  common 
trocar  and  cannula,  but  in  the  latter  case  air  must  not  be  allowed  to  enter  unless 
antiseptic  spray  is  used. 

The  place  of  operation  will  vary,  within  given  limits,  according  to  the 
amount  of  fluid  collected.  The  indications  are,  to  secure  a  sufiiciently  de- 
pendent position  and  to  avoid  wounding  the  arteries  and  the  diaphragm.  In 
general,  the  lower  portion  of  the  intercostal  space  must  be  selected,  as  the 
intercostal  arteries  approach  the  centres  of  the  spaces  posterior  to  the  angles 
and  anterior  to  the  anterior  third  of  the  spaces  ; 
the  upper  limit  should  be  the  sixth  rib,  and 
the  lower  the  eighth  rib  on  the  right  and  the 
ninth  rib  on  the  left  (Fig.  245).  The  point 
to  be  selected  when  there  are  no  special  indi- 
cations is  the  sixth  intercostal  space  on  the 
right,  owing  to  the  liver,  and  the  seventh  on 
the  left  and  midway  between  the  spine  and 
the  sternum.  Some  tap,  by  preference,  below 
the  angle  of  the  scapula  and  between  the  sev- 
enth and  eighth  ribs,  or  the  eighth  and  ninth 
ribs,  at  a  point  distant  from  two  to  three  inches 
from  the  angles. 

Operate  as  follows  :  Let  the  patient  sit  across 
the  bed  so  as  to  admit  of  the  body  being  readily 
lowered  and  supported  over  the  edge  ;  carbolize  all 
of  the  instruments ;  make  a  small  puncture  in  the 
skin,  just  at  the  upper  edge  of  the  rib,  with  a  nar- 
row-bladed  lancet  or  knife ;  puncture  the  cavity 
through  this  incision,  steadying  the  trocar  with  Poiuts  for  tapping, 

the  fore  finger  of  the  right  hand  pressed  upon  the 

chest,  giving  the  instrument  a  slight  obliquity  upward,  which  will  enable  it  to  clear 
the  edge  of  the  rib,  and  a  rotary  motion  ;  the  depth  to  which  the  trocar  or  needle 
penetrates  must  depend  on  the  thickness  of  the  parietes,  the  presence  of  fat,  muscle, 
or  oedema,  for  which  due  allowance  must  be  made. 

Or,  find  the  inferior  limit  of  the  sound  lung  behind,  and  tap  two  inches  higher 


910 


LOCAL  DISEASES. 


than  this  on  the  pleuritic  side,  at  a  point  in  a  line  let  fixll  perpendicularly  from  the 
angle  of  the  scapula ;  push  in  the  intercostal  space  here  with  the  point  of  the  finger 
and  plunge  the  trocar  quickly  in  at  the  depressed  part ;  be  sure  to  puncture  rapidly 
and  to  a  sufficient  depth,  to  prevent  the  occlusion  of  the  cannula  by  the  false  mem- 
brane. The  amount  of  fluid  withdrawn  in  any  case  must  depend  upon  the  condi- 
tion of  the  patient  and  the  lungs,  care  always  being  taken  to  avoid  faintness.  When 
the  flow  ceases,  instantly  withdraw  the  cannula,  and  place  the  point  of  the  finger  on 
the  puncture  until  adhesive  plaster  is  applied.  If  the  common  trocar  and  cannula 
are  used,  the  outward  flow  of  fluid  must  not  be  allowed  to  intermit,  lest  air  enter 
the  cavity. 

If  the  cavity  is  filled  with  pus,  drainage-tubes  must  be  employed.  Select 
a  trocar  and  cannula  of  the  size  of  a  No.  12  catheter,  and  rubber  tubing  No. 
10  catheter,  having  several  fenestrse  cut  in  the  sides,  and  four  inches  in 
length. 

Cleanse  the  region  of  the  wound  with  soap  and  water  and  bichloride  solution ; 
make  an  incision  thi'ough  the  skin  at  the  point  of  puncture  with  the  scalpel,  and 
thrust  the  trocar  into  the  cavity  firmly,  giving  a  slight  rotary  motion  to  the  point ; 
withdraw  the  trocar,  and  as  the  pus  flows  introduce  the  carbolized  tube  through  the 
cannula  into  the  chest-cavity.  To  prevent  its  escape  the  tube  must  be  transfixed 
with  a  safety  pin.  Or,  incision  may  be  made  directly  into  the  pleural  cavity,  select- 
ing the  upper  margin  of  the  rib,  and  when  pus  begins  to  flow  the  tube  may  be  intro- 
duced with  slender  forceps. 

There  have  been  many  instances  of  the  escape  of  the  tube  into  the  cavity  due  to 
defective  fastening,  as  by  safety-pins.  The  following  method  has  been  proposed : 
Cut  a  round  hole  in  a  piece  of  red  India-rubber  sheeting  one-twelfth  of  an  inch 
thick  and  about  one  and  a  half  to  two  inches  square ;  split  a  tube  of  the  size  re- 
quired, and  without  holes,  at  one  end  into  four  pieces,  and  draw  it  through  the  hole 

in  the  flat  piece  of  rubber,  turned 
Fig.  246.  down   and   fixed   in   position  by 

stitches  of  fine  silver  wire.  The 
tube  should  be  just  long  enough 
to  project  into  the  chest-cavity — 
one  and  a  half  to  two  inches — 
according  to  the  thickness  of  the 
chest-wall.  Nothing  is  gained  by 
curling  up  an  enormous  length  of 
tubing  in  the  chest.  Such  a  tube 
adapts  itself  to  a  sinus  leading  in 
any  direction,  and  requires  no 
special  manoeuvre  to  prevent  it 
entering  the  chest.  These  tubes 
can  be  made  in  a  few  minutes,  of 
any  size  required,  by  the  physi- 
cian himself. 

If  a  tube  escape  into  the  cav- 
ity, proceed  as  follows :  If  the  case 
is  seen  within  a  short  time  of  the 
accident,  before  the  position  of 
the  tube  has  been  changed  by  cough  or  other  movement,  we  may  seize  the  tube  with 
forceps  introduced  into  the  wound ;  if  the  orifice  be  too  small  to  admit  the  forceps, 
use  a  sponge-tent  or  dilator.  In  using  the  tent  we  must  bear  in  mind  the  possible 
existence  of  a  bony  ridge  of  union  between  the  ribs  in  chronic  cases,  the  tract 
passing  through  an  osseous  ring.  The  attempt  to  enlarge  such  a  sinus  by  means  of 
a  sea-tangle  tent  has  necessitated  the  removal  of  a  portion  of  two  ribs.  In  order  to 
gain  the  required  sense  of  touch  it  is  advisable  to  pinch  an  India-rubber  tube  with 
forceps  before  blindly  searching  the  cavity.  A  wire  curved  properly,  with  a  hook 
at  the  end.  has  enabled  the  operator  to  fish  up  the  tube. 

If  we  fail  after  passing  forceps  of  various  kinds  into  the  thoracic  cavity  in  dif- 
ferent directions,  place  the  patient  in  the  horizontal  position,  the  fistulous  opening 
being  most  dependent,  and  then  search  again  with  forceps,  bent  probe,  etc. ;  not 
succeeding,  inject  the  cavity  with  water,  in  the  hope  that  the  return  stream  will 


Drainage-tube  for  pleural  cavity. 


PLEURISY.  911 

carry  the  tube  into  the  vicinity  of  the  opening.  These  means  proving  unsuccessful, 
enlarge  the  orifice  with  a  knife,  so  that  the  finger  can  be  introduced.  If  the  space 
be  still  too  small,  a  portion  of  a  rib  must  be  removed  in  order  to  accomplish  our 
object.  Bear  in  mind  that  the  adhesions  which  have  occurred  between  the  pul- 
monary and  costal  pleura  in  some  cases  will  probably  retain  the  foreign  body  in  the 
neighborhood  of  the  fistula,  rendering  the  removal  a  simple  and  easy  process.  The 
case  is  apt  to  be  more  serious  if  the  affection  be  recent :  adhesions  not  having  had 
time  to  form,  the  tube  has  probably  gained  the  most  dependent  portion  of  the  cavity, 
and  will  in  all  probability  be  found  in  the  costo-diaphragmatic  sinus.  The  compli- 
cation is  greater  if  the  original  incision  have  been  made  high  up.  A  second  open- 
ing in  one  of  the  lower  intercostal  spaces  may  be  required  before  we  can  reach  the 
tube  in  the  chest. 

Excision  of  the  rib  must  be  practised  in  more  severe  cases  of  empyema. 
The  ninth  rib  is  selected  by  Godlee,  because  it  is  just  above  the  point  where 
the  diaphragm  is  united  to  the  ribs  when  it  has  been  drawn  vip  as  much  as 
possible,  and  is  also  the  most  dependent  part  when  the  patient  is  in  a  recum- 
bent position.  It  is,  therefore,  the  most  suitable  place  for  drainage  of  the 
entire  cavity,  both  anteriorly  and  posteriorly. 

Make  an  incision  over  the  rib,  two  or  two  and  a  half  inches  in  length,  down 
to  the  bone  ;  the  periosteum  is  then  raised  from  the  bone  the  length  of  the 
wound,  in  front  and  behind ;  bone-forceps  are  now  applied  and  about  an  inch 
of  the  rib  is  removed,  the  anterior  cut  being  made  first.  The  ends  of  the 
bones  must  be  rounded  off  with  a  raspatory.  The  pleura  must  now  be  cau- 
tiously opened.  It  may  be  punctured  with  a  director  and  the  opening  en- 
larged with  forceps,  or  it  may  be  incised  if  it  is  very  dense.  When  opened 
sufficiently  the  patient  must  be  turned  upon  his  back  and  the  pus  allowed  to 
flow  out  freely.  The  cavity  should  not  be  irrigated  unless  the  pus  is  offen- 
sive, when  hot  boric-acid  solution  may  be  injected.  A  drainage-tube  (Fig. 
246)  must  be  fixed  in  the  wound  and  antiseptic  dressings  applied.  The  tube 
is  retained,  smaller  tubes  being  used  as  the  discharge  declines,  until  the  flow 
ceases.  In  some  cases  the  eighth  rib  may  also  require  exsection.  The 
recovery  of  the  patient  is  usually  rapid  and  the  repair  complete,  for  new 
bone  will  form  and  replace  the  lost. 


SEOTIOI^  T. 
DISEASES   OF  THE   CIKCULATORY   SYSTEM. 


CHAPTER    I. 

DISEASES  OF  THE  HEAET. 

The  heart  is  liable  to  many  forms  of  malformation,  but  those  defects 
which  give  rise  to  cyanosis  are  of  the  greatest  practical  importance.  This 
subject  has  already  been  considered  at  length. 

The  position  of  the  heart  in  childhood  has  not  hitherto  been  sufficiently 
understood.  Recently  more  accurate  studies  of  frozen  sections  have  deter- 
mined some  facts  of  interest.  Symington  ^  concludes  that  the  cardiac  im- 
pulse in  infants  and  children  usually  takes  a  more  external  position  than  in 
adults,  for  while  in  the  latter  the  impulse  is  usually  about  an  inch  internal 
to  the  nipple  line,  in  children  it  is  usually  either  in  the  nipple  line  or  it  may 
be  I4  inches  external  to  that  line.  This  he  attributes  to  the  greater  relative 
narrowness  of  the  infant's  chest  in  the  transverse  diameter,  while,  at  birth 
at  least,  the  heart  is  relatively  larger  than  in  the  adult.  Some  are  of  the 
opinion  that  when  the  impulse  is  raised,  it  is  visible  in  the  fourth  instead  of 
in  the  fifth  intercostal  space.  Rotch  alludes  to  the  fact  that,  owing  to  the 
small  size  of  the  child's  thorax,  the  heart  and  pericardium  are  much  nearer 
the  anterior  surface  of  the  thoracic  cavity  than  is  the  case  with  these  organs 
in  the  adult.  This  occurs  both  normally  and  in  diseased  conditions,  especially 
where  there  is  flattening,  and  thus  levelling,  of  the  chest.  Under  these  con- 
ditions the  heart  and  pericardium  are  brought  in  such  close  contact  with  the 
examiner's  ear  that  on  palpation  he  will  feel  the  heart's  impulse,  and  on  aus- 
cultation will  hear  the  heart-sounds  in  a  more  advanced  stage  of  the  eiFusion 
than  would  be  possible  in  the  adult  with  a  proportionately  large  increase  of 
the  fluid.  Ashby  says  it  is  due  to  the  frequency  with  which  the  stomach 
and  bowels  are  distended  with  gas  during  childhood,  pushing  up  the  diaphragm 
and  heart.  Symington  found  that  the  position  of  the  heart  and  great  vessels 
is,  normally,  practically  the  same  as  in  the  adult. 

Functional  Disorders. 

DaCosta,^  who  has  written  ably  on  this  subject,  calls  attention  to  the  fact 
that  up  to  about  the  seventh  year  the  heart's  action  is  often  of  unequal 
strength  and  rhythm,  and  prone  to  be  irregular  in  the  healthiest  children 
during  sleep,  and  greatly  influenced  by  the  act  of  breathing.  When  the 
irregularity  persists  during  waking  hours  and  quiet  breathing,  it  indicates 
cardiac  disorder  unless  there  are  evidences  of  meningeal  disease.  A  form 
of  irregular  action  is  mentioned  that  is  regarded  as  idiopathic,  in  which  ir- 
regular rhythm  constitutes  the  entire  malady.     The  heart's  action  is  at  times 

1  Ashby  and  Wright,  Dk.  Chil. 
^  Cydopcedia  Dis.  of  Children  (Keating). 
912 


PEBICARDITIS.  913 

very  slow,  having  sixty  or  even  fifty  beats ;  intermissions  are  common,  or 
tliere  is  a  series  of  small  beats  followed  by  fuller  strokes  ;  the  first  sound  may 
be  defective ;  the  organ  is  impressionable,  and  exhibits  in  a  marked  manner 
the  influence  of  the  respiratory  act,  becoming  irregular  if  the  breath  is  held. 
This  changed  rhythm  appears  at  from  three  to  six  years  ;  rarely  in  infants. 
On  the  occurrence  of  a  fever  the  irregularity  disappears.  It  sometimes 
appears  to  be  hereditary. 

The  DIAGNOSIS  is  not  difficult.  There  is,  as  in  the  adult,  increased  im- 
pulse, normal  percussion  dulness,  distinct  second  sound,  and  first  sound  either 
weak  and  short  or  sharp  and  valvular. 

The  PROGNOSIS  is  favorable  in  those  cases  in  which  a  removable  cause  is 
discovered.  The  least  promising  cases  are  those  of  the  idiopathic  variety, 
where  the  heart  is  impressionable.  No  permanent  injury  to  the  heart,  as 
dilatation,  has  been  detected. 

The  TREATMENT  consists  in  the  removal  of  every  condition  which  seems 
fo  cause  or  aggravate  the  trouble.  Careful  regulation  of  the  diet  and  of  the 
digestive  organs  is  important.  If  there  is  anaemia,  iron,  arsenic,  liberal  diet, 
out-door  exercise,  and  sea-bathing  are  the  remedies.  Light  gymnastics,  prop- 
erly guarded,  are  useful.  The  most  serviceable  heart-tonic  is  tr.  digitalis,  3  to 
5  drops  to  a  child  of  six  years  of  age,  soon  after  meals.  It  must  be  continued 
several  months,  with  intervals  of  ten  days  every  month.  Belladonna  is  some- 
times useful  in  connection  with  digitalis  or  as  a  substitute  for  it. 


CHAPTER    II. 

PEEICAEDITIS. 

This  disease  is  most  frequent  in  the  later  years  of  childhood,  but  it  may 
occur  in  infancy,  and  even  in  the  foetus  (Billard,  Bednar).  As  in  the  adult, 
rheumatism  is  the  more  frequent  cause  of  pericarditis  in  children.  Though 
there  may  be  no  outward  manifestations  of  rheumatism,  as  swelling  of  the 
joints,  still  there  can  be  little  doubt  that  after  the  age  of  five  the  conditions 
which  cause  rheumatism  in  the  adult  are  often  present.  Pericarditis  may 
complicate  pleuritis,  especially  in  infants,  or  be  caused  by  septicaemia,  peri- 
ostitis, and  osteitis,  or  follow  scarlet  fever  and  other  eruptive  diseases.  It  is 
always  important  to  examine  the  heart  when  a  child  is  passing  through  any 
severe  disease,  as  the  exanthemata,  pleurisy,  pneumonia,  for  frequently  peri- 
carditis is  masked  by  other  symptoms  or  conditions.  Its  existence  is  often 
suddenly  made  apparent  by  severe  symptoms,  as  dyspnoea,  when  it  may  have 
been  in  progress  several  days. 

The  PATHOLOGY  of  pericarditis  in  children  difi'ers  in  some  respects  from 
that  of  the  same  disease  in  adults.  In  the  former  there  is  a  greater  tendency 
to  effusion,  and  it  occurs  earlier  and  more  rapidly.  Hence  dry  pericarditis 
(sicca)  is  rarely  met  with  in  children.  The  efi'used  fluid  is  also  more  likely 
to  be  tinged  with  blood,  owing  to  the  rupture  of  minute  capillary  vessels, 
but  this  symptom  has  no  special  significance,  as  in  the  adult.  It  is  notice- 
able also  that  the  eifusion  is  more  liable  to  become  fibrinous,  and  even  puru- 
lent, in  children,  especially  when  suffering  from  some  other  affection.  This 
latter  condition  is  due  to  the  susceptibility  of  the  child  to  the  lodgement  of 
the  pus-microbe,  derived  from  some  suppurating  surface  in  the  system,  on  the 
walls  of  the  vessels  of  the  pericardium  damaged  by  inflammation.     The  child 

58 


914  LOCAL  DISEASES. 

rarely  suffers  from  tuberculosis  of  the  pericardium,  compared  with  the  adult, 
as  it  is  not  so  liable  to  the  formation  of  tubercle  in  the  bronchial  glands. 

The  SYMPTOMS  of  pericarditis  in  the  child  are  liable  to  be  very  obscure 
at  first.  Pain  is  unreliable,  fever  may  be  slight,  and  dyspnoea  absent.  It  is 
only  by  physical  examination  that  its  presence  is  detected.  A  friction-sound 
is  early  heard ;  then  there  is  an  increased  area  of  dulness  on  percussion ;  the 
apex-beat  is  obscure  and  is  felt  more  widely,  sometimes  in  the  fourth  and  fifth 
spaces,  and  dyspnoea  may  become  marked,  with  a  tendency  to  orthopncea.  In 
an  ordinarily  well-marked  case  the  reliable  symptoms  are — 1,  a  friction-sound 
of  the  pericardium  ;  2,  diminution  or  disappearance  of  the  apex-beat ;  and  3, 
an  increase  of  the  area  of  percussion  dulness. 

Diagnosis. — If  the  practitioner  is  intelligently  watchful  of  his  patient, 
he  will  detect  the  friction-sound  before  the  disease  is  indicated  by  any  other 
symptom,  and  even  before  it  may  have  been  suspected  from  any  apparent 
condition  existing.  The  effusion  at  this  moment  has  not  taken  place,  or  is  of 
small  amount.  This  friction-sound  varies  much  in  its  intensity,  depending 
upon  the  condition  of  the  surfaces  which  rub  together.  Thus,  if  the  surfaces 
are  very  dry,  as  is  the  case  before  plastic  material  is  thrown  out,  the  sound 
will  be  very  harsh,  and  may  even  be  grating  in  its  intensity.  This  sound 
marks  an  early,  probably  the  earliest,  recognizable  stage  of  the  disease.  As 
the  surfaces  become  lubricated  by  the  effusion  the  friction-sounds  change, 
becoming  less  harsh,  until  they  finally  disappear  as  the  surfaces  become  com- 
pletely sepai'ated  by  the  increasing  accumulation  of  fluid. 

The  diminished  heart-beat  follows  upon  the  loss  of  the  friction-sound,  and 
is  due  to  the  same  cause — viz.  effusion  into  the  pericardium.  Its  complete 
absence  marks  the  distention  of  the  cavity  to  such  an  extent  that  the  apex 
no  longer  impinges  upon  the  pericardial  wall. 

If  the  friction-sound  has  escaped  detection,  Rotch  regards  percussion  as 
the  most  important  method  of  determining  whether  pericarditis  is  present, 
and  as  the  best  guide  to  prognosis  and  treatment. 

He  states  that  in  effusions  of  exactly  the  same  amount  the  area  of  dulness  may 
differ,  owing  to  the  difference  in  the  elasticity  of  the  lungs  and  the  presence  or  ab- 
sence of  adhesions.  The  greater  the  elasticity  of  the  lungs  and  the  fewer  the  adhe- 
sions, the  more  regular  will  be  the  outline  of  absolute  dulness  and  the  greater  its 
significance  as  compared  with  that  of  the  relative  dulness,  while  the  reverse  of  this 
is  true  of  the  relative  dulness.  Thus,  the  absolute  dulness  is  determined  by  the 
retraction  of  the  borders  of  the  lungs,  which  withdraw  from  the  chest-walls  as  the 
effusion  gradually  distends  the  pericardium.  The  enlargement  of  the  area  of  rela- 
tive dulness  is  due  to  the  distended  pericardium  compressing  the  lungs,  which  may 
be  held  more  or  less  in  position  by  adhesions.  Again,  the  greater  the  elasticity  and 
the  freer  the  displacement  the  greater  will  be  the  compression. 

If  the  effusion  is  slight,  the  area  of  dulness  is  limited  to  an  extension  in 
the  fifth  intercostal  space  and  below  the  nipple.  At  this  time  it  may  be  dif- 
ficult to  define  the  boundary  of  the  effusion,  or  even  to  determine  satisfac- 
torily its  existence.  But  when  the  pericardium  is  filled,  its  capacity  at  the 
age  of  eight  being  about  six  ounces,  the  area  of  dulness  is  increased  laterally 
and  the  left  lung  is  displaced  outward  and  upward.  When  the  effusion  is 
very  great,  the  dulness  extends  not  only  laterally  on  the  left  side,  but  also 
on  the  right  side  of  the  sternal  border,  and  upward  to  the  second  intercostal 
space. 

Rotch  states  that,  owing  to  the  flexible  thorax  of  the  child,  there  is  a 
greater  opportunity  for  the  neighboring  parts  to  yield  before  the  pressure  of 
an  effusion,  and  we  are  thus  more  likely  to  have  bulging  of  the  intercostal 
spaces,  and  on  inspection  a  visible  alteration  of  the  cardiac  area,  than  in 
adults. 


PERICARDITIS.  915 

Proonosis. — Pericarditis  when  diffuse  is  always  a  grave  disease  in  chil- 
dren, and  is  generally  fatal  in  infants.  If  there  has  been  pre-existing  disease 
of  the  heart  which  has  caused  hypertrophy,  the  effusion  of  pericarditis  may 
embarrass  its  action,  so  as  to  cause  rapidly  fatal  results.  If  there  is  valvular 
disease,  as  mitral  regurgitation  with  dilatation  of  the  left  ventricle,  the  peri- 
cardial inflammation  will  almost  inevitably  lead  to  acute  dilatation  and  speedy 
death.  Organized  adhesions  are  the  more  remote  results  of  pericarditis, 
which;  if  extensive,  permanently  interferes  with  the  action  of  the  heart. 

Treatment. — The  treatment  of  pericarditis  in  the  child  does  not  differ 
in  kind  from  the  same  disease  in  all  its  forms  in  the  adult.  Of  the  first  im- 
portance is  absolute  rest  in  bed  in  order  to  secure  a  quiet  circulation.  The 
food  should  be  nutritious,  but  unstimulating,  as  milk.  If  the  disease  com- 
plicates rheumatism  or  depends  upon  a  rheumatic  condition,  salicylate  of  soda 
and  liq.  ammo.  acet.  are  most  useful.  If  there  is  any  evidence  of  cardiac 
weakness,  as  dyspnoea,  tr.  digitalis  in  2-  to  6-minim  doses  every  three  or  four 
hours  should  take  the  place  of  the  latter  remedy.  Opium  always  has  a  place 
in  the  treatment  of  pericarditis.  It  should  be  given  to  relieve  pain  and  rest- 
lessness, and  thus  quiet  the  action  of  the  heart,  and  at  the  same  time  promote 
the  action  of  the  skin.  Dover's  powder  at  night,  in  1-  or  2-grain  doses,  re- 
peated once  or  twice  during  the  day  if  necessary,  is  very  useful. 

Of  local  applications  in  the  early  stage,  a  hot  flaxseed  poultice,  with  one- 
sixth  or  eighth  part  of  mustard,  will  prove  beneficial.  Other  measures  are 
spongio-piline  wrung  out  of  hot  water  and  wet  with  laudanum  ;  ext.  of 
belladonna,  with  a  small  amount  of  glycerin,  spread  on  flannel,  may  be 
applied  over  the  heart. 

When  effusion  has  become  a  feature  in  the  progress  of  the  case,  repeated 
small  blisters  made  with  blistering  liquid  often  relieve  pain  and  promote  ab- 
sorption. If  care  is  taken  to  rupture,  and  not  remove,  the  vesicle  in  evacuat- 
ing its  contents,  and  then  applying  soft  dressings,  as  sterilized  cotton,  the 
blisters  will  create  no  inconvenience. 

If  the  case  progress  to  the  accumulation  of  fluid,  so  that  the  action  of 
the  heai't  is  seriously  embarrassed,  the  question  of  its  removal  by  operation 
will  arise.  Before  proceeding  to  operate  it  should  be  determined,  as  accu- 
rately as  possible,  to  what  extent  the  percussion  dulness  is  due  to  effusion 
alone,  and  whether  it  may  not  be  due  in  part  or  whole  to  dilatation  or  hyper- 
trophy of  the  heart.  This  question  can  be  answered  correctly  only  by  a 
careful  inquiry  as  to  the  previous  history  of  the  patient  and  study  of  the 
progress  of  the  case. 

Roteh  states  that  a  girl  aged  five  years  entered  the  service  of  Dr.  Henri  Roger 
of  the  Hopital  des  Enfants  Malades  with  all  the  signs  of  an  abundant  pericardial 
effusion.  The  case  was  under  observation  several  weeks,  and  Dr.  Roger  repeatedly 
marked  out  the  area  of  dulness  in  his  usual  minutely  careful  way,  and  designated 
the  precise  spot  where  he  intended  to  insert  the  trocar.  His  colleague  opposed  the 
operation  on  general  principles,  and,  the  child  dying,  an  autopsy  disclosed  no 
effusion,  Ijut  an  enormously  dilated  heart. 

If  it  is  decided  that  there  is  little  or  no  hypertrophy,  and  that  the  symp- 
toms are  due  to  the  effusion,  aspiration  of  the  fluid  should  be  performed. 
The  smaller  needle  should  be  selected.  The  point  of  operation  is  in  the 
fourth  or  fifth  intercostal  space,  according  to  the  location  of  the  apex-beat 
and  the  indications  of  distention  of  the  pericardium,  and  midway  between  the 
nipple  and  the  margin  of  the  sternum.  It  is  well  to  make  a  slight  incision 
of  the  skin  to  aid  the  penetration  of  the  needle.  The  needle  should  point 
upward  and  backward,  and  should  be  introduced  with  a  rotary  movement, 
care  being  taken  not  to  penetrate  too  deeply,  lest  the  heart  be  wounded. 


916  LOCAL  DISEASES. 

Roberts  prefers  the  space  between  the  ensiform  appendix  and  the  seventh  left 
cartilage  as  the  safest  point  for  tapping  (Rotch). 

If  the  effusion  is  purulent  and  the  fluid  rapidly  accumulates,  it  will  be 
necessary  to  open  the  pericardium  by  incision  and  disinfect  the  cavitj-.  Boric 
acid  is  most  useful.  It  will  be  advisable  to  introduce  a  drainage-tube,  as  in 
a  common  abscess. 

There  is  often  a  strong  tendency  to  heart  failure  in  these  more  serious 
cases,  which  must  be  guarded  against  by  the  judicious  use  of  heart  stimu- 
lants and  tonics,  as  tr.  digitalis,  strychnia,  ammonia,  and  quinine. 


CHAPTER    III. 

MYOCARDITIS. 

Inflammation  of  the  walls  of  the  heart  is  a  very  rare  affection  in  chil- 
dren, and  may  be  acute  or  chronic.  It  especially  affects  the  intermuscular 
connective  tissue.  It  may  be  diffused  or  circumscribed.  Bruce,  whose  arti- 
cle on  myocarditis  ^  should  be  consulted,  states  that,  "  microscopically,  acute 
myocarditis  is  characterized  by  infiltration  of  the  intermuscular  spaces,  with 
an  exudation  of  leucocytes,  sero-fibrinous  material,  and  extravasated  blood, 
and  by  compression  and  albuminous  and  fatty  degeneration  of  the  muscular 
fibres." 

The  acute  diffused  form  differs  from  the  circumscribed  form  only  in  the 
area  of  the  inflammation  :  in  the  former  a  large  extent  of  the  wall  is  infil- 
trated, while  in  the  latter  the  inflammation  has  a  limited  area,  more  often  in 
the  left  ventricle  and  septum.  The  appearance  of  the  tissues  is  either  dark 
red,  injected,  and  frequently  ecchymosed,  or  of  a  peculiar  mottled  yellowish 
hue ;  when  localized  the  part  becomes  swollen  and  softened,  and  finally  of  a 
grayish-red  color,  which  precedes  the  formation  of  an  abscess.  The  abscess 
of  the  wall  may  open  into  the  pericardium  and  set  up  a  pericarditis,  or  into 
a  cavity  of  the  heart,  causing  a  cardiac  aneurysm. 

Chronic  myocarditis  tends  to  a  growth  of  the  intermuscular  connective 
tissue  and  degeneration  and  disappearance  of  the  muscular  fibres,  more  or 
less  completely. 

The  CAUSE  of  acute  myocarditis,  except  when  it  results  from  an  injury, 
is  some  pre-existing  disease;  as  endocarditis.  It  may  also  complicate  acute 
articular  rheumatism  and  infective  diseases,  and  it  may  result  from  embolism 
when  destructive  diseases  of  the  lungs  or  other  organs  are  in  progress.  In 
general,  the  diffuse  or  parenchymatous  form  of  inflammation  occurs  during 
an  attack  of  endocarditis,  rheumatism,  or  the  exanthemata,  while  abscess 
results  from  embolism.  But  the  progress  of  the  two  forms  does  not  mate- 
rially  differ. 

The  SYMPTOMS  are  those  dependent  upon  a  diminution  of  the  functional 
capacity  of  the  heart,  and  a  consequent  weakening  of  the  blood-pressure  in 
the  aortic  system,  over-distention  of  the  pulmonary  circulation  and  of  the 
veins  of  that  system  (Schroetter).  The  pulse  is  frequent,  weak,  and  often 
irregular;  the  skin  pale  or  cyanotic ;  the  fever  usually  moderate  in  degree. 
Auscultation  reveals  a  feeble  heart-impulse,  the  sounds  are  indistinct,  and  the 
area  of  dulness  may  increase  laterally. 

^  Keating' s  Cyclopoedia  of  Dis.  of  Children. 


ENDOCARDITIS.  91 7 

The  DIAGNOSIS  of  myocarditis  following  diseases  of  the  heart  must  be 
made  in  connection  with  existing  diseases  and  a  careful  study  of  the  phe- 
nomena as  they  appear  connected  with  the  heart.  In  idiopathic  myocarditis 
the  diagnosis  will  be  based  principally  upon  pain  in  the  region  of  the  heart 
and  sense  of  constriction  of  the  chest;  anxiety,  slight  fever,  dyspnoea,  rapid, 
irregular,  and  feeble  pulse,  increasing  weakness,  with  the  gradual  develop- 
ment of  bronchial  catarrh  and  the  symptoms  of  Bright's  disease. 

The  TREATMENT  must  be  adapted  to  the  particular  features  of  each  case. 
Rest  must  be  maintained,  and  relief  from  pain  secured  by  opium  or  other 
narcotics.  If  articular  rheumatism  has  preceded  the  attack,  salicylate  of 
sodium  must  be  given.  Proper  feeding  is  most  important,  and  predigested 
milk  and  beef  are  always  indicated.  Cardiac  stimulants  must  be  reserved 
for  symptoms  of  heart  failure,  and  then  be  administered  with  great  care. 
CaiFeine,  digitalis,  quinine,  ammonia,  and  strychnine  are  valuable  at  the 
proper  time. 

Chronic  myocarditis  and  cardiac  aneurysm  are  to  be  treated  on  the 
same  principles  as  govern  the  treatment  of  chronic  valvular  disease. 


CHAPTER    IV. 

ENDOCAEDITIS. 

Endocarditis  may  be  acute  or  chronic.  In  its  acute  form  it  takes  its 
rise  in  a  proliferation  of  the  fibrous  connective  tissue  vinderlying  the  endo- 
thelial cells  of  the  endocardium.  The  most  important  feature  of  the  disease 
is  the  cell-proliferation  of  the  fibro-eonnective  tissue  of  the  valves,  which 
forms  nodules — the  well-known  vegetations.  They  appear  at  first  as  a  series 
of  gelatinous-looking,  translucent  beads  on  the  margins  of  the  valves.  They 
may  be  absorbed  or  they  may  gradually  enlarge  and  become  opaque.  As  the 
disease  progresses  similar  nodules  may  form  on  the  tendinous  cords  and 
undergo  similar  transformations. 

The  left  side  of  the  heart  is  far  more  often  affected.  The  valves  of  the 
pulmonary  artery  are  very  rarely  the  seat  of  inflammatory  changes.  The 
tricuspid  valve  may  be  aff"ected,  but  it  more  often  escapes.  The  disease  is 
usually  confined  to  the  left  side,  and  the  mitral  valves  are  in  general  chiefly 
implicated. 

Sibson  attributes  the  susceptibility  of  the  mitral  valves  to  the  fact  that  the  flaps 
of  the  mitral  valves  press  against  each  other  when  the  valve  is  shut  with  much 
greater  force. 

The  future  disastrous  consequences  of  endocarditis  in  children  depend 
upon  the  organization  of  these  nodular  masses.  Cheadle  ^  thus  graphically 
sums  up  the  eff"ects  of  endocarditis :  "  The  changes  which  follow  acute  or 
subacute  endocarditis  are  both  grave  and  numerous.  Fibrous  contraction 
and  thickening  and  puckering  or  ulceration  or  perforation  of  the  valves  and 
tendinous  cord,  leading  to  narrowing  of  the  valvular  openings  or  causing 
imperfect  closure  and  regurgitation ;  consequent  changes  in  the  cardiac 
chambers,  such  as  dilatation  and  hypertrophy ;  simple  dilatation,  partial  or 
general,  from  injury  to  the  muscular  tissues  of  the  walls  by  accompanying 

^  Keating'  s  Cydopcedia  of  Diseases  of  Children. 


918  LOCAL  DISEASES. 

myocarditis ;  sometimes  embolisms  from  the  detachment  of  fibrinous  concre- 
tions on  the  valves  or  from  thrombi  in  the  cavities,- — all  these  occur  in  the 
case  of  children." 

The  evidences  of  the  existence  of  acute  endocarditis  are  not  always  prom- 
inent in  children.  It  often  happens  that  these  patients  pass  through  an  attack 
of  rheumatic  fever  without  a  suspicion  of  heart  complication.  It  is  not 
uncommon  to  discover  valvular  disease  in  children  that,  on  inquiry,  evi- 
dently had  its  origin  in  a  mild  attack  of  rheumatism  which  attracted  so  little 
attention  that  medical  advice  was  not  sought.  iVgain,  we  often  see  children 
in  the  first  stages  of  a  rheumatic  fever  who  have  well-marked  valvular  lesions. 
These  cases  are  readily  accounted  for,  if  the  previous  history  is  carefully 
studied,  as  relapses  of  previous  rheumatic  seizures,  during  which  the  val- 
vular complications  occurred.  These  facts  suggest  the  importance  of  con- 
stant watchfulness  of  the  heart  in  all  acute  diseases  of  children,  especially 
where  there  is  a  rheumatic  element  in  the  case,  although  it  may  not  be  at  all 
pronounced.  It  is  also  true  that  endocarditis  often  complicates  chorea,  ton- 
sillitis, diphtheria,  and  septicsemia. 

The  prudent  physician  will  not  fail  to  examine  the  heart  of  a  child  even 
when  the  disease  seems  to  be  only  a  transient  fever  which  occurs  without 
apparent  cause.  These  attacks  sometimes  prove  to  be  endocarditis,  probably 
from  a  latent  rheumatic  condition. 

The  SYMPTOMS  of  endocarditis  in  children  should  therefore  be  carefully 
studied,  in  order  that  an  early  diagnosis  may  be  made  and  prompt  treatment 
secured.  The  first  symptoms  which  indicate  endocarditis  are  discovered  by 
auscultation.  This  must  be  patiently  and  perseveringly  practised  at  every 
visit,  to  fully  appreciate  the  changes  which  are  in  progaess.  The  first  dis- 
coverable symptom  in  an  obscure  case  is  a  systolic  murmur  traceable  to 
the  mitral  valves  and  indicating  a  regurgitation.  It  will  also  be  noticed  that 
this  murmur  is  preceded  by  a  dull,  rumbling  sound,  which  is  due  to  mitral 
stenosis.  Cheadle  found  in  nearly  one-fourth  of  his  cases  the  systolic  mitral 
and  the  presystolic  exist  together.  He  states  that  in  a  very  small  proportion 
of  cases  the  murmur  is  basic  and  systolic,  signifying  aortic  obstruction ;  it  is 
rarely  diastolic,  indicating  aortic  regurgitation  ;  the  mitral  systolic  murmur 
is  usually,  the  presystolic  mitral  invariably,  organic  and  a  sign  of  endocarditis  ; 
the  aortic  systolic  murmur  is  rarely  h?emic  or  functional ;  the  diastolic  aortic 
is  invariably  organic  and  a  certain  evidence  of  endocarditis.  There  is  also 
often  noticeable  reduplication  of  the  second  sound,  which  is  heard  at  the 
apex  and  not  at  the  base  of  the  heart. 

The  action  of  the  heart  is  variable,  but  usually  it  is  increased,  and  may 
give  a  pulse  of  l-tO  to  150.  There  is  also  an  increased  area  of  dulness  very 
early  noticed,  which  at  first  is  sometimes  due  rather  to  the  increased  impulse 
of  the  heart  than  to  true  enlargement,  though  the  latter  condition  soon 
supervenes. 

In  the  progress  of  the  case  anaemia  supervenes,  and  this  becomes  more 
marked  when  relapses  occur  in  the  rheumatic  form  of  endocarditis.  Hyper- 
trophy of  the  heart  often  proceeds  rapidly,  with  its  usual  effects  upon  the 
circulation. 

The  DIAGNOSIS  of  endocarditis  depends  much  upon  the  care  with  which 
the  early  symptoms  are  sought  for  and  analyzed.  The  first  question  to 
determine  is  as  to  the  existence  of  an  abnormal  heart-sound.  If  present, 
what  are  its  peculiarities  ?  If  there  is  a  murmur,  consider  where  it  is  most 
distinct.  If  it  is  most  intense  at  the  apex  and  occurs  with  the  systole,  and 
if  it  is  recent  or  commenced  with  rheumatism,  scarlet  fever,  or  chorea,  endo- 
carditis is  undoubtedly  present,  and  has  already  crippled  the  valves.  The 
subsequent  development  of  symptoms  is  in  the  direction  of  the  progressive 


ULCERATIVE  ENDOCARDITIS.  919 

changes  which  the  inflammation  of  the  endocardium  causes,  especially  in  the 
integrity  of  the  valves. 

Cheadle  states  that  a  presystolic  murmur  is  always  organic,  and  therefore 
its  fresh  appearance  would  be  conclusive  of  the  presence  of  endocarditis,  past 
or  present ;  a  systolic  aortic  murmur  is  almost  invariably  organic,  except  in 
cases  of  extreme  anaemia ;  a  diastolic  aortic  murmur  is  invariably  organic, 
and  sometimes  occurs  as  the  earlier  sign  of  endocarditis. 

The  PROGNOSIS  in  a  first  attack  of  endocarditis,  uncomplicated  by  severe 
rheumatism  or  other  disease,  is  favorable.  In  many  cases  the  cardiac  symp- 
toms abate,  and  may  disappear ;  in  others,  although  the  valvular  defects  per- 
sist, the  development  of  the  heart  may  in  a  great  measure  compensate  for 
the  deficiency.  In  cases  of  recurrent  endocarditis  the  prognosis  is  more 
unfavorable.  Every  attack  aggravates  more  and  more  existing  lesions ; 
anaemia,  with  wasting  of  tissues,  becomes  a  marked  feature  ;  rapid  action  of 
the  heart  with  dyspnoea  supervenes,  and  the  case  assumes  a  most  unfavorable 
condition. 

The  TREATMENT  of  endocarditis  in  children  should  aim  to  restrain  the 
action  of  the  heart  and  to  support  the  strength  of  the  patient.  Best  in  bed 
is  of  the  first  importance,  and  everything  that  tends  to  excite  physical  or 
mental  disturbance  should  be  avoided.  The  diet  should  be  easily  digested 
and  taken  in  small  quantities,  frequently,  to  prevent  distention  of  the  stom- 
ach. Peptonized  milk,  beef-tea,  or  sarco-peptones  and  parapetone,  and  fari- 
naceous articles,  must  be  judiciously  given.  Stimulants  should  be  employed 
only  in  case  of  threatened  failure  of  the  heart,  unless  septicaemia  complicates 
the  case,  when  alcohol  becomes  useful. 

The  use  of  medicinal  remedies  must  be  directed  according  to  the  special 
features  of  each  case.  For  high  temperature,  or  septicsemia,  quinine  should 
be  given  freely  from  the  first.  Two  to  three  grains  every  four  hours  may 
be  given  to  a  child  of  five  years  of  age.  In  rheumatic  cases  salicin,  in  doses 
of  five  to  seven  grains,  in  sweetened  water,  every  four  hours  for  a  child  five 
years  old,  is  preferable  to  salicylate  of  sodium,  as  it  is  not  a  depressant. 
To  this  remedy  may  be  added  alkalies,  as  the  carbonate  or  citrate  of  sodium, 
in  doses  of  ten  grains  every  four  hours  until  the  urine  becomes  alkaline.  In 
cases  exhibiting  a  feeble  pulse,  but  a  rapid  action  of  the  heart,  digitalis  will 
be  required  in  doses  of  three  to  five  drops  of  the  tincture  every  four  hours. 
Opium,  in  some  of  its  forms  and  in  small  doses,  may  be  found  useful  where 
there  are  pericardial  adhesions  or  hypertrophy  and  there  is  distress  due  to 
the  violent  action  of  the  heart. 


CHAPTER  Y. 

ULCEEATIVE   ENDOCAEDITIS. 

Ulcerative  endocarditis  rarely  occurs  in  children.  Prof.  Osier,  who 
has  treated  the  subject  exhaustively  in  his  lectures  at  the  Royal  College  of 
Physicians,  in  his  researches  found  records  of  upward  of  200  cases,  but  few 
instances  among  children.  It  has  rarely  been  seen  in  the  institutions  of  New 
York.  Kirkes,  who  reported  the  first  case,  discovered  the  disease  in  a  boy 
fourteen  years  old.  Cheadle  states  that  only  a  single  case  appears  in  the 
records  of  the  Hospital  for  Sick   Children,  London,  where  patients  are  ad- 


920  LOCAL  DISEASES. 

mitted  under  the  age  of  twelve,  during  the  last  twenty  years.     He  gives  the 
following  history : 

Case. — Child  aged  eight  years  ;  had  suffered  from  acute  articuhir  rheumatism 
three  years  before,  and  two  years  later  was  in  hospital  for  chorea  ;  she  soon  recov- 
ered, and  remained  well  until  five  weeks  before  admission ;  was  seized  with  inces- 
sant vomiting  and  headache,  followed  by  general  convulsions,  twitchings,  and  un- 
consciousness lasted  twelve  hours,  Ijut  no  paralysis  remained  ;  three  days  after  had 
another  attack  of  convulsions.  On  admission  she  had  great  dyspnoea,  respirations 
60,  pulse  132,  temperature  104.2°  F. ;  face  extremely  pallid,  with  a  greenish  tinge, 
but  no  jaundice;  no  oedema  or  dropsy.  The  cardiac  region  was  bulging,  with 
heaving  impulse  reaching  outside  of  the  nipple  to  the  sixth  space,  and  a  large  area 
of  cardiac  dulness.  There  was  a  prolonged  systolic  apex-murmur ;  a  few  rales  at 
the  base  of  the  lung ;  liver  and  spleen  not  enlarged ;  a  trace  of  albumen  in  the 
urine.  Convulsions  recui'red,  with  squinting,  contracted  pupils,  and  almost  com- 
plete unconsciousness.  On  the  following  day  speech  and  consciousness  returned, 
but  the  left  side  was  completely  paralyzed.  The  pulse  rose  to  158,  respirations  56, 
temperature  103°  F.  She  died  on  the  sixth  day,  and  the  autopsy  showed  the  peri- 
cardium firmly  adherent,  the  heart  greatly  hypertrophied  and  weighing  12j  ounces, 
the  left  auricle  much  dilated,  its  lining  membrane  opaque,  and  just  above  the  aortic 
segment  of  the  mitral  valve  was  composed  of  thickened  endocardium,  with  adherent 
lymph  attached  in  polypoid  masses,  and  sharply-cut  ulcers  owing  to  the  breaking 
down  of  athei-omatous-looking  patches  just  above  the  root  of  the  flaps  at  their 
junction.  The  mitral  valve  was  greatly  thickened  and  shortened,  and  polypoid 
vegetations  were  attached,  but  there  was  no  ulceration  on  the  flaps  themselves ; 
infarcts  were  found  in  the  kidneys,  spleen,  and  I'ight  middle  cerebral  artery. 

Ulcerative  endocarditis  has  the  subjective  symptoms  of  a  septicaemic 
disease.  There  are  rigors,  followed  by  sweating,  diarrhoea,  high  temperature 
at  intervals,  rapid  and  feeble  pulse,  and  prostration.  The  liver  and  spleen 
may  enlarge,  the  skin  become  sallow,  and  even  hemorrhagic  spots  may  appear. 
It  is  liable  to  be  mistaken  for  typhoid  fever,  and  when  convulsions  are  present 
it  has  been  diagnosed  meningitis.  The  symptoms  pointing  to  the  heart,  how- 
ever, if  properly  appreciated,  will  lead  the  practitioner  to  detect  the  true 
nature  of  the  aifection.  The  fact  that  ulcerative  endocarditis  complicates 
such  diseases  as  diphtheria,  rheumatism,  and  scarlet  fever  must  be  remem- 
bered, for  they  tend  to  obscure  its  real  presence. 

The  TREATMENT  of  this  formidable  disease  must  be  governed  by  the 
symptoms.  As  it  is  closely  allied  to  septic  diseases,  such  remedies  as  quinine 
and  iron,  stimulants,  opium,  highly  nourishing  foods,  and  pure  air  are  chiefly 
useful. 


CHAPTER   VI. 

CHRONIC    ENDOCARDITIS. 

Acute  rheumatic  endocarditis  is  very  liable  to  terminate  in  chronic 
disease  of  the  valves  of  the  heart  of  a  most  serious  character.  Sansom 
states  that  in  rheumatism  the  endocardium  is  more  vulnerable  in  the  child 
than  in  the  adult ;  of  the  cases  of  acute  and  subacute  rheumatism  treated 
at  a  children's  hospital  where  the  patients  were  not  admitted  after  twelve 
years  of  age,  he  found  valvular  disease,  at  the  time  of  the  patient's  leaving 
the  hospital,  manifest  in  from  50  to  60  per  cent.  It  has  already  been  stated 
that  the  evidences  of  the  presence  of  a  rheumatic  condition  may  be  so  obscure 
that  it  is  often  overlooked  as  a  cause  of  valvular  disease.     It  may  occur  in 


CHRONIC  ENDOCARDITIS.  921 

the  progress  of  scarlet  fever  and  otlier  infectious  diseases,  and  even  as  a 
result  of  injuries. 

The  lesion  created  is  usually  such  a  thickening  of  the  mitral  valves  and 
retraction  of  their  margins  that  in  the  systole  the  blood  regurgitates  into 
the  left  auricle.  In  other  cases  the  curtains  of  the  mitral  valves  become 
adherent  to  the  orifice  narrowed,  so  as  to  cause  stenosis.  Two  conditions 
of  the  apparatus  of  the  heart  must  be  considered — viz.  mitral  inadequacy 
and  mitral  stenosis. 

1.  Mitral  inadequacy  is  attended  by  a  reflex  of  blood  into  the  left  auricle 
in  ventricular  systole.  The  symptom  most  directly  indicating  mitral  regur- 
gitation is  a  murmur  heard  over  the  apex  of  the  heart  during  the  systole 
of  the  ventricle.  It  is  sometimes  heard  in  the  direction  of  the  left  axilla, 
and  again  under  the  angle  of  the  left  scapula.  If  this  murmur  is  well 
defined  and  the  child  has  the  evidences  of  a  rheumatic  condition,  present 
or  past,  the  diagnosis  of  mitral  inadequacy  is  quite  certain.  It  is  only  when 
this  murmur  follows  pericarditis,  without  any  trace  of  rheumatism,  that  the 
doubt  may  be  justified,  for  this  murmur  may  be  detected  temporarily  in  such 
cases,  and  finally  disappear.  Sansom  states  that  in  a  large  majority  of  cases 
persistent  systolic  murmur  at  the  apex  indicates  structural  alteration  of  the 
valve  or  its  attachments,  but  exceptions  may  occur  in  the  condition  of  myo- 
carditis which  accompanies  pericarditis,  and  in  the  systolic  murmur  due  to 
dilatation  of  the  ventricles  without  any  disease  of  the  valves.  The  latter 
aifection  is  very  rare. 

The  DIAGNOSIS  of  mitral  insufficiency  requires  a  careful  inquiry  into  the 
preceding  history  of  the  patient  with  reference  to  open  or  latent  attacks 
of  rheumatism,  and  a  recognition  of  the  above  symptoms. 

The  TREATMENT  of  mitral  insufficiency  is  most  important  in  its  earlier 
stages.  Every  effort  .should  be  made  to  remove  the  conditions  which  aggra- 
vate it.  for  the  progressive  changes  which  naturally  follow  the  initial  lesion 
are  destined,  unless  arrested,  to  result  in  completely  incapacitating  the  heart. 
There  is  also  a  constant  liability  to  a  renewed  attack  of  endocarditis  or 
pericarditis,  or    both   combined,  which  must  be   carefully  guarded    against. 

The  first  efforts  made  should  be  directed  to  securing  rest  and  quiet.  For 
a  limited  period  the  child  should  be  confined  to  the  room,  and  for  the  most 
part  to  the  bed.  All  conditions  which  cause  physical  and  mental  unrest  or 
excitement  must  be  rigidly  excluded.  If  there  is  much  pain  or  distress  in 
the  region  of  the  heart,  warm  poultices  will  give  relief.  If  mustard  is  added 
to  the  poultice  in  such  quantities  as  to  cause  redness  of  the  skin  without 
exciting  the  heart,  the  relief  is  more  complete.  The  digitalis  poultice  is 
recommended  by  Sansom,  thus : 

R  .  Digitalis-leaves,  dried,         2  ounces  ; 
Linseed-meal,  2  ounces ; 

Water,  1  pint. 

Boil  the  leaves  with  the  water  for  ten  minutes,  then  add  the  linseed- 
meal  gradually,  stirring  constantly  ;  spread  the  mass  on  tow,  and  smear 
a  little  olive  oil  on  the  surface  of  the  poultice. 

As  the  patient  begins  to  improve  gentle  exercise  may  be  allowed,  but  for 
a  time  not  to  the  extent  of  increasing  markedly  the  heart's  action.  The 
clothing  next  to  the  skin  should  be  woollen  and  tightly  fitting  to  protect 
against  changes  of  temperature.  Massage  of  the  chest  is  useful  when 
properly  performed. 

The  diet  should  be  very  nutritious,  unstimulating,  and  easily  digested. 
Milk  should  be  freely  given,  and,  if  the  stomach  is  disturbed,  the  milk 
should  be  peptonized.     The  sarco-peptones  are  readily  digested.     In  cases 


922  LOCAL  DISEASES. 

of  feeble  digestion  oi"  navisea  and  vomiting  Sansom  recommends  nutritive 
enemata,  made  by  shaking  together  in  a  bottle  two  ounces  of  warm  milk 
with  one  ounce  of  cod-liver  oil,  or  an  egg  with  an  ounce  of  hot  milk  and  an 
ounce  of  cod-liver  oil.  These  should  be  administered  three  times  daily 
through  a  soft  catheter  well  introduced. 

If  there  is  any  manifestation  of  the  presence  of  rheumatic  conditions,  the 
citrate  or  acetate  of  potassium  should  be  given.  If  the  symptoms  do  not 
improve,  sodium  salicylate  or  salicin  should  be  added,  in  from  three-  to  ten- 
grain  doses,  in  a  mixture  containing  extract  of  liquorice.  Of  other  remedies, 
cod-liver  oil  aids  general  nutrition  and  is  usually  readily  taken  by  the  patient. 
Sansom  advises  that  it  be  given  finely  divided  as  an  emulsion,  and  in  doses 
of  from  twenty  minims  to  one  drachm  three  times  daily :  ^ 

R .  Cod-liver  oil.  30  minims  ; 

Pure  glycerin,  10  minims  ; 
Solution  of  lime  or 

Mucilage  of  acacia,  1  fluidrachm. 

Iron  in  the  form  of  the  syrup  of  the  phosphate,  or  mist,  ferri  comp.,  or 
the  tartarate  may  be  given  according  to  indications. 

If  the  heart  lesion  progress  and  compensation  does  not  occur,  cardiac 
tonics  will  be  required.  Dyspnoea  may  become  a  troublesome  symptom, 
when  the  tincture  or  infusion  of  digitalis  is  the  best  remedy.  If  it  is  not 
well  borne  on  account  of  irritability  of  the  stomach,  caffeine  may  be  substi- 
tuted, in  the  form  of  the  citrate,  in  one-  to  three-grain  doses.  Sansom 
recommends  convallaria  majalis,  the  liquid  extract,  in  from  four  to  fifteen 
drops.  He  advises  that  cardiac  tonics  should  be  interrupted  for  a  day  after 
continuous  administration  for  a  week,  for,  though  preliminarily  increasing  the 
renal  secretion,  after  prolonged  action  they  may  diminish  it. 

As  the  disease  advances  heart-sedatives  must  be  employed  to  relieve  rest- 
lessness and  sleeplessness  due  to  palpitation  and  distress  in  the  praecordial 
region.  One  of  the  simplest  remedies  for  this  purpose  is  bromide  of  potas- 
sium or  sodium  in  two  to  ten  grains.  Chloral  hydrate  may  be  added  to  the 
bromide  in  two  to  four  grains  if  the  symptoms  are  severe  and  unrelieved  by 
the  latter  remedy.  In  some  cases  opium  must  be  substituted  in  the  form  of 
paregoric  for  young  children  and  laudanum  for  older  children. 

Dropsical  effusions  often  occur,  and  they  may  take  the  form  of  oedema  or 
of  collections  of  fluid  in  cavities.  In  any  case,  they  mark  the  progress  of  the 
disease  in  the  increased  embarrassment  of  the  circulation.  By  careful  atten- 
tion to  the  condition  of  the  patient  and  the  judicious  use  of  remedies  the 
effusions  can  frequently  be  removed.  The  skin,  bowels,  and  kidneys  are  the 
chief  means  of  eliminating  the  fluid.  The  skin  is  best  acted  upon  by  the  hot- 
air  bath,  which  may  be  readily  extemporized  with  the  simple  apparatus  now 
generally  in  use,  or  hot-water  bags  may  be  placed  under  the  bed-clothes 
raised  above  the  body  on  hoops.  In  some  cases  sweating  may  be  induced  by 
sponging  with  hot  carbonate-of-soda  solutions,  and  then  wrapping  the  body  in 
woollen  blankets.  The  most  useful  cathartic  for  the  removal  of  effusions  is 
the  compound  jalap  powder  in  five-  to  ten-grain  doses.  As  a  diuretic,  digi- 
talis, properly  combined,  has  the  advantage  of  also  sustaining  the  heart. 
Sansom  gives  the  following  combination  every  four  hours : 

B. 


Tinet.  digital., 
Spiritus  aetheris  nitrosi, 
Tinct.  scillae, 

in.ij-v  ; 

TT^v-xx ; 

^iij-x ; 

Potass,  acetat, 

.V. 

gr.iij-x ; 

Decoct,  scoparii, 

3J-iv- 

Cydopcedia  Lis.  Chil. 


DISEASES  OF  THE   VESSELS.  923 

By  these  means  great,  and  often  complete,  temporary  relief  may  be  ob- 
tained by  the  removal  of  the  effusion.  If  the  kidneys  and  skin  fail  to 
respond  to  remedies,  as  sometimes  happens,  tapping  of  cavities  where  the 
fluid  has  accumulated  in  large  quantities  or  the  puncture  of  oedematous  limbs 
must  be  practised. 

2.  Ilitral  stenosis  consists  in  a  thickening  of  the  tissues  around  the 
auriculo-ventricular  orifice,  which  obstructs  the  passage  of  the  blood  from 
the  auricle  to  the  ventricle.  At  first  the  vegetations,  already  noticed,  slightly 
diminish  the  orifice ;  then  follow  thickening  of  the  folds  of  the  mitral  valve, 
extending  also  to  the  cords,  and  at  length  the  usual  condensation  of  all  the 
tissues  about  the  orifice,  attended  by  a  constant  narrowing  of  the  opening, 
which  may  preserve  the  rounded  form  or  be  reduced  to  a  mere  slit.  The 
cavity  of  the  left  auricle  becomes  enlarged  and  its  walls  thickened,  but  the 
left  ventricle  remains  unaiFected.  The  right  auricle  and  ventricle  become 
necessarily  dilated  from  the  engorgement  which  exists. 

The  evidences  of  the  existence  of  mitral  stenosis  are  found  (1)  in  the 
antecedent  history  of  rheumatic  attacks  ;  (2)  in  the  existence  of  an  increased 
area  of  dulness  on  the  right  side  of  the  heart,  due  to  the  dilatation  and  en- 
gorgement of  the  right  cavities  of  the  heart ;  (3)  a  thrill  felt  over  the  apex 
of  the  heart,  which  suddenly  ceases  when  the  beat  or  pulse  occurs ;  (4)  a 
murmur,  varying  in  its  character,  which  also  suddenly  ceases  when  the  apex 
impinges  upon  the  chest ;  (5)  the  first  sound  is  short  and  sharp. 

The  DIAGNOSIS  must  depend  upon  an  accurate  observation  of  the  above 
symptoms  and  others  more  obscure.  This  systolic  murmur  may  finally  be 
associated  with  a  presystolic  murmur,  and  the  latter  may  even,  in  some  cases, 
supersede  the  former.  Embolism  of  a  cerebral  artery  may  occur,  indicating 
the  escape  of  particles  from  the  vegetations  on  the  valve.  Epilepsy  and 
chorea  have  developed  in  many  cases. 

The  TREATMENT  must  be  conducted  on  the  same  principles  as  have  been 
given  for  mitral  insufficiency. 


CHAPTEK    VII. 

DISEASES  OF  THE  VESSELS. 

The  arteries  are  rarely  aff'ected  by  degeneration  in  childhood.  The 
aneurysms  which  occur  under  the  age  of  twenty,  if  not  of  traumatic  origin, 
are  due  rather  to  embolism  resulting  from  pre-existing  endocarditis.  In  15 
cases  collected  by  Parker  there  were  but  2  eases  in  which  the  arteries  were 
diseased,  and  in  but  2  cases  was  the  heart  free  from  disease.  One  boy,  aged 
twelve,  had  a  femoral  aneurysm,  with  old  hip  disease  on  the  opposite  side. 

Keen  ^  added  to  Parker's  collection  11  cases.  In  3  cases  aneurysm  of  the 
arch  of  the  aorta  was  found,  and  in  1  of  these  the  child  was  still-born. 
Madrazo  ^  has  reported  a  case  of  popliteal  aneurysm  in  a  boy  aged  fifteen 
years,  which  ruptured  into  the  knee-joint. 

Aneurysm  of  the  cerebral  arteries  is  more  common  in  children  than  of  the 
arteries  in  any  other  part.  It  is  almost  universally  associated  with  vegeta- 
tion on  the  valves  of  the  heart,  and  hence  is  embolic  in  its  origin. 

Traumatic  aneurysm  is  not  infrequent  in  boys,  and  is  caused  most  fre- 
quently by  stab-wounds. 

1  Medical  News,  1887.  '  E  Echo  med.,  Toulouse,  1888. 


924  LOCAL  DISEASES. 

The  TREATMENT  of  aneurysm  of  tlie  arteries  of  the  extremities  in  the 
child  does  not  differ  essentially  from  the  treatment  of  the  same  individual 
disease  in  the  adult.  In  general  it  may  be  assumed  that  in  the  child  asepsis 
is  of  the  first  importance ;  the  ligature  of  the  affected  artery  will  be  prefer- 
able to  other  methods  of  treatment ;  in  the  selection  of  the  ligature  catgut 
or  silkworm  gut  is  better  than  silk ;  the  ligature  need  not  be  applied  so 
tightly  as  to  rupture  the  internal  coat ;  the  ligature  should  be  buried  by 
firmly  closing  the  wound. 

Naevus. 

X^evi  are,  for  the  most  part,  congenital  formations.  They  may  be  simple 
maculce,  an  excess  of  pigment ;  moles ;  an  enlargement  of  the  tissues  of  the 
skin,  port-wine  stains;  fire-marks,  collections  of  dilated  capillaries;  vascular 
tumors,  consisting  of  masses  of  large  vessels  or  cavernous  sinuses  filled  with 
blood. 

The  maculae,  moles,  and  similar  mother's  marks  are  unimportant,  as  they 
are  only  blemishes  or  disfigurements.  They  may  be  removed  by  excision  or 
by  escharotics,  as  nitric  acid,  Vienna  paste,  or  chloride  of  zinc. 

The  naevi  are  properly  classified  as  angiomata,  hsemangiomata,  or  tumors, 
chiefly  made  up  of  blood-vessels,  some  of  which  are  new-formed  and  others 
are  pre-existing  vessels,  more  or  less  altered  by  dilatation  or  thickening  of 
their  walls.     Ziegler  gives  the  following  subdivisions : 

1.  Simple  angioma  (telangiectasis  or  simple  erectile  tumor),  a  structure 
made  up  of  some  normal  basis-tissue,  containing  an  abnormal  number  of  dis- 
tended and  altered  veins  and  capillaries.  They  chiefly  occur  in  the  skin  at 
places  where  foetal  clefts  have  been  closed.  The  color  is  bright  red  (straw- 
berry mark)  or  livid  (port-wine  mark).  They  consist  essentially  of  localized 
dilatations  of  new-formed  or  pre-existing  capillaries.  The  dilatations  are  fusi- 
form, cylindrical,  sacculated,  or  spherical,  combined  in  all  possible  ways. 
There  are  several  forms.  In  one  there  are  wide  cavities  connected  together 
by  normal  or  but  slightly  dilated  capillaries,  the  walls  of  which  are  not  per- 
ceptibly thicker  than  the  normal.  In  another  form  the  mass  consists  of 
dilated  capillaries  whose  walls  are  considerably  thickened  and  the  basis- 
tissue  is  thrust  out  of  sight.  In  still  another  form,  the  venous  or  varicose 
tumor,  the  small  veins  instead  of  the  capillaries  are  chiefly  thickened  and 
dilated. 

2.  Cavernous  angioma  is  distinguished  from  the  simple  angioma  in  this, 
that  the  tubular  form  of  the  vessels  is  more  or  less  lost,  and  the  tumor  is 
made  up  of  variously-shaped  cavities  separated  by  fibrous  septa.  These 
tumors  are  commonly  seated  in  the  skin  and  may  be  congenital,  or  may  be 
developed  from  simple  angiomata  by  continued  dilatation  of  the  already 
dilated  vessels. 

Though  ngevi  may  appear  in  nearly  every  region  of  the  body,  they  are  more 
frequently  met  with  on  the  scalp,  face,  lips,  eyelids,  and  cheeks.  They  may 
appear  on  the  labia  and  about  the  anus. 

The  DIAGNOSIS  of  naevi  is  easily  made.  The  color  indicates  the  class  of 
vessels  principally  involved.  If  the  color  is  bright  red,  the  small  arteries  and 
capillaries  are  chiefly  involved ;  if  it  is  dark  or  purplish  in  color,  the  veins 
compose  the  greater  part.  The  simple  angiomata  are  scarcely  elevated  above 
the  skin,  while  the  cavernous  variety  may  form  a  considerable  tumor. 

The  PROGNOSIS  depends  upon  the  variety  of  angioma  present.  The 
simple  forms  often  remain  stationary  for  a  time  and  then  fade  away.  Some 
disappear  after  an  injury  of  the  part,  and  still  others  fade  after  an  exanthem- 
atous  disease  or  even  after  whooping  cough.     Others  enlarge  for  a  time  and 


DISEASES  OF  THE   VESSELS. 


925 


then  disappear,  while  some  have  an  intermittent  growth.  But  a  certain 
number  take  on  active  growth  from  the  first.  The  method  of  cure,  when  it 
is  spontaneous,  may  be  by  a  process  of  shrinking  of  the  vessels  until  they 
are  merely  fibrous  cords ;  or  thrombosis  may  occur  ;  or  the  degeneration 
may  be  calcareous.  Cysts  may  form,  owing  to  the  closure  of  the  spaces, 
especially  during  the  progress  of  degenerative  processes.  The  cavernous 
angioma  may  remain  long  as  a  mere  disfigurement,  but  there  is  a  constant 
liability  that  it  will  take  on  active  enlargement. 

The  TREATMENT  must  be  governed  by  the  nature  of  the  angioma.  The 
simple  variety  requires  no  treatment  when  it  is  so  situated  that  it  does  not 
disfigure  and  remains  inactive.  If  it  is  on  exposed  parts,  as  the  face,  an 
attempt  to  obliterate  it  may  be  made. 

Ncevi  are  sometimes  as  large  as  a  pin's  head,  and  again  as  a  hempseed ; 
some  are  moderately  thick,  others  scarcely  rise  above  the  level  of  the  skin  ; 
as  a  rule,  this  proliferation  of  vessels  does  not  extend  beyond  the  sub- 
cutaneous cellular  tissue ;  they  frequently  not  only  cease  to  enlarge,  but 
undergo  a  gradual  contraction  and  obliteration  ;  hence  the  propriety  of  treat- 
ing them  at  first  with  mild  remedies,  as  pressure,  applications  of  collodion, 
vaccination.  If  more  radical  measures  become  necessary,  inject  persulphate 
of  iron,  using  precautions  by  pressure  around  the  growth  to  prevent  the 
entrance  of  coagula  into  the  circulation,  or  pass  red-hot  needles  under  it  at 
several  points  and  secure  a  slough.  Strangulation  of  the  mass  by  subcuta- 
neous ligature,  when  the  growth  is  accessible,  is  adapted  to  the  larger  n^evi, 
and  may  be  applied  in  many  ways,  as  follows  :  (1)  The  single  ligature,  strong 
whip-cord  (Fig.  217),  is  carried  around  the  tumor  by  entering  it  at  one  point 
and  carrying  it  as  far  as  possible  round  the  base,  then  emerging  and  re-enter- 
ing at  the  same  puncture,  and  is  carried  around  another  portion  until  it 
reaches  the  point  of  first  entrance,  where  the  two  ends  are  firmly  tied  ;  (2)  or, 
if  the  growth  is  too  large,  the  ligature  may  be  carried,  double,  under  the 


Fig.  247. 


Fig.  248. 


...HgZ^ 


Subcutaneous  ligature  of  naevus  (Holmes). 


Ligature  of  a  mixed  nayus  :  a  pin  is 
passed  througli  the  gro-\vth,  and  a 
needle  at  right  angles  to  the  pin  is 
armed  with  a  double  ligature. 


tumor,  and  then  each  section  may  be  carried  round  the  half  and  tied  under 
a  pin  (Fig.  248).  For  a  large  naevus  the  following  knot  may  be  made :  Pass 
the  needle  under  the  centre  of  the  tumor  (Fig.  249)  ;  divide  one  thread  near 
the  needle ;  pass  the  other  end  of  the  ligature  into  the  needle's  eye ;  now 


926 


LOCAL  DISEASES. 


enter  the  needle  at  a  quarter  of  the  circumference,  and  pass  it  under  the 
base  at  right  angles  to  its  former  direction  ;  before  tying  the  ends  make  a 
lunated  incision  between  each  puncture  into  which  the  ligature  sinks ;  finally, 
tie  the  opposed  ends  (Fig.  250). 

If  the  tumor  is  elongated  in  form,  the  ligature  may  be  applied  as  follows 


Fig.  249. 


Fig.  250. 


Fig.  251. 


Ligature  of  iiEevus  :  the  other  end  of 
the  divided  thread  passed  into  tlie 
needle's  eye,  and  the  needle  passed 
through  a"t  right  angles  to  its  for- 
mer direction. 


Incisions  for  ligature. 


An  elongated  nsevus. 


(Fig.  251)  :  Pass  a  double  ligature  under  its  base  from  side  to  side  ;  color  the 
end  of  one  ligature  white  and  the  other  black ;  leave  each  loop  long,  the 
whole  ligature  being  of  great  length ;  divide  the  white  loops  on  one  side  and 
the  black  on  the  other,  and  tie  the  pairs  of  white  and  black  strings  tightly ; 
the  skin  is  destroyed  by  this  method. 

The  elastic  ligature  has  been  successfully  used  thus :  Select  straight  needles 
without  cutting  edges,  threaded  with  common  band  elastic  of  pure  gum  rubber, 
and  pass  subcutaneously  beneath  one  side  of  the  growth  in 
succession,  each  successive  needle  with  its  ligature  entering 
at  the  point  of  exit  of  the  last  one. 


Fig.  252. 


The  cavernous  tumor  must  be  destroyed  by  (1)  ex- 
cision, when  the  growth  is  large,  the  line  of  incision  being 
quite  external  to  the  capsule;  (2)  injection  of  persulphate 
of  iron,  in  small  quantities,  when  the  tumor  is  small  and 
not  amenable  to  other  remedies,  as  on  the  face,  great  care 
being  taken  to  compress  the  vessels  around  the  tumor  to 
prevent  the  escape  of  the  fluid  into  the  general  circulation. 
Naevi  of  the  lips  (Fig.  252)  require  different  treatment 
according  to  the  amount  of  substance  involved.  When 
pendulous  from  the  margin  the  double  or  quadruple  liga- 
ture may  be  used. 

Electrolysis   is    a   most    effective    method    of  treating 
naevi.     The  needle  should  be  very  slender  and  the  battery 
twenty  cells.     First  apply  the  needle  to  any  vessels ;  then  introduce 
several  points ;  repeat  the  operation  in  one  week. 


Large  nsevus 
per  lip,  side 


It  at 


SECTION   VI. 
DISEASES  OF  THE  GENITO-URINARY  ORGANS. 


Infarctions  of  uric  acid  or  the  urates  are  very  common  in  new-born 
infants.  They  are  seen,  if  an  opportunity  of  examining  the  kidneys  occurs, 
as  yellowish-red  lines  in  the  tubules  or  lying  in  the  pelvis  of  the  kidney, 
forming  small  yellowish  granules.  As  they  are  washed  away  by  the  urine, 
we  often  find  them  upon  the  diaper.  The  irritation  produced  by  these  infarc- 
tions sometimes  causes  painful  micturition.  Children  a  few  months  old  often 
fret  or  cry  from  pain  during  urination  in  consequence  of  the  irritating  action 
of  the  uric  acid,  while  in  the  intervals  between  the  passing  of  water  they 
may  or  may  not  be  free  from  suffering.  Perhaps  they  pass  only  a  few  drops 
of  urine  with  straining,  and  in  it  we  find  crystals  of  uric  acid  or  the  urates. 
Urine  highly  acid  from  the  presence  of  this  substance  causes  a  burning  pain 
in  the  urethra,  and  sometimes  redness  not  only  of  the  urethra,  but  even  of 
the  labia  over  which  the  urine  flows.  Although  infants  perhaps  suffer  most 
from  this  cause,  the  same  condition  not  infrequently  occurs  in  older  children. 
Their  urine,  previously  normal,  becomes  unduly  acid  from  some  error  in  feed- 
ing or  in  the  digestive  process,  and  uric-acid  crystals  or  concretions  form. 
An  exaggerated  secretion  of  mucus  occurs  from  the  surface  of  the  bladder 
or  from  the  urinary  canal  in  consequence  of  the  irritation  produced  by  the 
acid,  and  sometimes  pus-cells  are  also  seen  under  the  microscope  mixed  with 
the  mucus. 

The  state  of  the  urine  described  above  should  be  at  once  rectified,  for  it 
furnishes  the  conditions  in  which  calculi  form  either  in  the  pelvis  of  the  kid- 
ney or  in  the  bladder.  Urine  unduly  acid  and  irritating  probably  at  first 
causes  catarrh  of  the  delicate  membrane  lining  the  tubules  and  pelvis  of  the 
kidneys,  and  if  the  irritation  be  sufiiciently  severe  the  catarrh  extends  along 
the  ureters  to  the  bladder,  causing  a  degree  of  cystitis.  Now,  a  catarrh  of 
the  pelvis  of  the  kidney  or  the  bladder  greatly  increases  the  tendency  to  the 
formation  of  calculi,  since  the  crystals  become  imbedded  in  the  mucus,  which 
serves  to  agglutinate  them.  Uric  acid,  when  so  abundant  in  the  urine  as  to 
cause  symptoms,  should  be  at  once  treated  and  the  acid  neutralized  by  an 
alkali.  The  liquor  potassae,  employed  as  recommended  in  our  remarks  on 
the  treatment  of  Enuresis,  is  the  best  alkali  for  this  purpose.  For  an  infant 
of  one  year,  two  drops  sufficiently  diluted  in  mucilage  will  be  sufiicient, 
repeated  in  three  or  four  hours. 

The  various  forms  of  nephritis  have  been  considered  in  connection  with  the 
diseases  with  which  they  occur,  as  scarlet  fever  and  diphtheria. 

Enuresis,  or  incontinence  of  urine,  is  a  common  and  troublesome  infirmity 
in  children.  It  occurs  both  in  boys  and  girls,  but  is  more  common  in  the 
former  than  in  the  latter.  In  many  children  it  dates  back  to  infancy,  but 
others  have  a  respite  from  it  in  the  years  immediately  succeeding  infancy 
until  the  sixth  or  seventh  year,  when  it  returns.  It  may  be  diurnal  as  well 
as  nocturnal,  interfering  seriously  with  the  comfort  of  the  child  and  render- 
ing his  schooling  inconvenient ;  but  the  annoyance  which  it  causes  is  com- 

927 


928  LOCAL  DISEASES. 

monly  most  at  night,  and  it  is  for  nocturnal  enuresis  that  the  physician  is 
most  frequently  consulted.  The  child  may  pass  his  urine  in  bed  every  night, 
or  even  more  than  once  each  night,  or  there  may  be  occasional  nights  of 
immunity. 

The  bladder  consists  of  three  concentric  coats:  1.  On  the  outside,  the 
peritoneal,  which  covers  the  posterior,  the  superior  part  of  the  lateral,  and 
the  anterior  aspects  of  the  organ ;  2.  The  muscular,  which  chiefly  coucei'ns 
us  at  present,  and  which  consists  of  two  layers — the  one  external,  the  fibres 
of  which  have  a  general  longitudinal  direction ;  the  other  internal,  whose 
fibres  are  circular.  The  circular  fibres  become  more  abundant,  producing 
greater  thickness  of  this  layer,  at  the  urethral  orifice,  and  they  extend  a  dis- 
tance over  the  urethra.  This  increase  in  the  number  of  circular  muscular 
fibres  at  the  urethral  orifice  constitutes  the  sphincter  vesicae.  The  fibres  in 
the  muscular  coat  of  the  bladder  are  unstriped,  and  are  not  under  the  control 
of  the  will. 

A  second  sphincter,  which  aids  materially  in  the  retention  of  urine,  is 
formed  by  the  compressor  urethrae.  This  muscle,  arising  by  aponeiirotic 
fibres  from  the  ramus  of  the  pubes,  surrounds  the  whole  membranous  por- 
tion of  the  urethra,  extending  from  the  prostate  to  the  bulbous  portion.  The 
compressor  urethras  is  a  striped  muscle,  and  its  action  is  therefore  controlled 
by  the  will.  Certain  accessory  muscles  influence  the  retention  as  well  as  the 
expulsion  of  urine — to  wit,  the  levator  ani,  acceleratores  urinae,  and  the  abdom- 
inal muscles. 

Nerves. — The  muscular  coat  of  the  bladder  receives  its  nerves  from  the 
hypogastric  plexus,  which  belongs  to  the  sympathetic  system,  although  fila- 
ments enter  the  plexus  from  the  spinal  system.  The  innervation  of  the  blad- 
der is  therefore  twofold,  that  derived  from  the  sympathetic  system  predom- 
inating over  that  from  the  spinal  system,  as  shown  by  the  relative  number  of 
filaments  from  the  two  sources.  According  to  Belfield,  the  spinal  centre  of 
the  motor  nerves  of  the  bladder  is  in  the  vicinity  of  the  third  lumbar  verte- 
bra ;  but  Budge,  in  his  experiments  on  rabbits,  locates  it  in  this  animal  in 
the  vicinity  of  the  fourth  lumbar  vertebra.  The  spinal  centre  of  the  nervous 
supply  of  the  bladder,  says  Coulton,  "  is  connected  with  the  brain  by  a 
strand  of  fibres  which  may  be  traced  from  the  cerebral  peduncle  along  the 
anterior  columns  of  the  spinal  cord."  The  neck  of  the  bladder,  including 
the  sphincter  vesicse,  derives  nervous  fibres  directly  from  the  anterior  or 
motor  roots  of  the  third,  fourth,  and  fifth  sacral  nerves,  and  it  is  more 
abundantly  supplied  with  nervous  filaments  than  is  the  muscular  coat  of  the 
organ.  That  the  sphincter  vesicae  is  under  the  control  of  the  will  is  there- 
fore apparent  from  the  anatomical  characters,  since  a  strand  of  fibres  con- 
nects the  peduncles  with  the  motor  centre  of  the  bladder  in  the  spine,  and 
this  centre  connects  with  the  sphincter  through  the  spinal  nerves.  In  nor- 
mal ui'ination  the  sphincter  is  relaxed  by  the  volition  of  the  individual,  while 
the  muscular  coat  of  the  organ,  being  under  the  control  of  the  sympathetic 
system  and  involuntary  in  its  action,  expels  the  urine  as  soon  as  the  sphinc- 
ter is  open. 

The  pudic  nerve  also  sustains  an  important  relation  to  the  function  of  the 
bladder.  Arising  from  the  sacral  plexus,  it  is  distributed  "  to  the  base  of  the 
bladder,  the  prostate,  the  integument  of  the  penis,  scrotum,  and  perineum, 
the  urethral  muscles  and  mucous  membrane,  and  the  sphincter  of  the  anus ; 
in  the  female,  the  uterus,  vagina,  and  vulva  are  supplied  by  branches  of  the 
same  nerve."  Knowledge  of  the  distribution  of  the  pudic  nerve  enables  us 
to  understand  the  manner  in  which  disease  or  abnormal  conditions  of  the 
genital  organs  and  anus  disturb  the  functions  of  the  bladder.  Irritation 
of  the   inferior  branches    of  this    nerve  aff'ects  the  action  of  the  superior 


DISEASES  OF  THE  OENITO-URINABY  ORGANS.  929 

branches,  or  those  which  supply  the  base  of  the  bladder  and  the  urethral 
muscles,  so  as  to  produce  in  certain  patients  dysuria  or  incontinence,  or 
both. 

Etiology. — In  all  cases  the  urine  should  be  examined,  since  the  cause 
of  the  enuresis  is  often  discovered  in  the  deviations  in  it  from  the  normal 
state  which  are  apparent  on  inspection.  The  chief  causes  may  be  grouped 
as  follows,  but  often  two  or  more  of  them  are  present  in  the  same  case : 

1.  Too  great  acidity  of  the  urine.  The  urine  in  its  normal  state  is  acid 
from  the  presence  of  the  acid  phosphate  of  sodium  (Robin),  but  in  certain 
conditions  the  acidity  becomes  so  great  that  the  urine  is  unduly  stimulating 
to  the  surface  of  the  bladder.  Now,  stimulating  or  irritating  urine  causes 
the  bladder  to  contract,  just  as  an  irritating  substance  in  the  intestines 
increases  the  peristaltic  and  vermicular  movements  of  this  tube.  Exces- 
sive acidity  of  the  urine  is  commonly  due  to  the  presence  of  uric  acid, 
resulting  from  decomposition  of  the  urates ;  but  in  certain  conditions  lactic 
and  hippuric  acids,  resulting  from  faulty  digestion,  appear  in  the  urine 
(Robin)  ;  urine  unduly  acid  renders  its  retention  difficult,  except  in  mod- 
erate quantity,  so  that  enuresis  results. 

2.  Increased  quantity  of  urine.  This  sometimes  occurs  from  the  free 
use  of  liquids,  as  of  water  or  milk.  Renal  disease,  attended  by  an  exag- 
gerated excretion  of  urine,  sometimes  produces  enuresis.  Henoch  ^  says : 
"  I  would  advise  you  never  to  omit  an  examination  of  the  urine,  because 
cases  of  diabetes  mellitus  and  chronic  nephritis  are  known  which  were  first 
manifested  by  nocturnal  incontinence." 

3.  A  vesical  calculus.  This  is  an  infrequent  cause,  but  when  present  it 
is  likely  to  produce  both  diurnal  and  nocturnal  enuresis.  If  micturition  be 
frequent  and  painful  by  day  and  by  night,  if  the  urine  contain  a  large 
amount  of  mucus  or  muco-pus  so  as  to  render  it  turbid,  and  if  the  dysuria 
and  frequent  urination  be  not  soon  relieved  by  treatment,  a  calculus  is  prob- 
ably present.  In  such  cases  the  bladder  should,  of  course,  be  sounded  by 
the  proper  instrument  to  render  diagnosis  certain. 

4.  The  muscular  coat  of  the  bladder  may  have  an  exaggerated  contractile 
power  in  itself,  and  not  imparted  to  it  by  any  extraneou^s  stimulating  agency. 
The  surrounding  conditions  may  be  normal,  while  the  bladder  is  hypersensi- 
tive, so  as  to  contract  with  undue  energy  by  ordinary  stimulation.  The  fault 
is  in  the  bladder  itself,  whose  functional  activity  is  in  excess ;  this  appears  to 
be  the  most  common  cause  of  enuresis  in  children.  It  is  the  condition  of  the 
bladder  which  Trousseau  had  in  mind  when  he  wrote :  "  I  repeat  that  the 
nocturnal  incontinence  of  urine  is  a  neurosis,  and  I  now  add  that  it  is  a  neur- 
osis manifesting  itself  by  excessive  irritability  of  the  bladder ;  in  fact,  the 
immediate  cause  of  incontinence  is  this  excess  of  irritability  in  the  muscular 
fibres  of  the  bladder."  As  Bretonneau  pointed  out,  children  with  enuresis 
from  this  cause  habitually  pass  urine  in  a  full  and  rapid  stream,  and  therefore 
in  less  time  than  other  children,  showing  that  the  contractile  power  of  the 
muscular  coat  is  in  excess.  From  the  fact  that  belladonna  relieves  so  many 
patients,  we  infer  that  irritability  of  the  muscular  coat  is  a  common  cause 
of  enuresis  in  children,  since  this  agent  acts  by  diminishing  muscular  con- 
tractility. 

5.  Weakness  of  the  muscular  fibres  which  constitute  the  sphincter  of  the 
bladder.  Diminished  tonicity  of  the  sphincter  muscles  does  not  occur,  or  it 
occurs  very  rarely,  in  those  who  have  had  previous  good  health  and  are  robust. 
Ordinarily,  children  affected  by  enuresis  from  this  cause  are  in  habitual  ill- 
health.  They  have  had  long  and  prostrating  sickness,  Which  has  diminished 
muscular  tonicity,  or  they  have  local  disease  in  the  spine  or  in  the  course  of 

^  Diseases  of  Children,  p.  257. 
59 


930  LOCAL  DISEASES. 

spinal  nerves,  which  lias  impaired  the  innervation  of  the  sphincter.  Some- 
times incontinence  of  feces  is  also  present,  and  examination  of  the  sphincter 
ani  by  introducing  the  finger  shows  that  its  contractile  power  is  insufficient. 
We  infer  the  presence  of  atony  of  the  sphincter  vesicae  from  the  atony  thus 
easily  discovered  of  the  sphincter  ani.  As  an  example  of  enuresis  from  atony 
of  the  sphincter  vesicas  we  may  mention  the  case  of  a  boy  of  thirteen  years 
who  had  "  a  flat,  doughy  tumor  "  at  the  lower  end  of  the  dorsal  vertebras,  in 
the  middle  of  which  a  deficiency  in  the  bony  arch  which  covers  the  spinal 
cord  was  detected  by  the  fingers,  showing  that  the  tumor  was  a  spina  bifida 
containing  a  considerable  amount  of  adipose  and  granulation  tissue.  The 
congenital  deficiency  in  the  spinal  column,  and  consequent  injury  of  the 
spinal  cord,  had  produced  incontinence  of  both  urine  and  feces. 

6.  We  have  already,  in  speaking  of  the  distribution  of  the  pudic  nerve, 
alluded  to  the  fact  that  enuresis  in  children  is  not  infrequently  produced 
thi'ough  reflex  action  by  disease  or  an  abnormal  condition  external  to  the 
bladder  in  parts  which  receive  their  nerves  from  the  same  source  as  the 
bladder.  Henoch  says :  "  Occasionally  congenital  phimosis,  stricture  of  the 
urethra,  irritation  of  asearides,  fissure  of  the  anus,  onanism,  or  vulvitis  can 
be  detected,  upon  the  removal  of  which  the  enuresis  ceases."  Trousseau 
relates  the  case  of  a  young  man  of  seventeen  years  who  from  childhood  had 
been  in  the  habit  of  wetting  the  bed  two  or  three  times  every  night.  After 
unsuccessful  trial  of  belladonna,  strychnia,  and  mastich,  it  occurred  to  Trous- 
seau that  the  infirmity  might  be  due  to  congenital  phimosis,  and  accordingly 
Professor  Jobert  circumcised  him.  With  the  exception  of  three  consecutive 
nights  he  was  entirely  relieved  of  enuresis  during  his  subsequent  stay  of 
nine  months  in  the  hospital.  In  dispensary  practice  in  New  York  City  we 
find  preputial  adhesions,  with  the  accumulation  of  smegma  between  the  glans 
and  foreskin  and  more  or  less  balanitis,  a  common  cause  of  disturbed  func- 
tion of  the  bladder.  The  dysuria  and  enuresis  cease  when  the  adhesions  are 
divided  by  the  probe,  the  smegma  removed,  and  the  preputial  inflammation 
or  irritation  has  abated. 

7.  A  psychical  cause,  to  which  Bartholow  alludes.  The  patient  dreams 
that  he  is  in  a  convenient  place  for  urination,  the  desire  of  which  is  impressed 
on  his  thoughts,  and  awakens  to  find  that  he  has  urinated  in  bed.  Since  the 
action  of  the  bladder  is  largely  under  the  control  of  the  will,  a  strong  will 
or  determination,  if  the  patient  be  not  too  sound  a  sleeper,  does  exercise  a 
controlling  action  over  the  bladder  even  during  sleep.  We  sometimes  observe 
this  efi'ect  of  will-power  in  the  fact  that  the  patient  breaks  the  habit  of 
enuresis  through  a  sense  of  shame  or  by  a  determination  to  avoid  the  dis- 
grace. Thus  one  writer  mentions  the  case  of  a  girl  in  whom  severe  flogging 
by  her  mother  put  a  stop  to  the  habit,  and  patients  sleeping  away  from  home, 
as  when  visiting  among  friends  or  at  a  boarding-school,  sometimes  break  the 
habit  through  an  efi"ort  of  the  will.  The  sense  of  profound  shame  which  the 
infirmity  produces  thus  enables  certain  patients  to  control  the  action  of  the 
bladder  even  in  sleep.  The  state  of  the  mind  should  therefore  be  considered 
as  an  element  both  in  the  causation  and  cure  of  the  infirmity. 

8.  Malformation  of  the  bladder  or  its  appendages.  These  are  of  various 
kinds.  Some  of  them  are  of  such  a  nature  that  cure  of  the  enuresis  is  diffi- 
cult or  impossible.  Thus,  Thomas  U.  Madden,  M.  D.,  F.  R.  S.  C.  E..  relates 
the  case  of  a  young  lady  who  had  been  treated  by  difi'erent  physicians  in 
various  localities  with  belladonna,  iron,  vesication  of  sacrum,  and  the  other 
usual  remedies,  without  the  least  benefit.  The  dribbling  of  urine  was  con- 
stant day  and  night,  so  that  she  was  debarred  from  school  and  ridiculed  and 
avoided  by  her  associates.  She  was  placed  under  chloroform,  and  her  blad- 
der was  found  to  have  the  power  to  retain  a  considerable  amount  of  urine. 


DISEASES  OF  THE  GENITO-UBINABY  ORGANS.  931 

Pursuing  the  examination,  Dr.  Madden  found  that  the  urine  dribbled  from  a 
small  orifice  about  half  an  inch  above  the  meatus  urinarius  and  covered  by 
rugas  of  the  mucous  membrane.  A  No.  1  catheter  was  introduced  its  entire 
length  through  the  opening,  so  that,  in  the  opinion  of  Dr.  Madden,  there  was 
malposition  and  elongation  of  the  right  ureter,  which,  instead  of  emptying 
into  the  bladder,  discharged  the  secretion  of  the  right  kidney  upon  the  vulva. 
In  malformations  like  the  above,  as  well  as  in  ectopia  vesicae,  recto-vesical  or 
vesico-vaginal  fistula,  the  result  of  abnormal  foetal  development,  the  urine 
obviously  dribbles  constantly  and  from  the  moment  of  birth.  In  perpetual 
lifelong  dribbling  a  malformation  or  congenital  defect  should  be  suspected, 
and  is  probably  the  cause. 

Prognosis. — The  prognosis  depends  on  the  cause  or  causes  of  the  enure- 
sis. Most  of  the  causes  are  of  such  a  nature  that  they  can  be  removed,  and 
the  majority  of  patients  can  therefore  be  cured  by  appropriate  remedies. 
Enuresis  due  to  irritating  properties  in  the  urine,  to  irritation  or  inflamma- 
tion in  the  genital  organs  or  rectum,  and  that  due  to  exaggerated  tonicity 
of  the  muscular  coat  of  the  bladder,  can  be  for  the  most  part  readily  cured 
by  appropriate  measures,  while  that  resulting  from  structural  disease  of  the 
spinal  cord  or  from  malformations  in  the  urinary  tract  is  least  amenable  to 
treatment. 

It  is  the  common  belief  that  those  epochs  in  life  which  produce  a  decided 
change  in  the  individual,  as  puberty  or  marriage,  are  likely  to  effect  a  cure 
in  cases  previously  obstinate.  This  opinion  is  to  a  certain  extent  founded  on 
fact.  The  development  of  the  sexual  organs  at  puberty  seems  to  render  the 
bladder  less  irritable  and  more  retentive  in  some  patients.  Cases  are  also 
related,  as  one  by  Trousseau,  in  which  incontinence  ceased  with  marriage  and 
pregnancy.  But  treatment  in  the  ordinary  form  of  enuresis  should  not  be 
deferred  in  the  hope  that  time  and  physical  changes  will  effect  a  cure,  for 
this  belief  is  likely  to  be  illusory. 

Treatment. — The  physician  asked  to  prescribe  for  a  case  of  enuresis 
should  carefully  examine  the  patient  in  order  to  ascertain  the  cause.  Since 
the  most  common  cause  is  irritability  of  the  bladder,  whether  inherent  in  the 
bladder  itself  or  imparted  to  it  by  the  stimulating  properties  of  the  urine, 
the  urine  should  be  rendered  as  bland  and  unirritating  as  possible.  This 
is  best  accomplished  by  rendering  it  neutral.  Excessive  acidity  of  the  urine, 
so  common  a  cause  of  enuresis,  is  promptly  removed  by  the  liquor  potassae 
administered  in  doses  of  a  few  drops  largely  diluted.  I  have  found  it  a  safe 
and  efficient  remedy  in  the  treatment  of  this  infirmity  when  the  bladder  is 
unduly  irritable.  If,  therefore,  in  the  examination  of  a  case  we  discover  no 
cause  of  the  incontinence  except  an  exaggerated  contractile  power  of  the 
bladder,  and  the  urine  is  acid,  from  three  to  five  drops  of  the  liquor  potassae 
should  be  given  three  or  four  times  daily  in  a  wineglassful  of  gum-water 
until  litmus-paper  shows  that  the  urine  is  neutral,  and  its  neutral  state 
should  be  maintained. 

In  belladonna  we  possess  an  agent  which  diminishes  the  functional  activ- 
ity of  the  bladder  when  the  latter  is  in  excess.  It  diminishes  the  contrac- 
tile power  of  the  muscular  fibres,  and  its  use  is  therefore  indicated  in  the 
class  of  cases  which  we  are  now  considering.  In  this  country  the  tincture 
of  belladonna  is  more  commonly  employed  than  the  extract,  which  is  used 
in  Europe,  especially  in  continental  Europe,  and  if  obtained  from  a  good 
laboratory  its  action  is  as  certain  as  that  of  the  extract,  while  its  dose  can 
be  better  regulated.  Five  drops  of  the  tincture  may  be  given  every  evening, 
or,  if  the  enure'sis  be  diurnal  as  well  as  nocturnal,  every  morning  and  even- 
ing, to  a  child  of  five  years,  and  the  dose  be  increased  by  one  drop  every 
second  day  if  improvement  do  not  occur  and  physiological  effects  are  not 


932  LOCAL  DISEASES. 

produced,  until  the  dose  is  doubled  or  even  trebled.  If  the  enuresis  be 
relieved,  or  if,  without  its  relief,  physiological  effects  be  observed,  as  dry- 
ness of  the  fauces,  cutaneous  efflorescence,  or  dilatation  of  the  pupils,  the 
dose  should  not  be  increased.  When  belladonna  produces  the  desired  effect, 
it  is  no  doubt  best  to  continue  its  use  for  some  weeks  in  the  dose  which  is 
found  to  be  effectual,  and  then  to  diminish  the  number  of  drops  gradually. 

Trousseau,  who,  as  we  have  seen,  considered  enuresis  in  most  eases  a 
neurosis,  highly  extolled  the  treatment  by  belladonna,  believing  it  the  most 
effectual  of  all  methods  of  cure.  He  prescribed  the  extract  of  belladonna, 
gr.  1,  or  the  sulphate  of  atropia,  gr.  yi-^,  but  he  did  not  state  the  age  of  his 
patients.  The  dose  was  increased  if  necessary,  and  whatever  dose  he  found 
sufficient  to  give  relief  he  administered  once  daily  for  three,  four,  or  five 
months,  after  which  it  was  gradually  diminished,  but  it  was  not  discontinued 
until  after  the  lapse  of  two  to  ten  months.  By  this  treatment  Trousseau 
states  that  a  majority  of  his  cases  were  signally  benefited,  and  not  a  few 
were  entirely  relieved.  The  following  case,  which  recently  occurred  in  my 
practice,  indicates  the  mode  of  treatment  in  enuresis  when  it  results  from  the 

cause  which  we  are  now  considering :  L ,  aged  eleven  years,  male,  had 

diurnal  and  nocturnal  enuresis,  which  seriously  interfered  with  his  comfort 
and  rendered  him  an  object  of  aversion  and  ridicule  among  his  schoolmates. 
He  had  previously  taken  belladonna  and  other  remedies  without  improve- 
ment. His  urine  was  found  highly  acid.  Five  drops  of  liquor  potassae  were 
ordered  to  be  given  in  water  three  or  four  times  daily,  and  the  tincture  of 
belladonna,  to  which  he  was  accustomed,  was  administered  in  nine-drop  doses 
three  times  daily,  to  be  increased,  if  need  be,  to  fourteen  or  fifteen  drops. 
The  liquor  potassae,  in  the  dose  mentioned,  immediately  rendered  the  urine 
neutral,  and  the  enuresis  from  that  time  ceased.  The  treatment  recommended 
above,  of  rendering  the  urine  as  little  irritating  as  possible  by  neutralizing  it, 
aided  by  belladonna,  which  diminished  the  contractility  of  the  muscular  fibres, 
cured  the  infirmity,  which  had  been  most  troublesome  and  tedious. 

If  the  enuresis  be  due  to  an  abnormally  large  secretion  of  urine,  the 
liquid  ingesta  in  the  latter  part  of  the  day  should  be  restricted.  If  it  be 
found  that  the  increased  flow  is  due  to  diabetes  or  chronic  nephritis,  the  enu- 
resis, though  an  unpleasant  symptom,  is  comparatively  unimportant,  and  the 
grave  disease  which  causes  it  requires  chief  attention.  The  quantity  of 
urine  may  be  diminished  in  diabetes  mellitus  by  the  use  of  proper  food,  and 
in  diabetes  insipidus  by  ergot. 

Enuresis  due  to  a  vesical  calculus  is  associated  with  symptoms,  as  we 
have  stated  above,  which  indicate  the  presence  of  stone,  such  as  painful 
micturition,  which  may  awaken  the  patient  at  night,  and  thus  prevent  the 
accident  of  which  we  are  treating.  Urination  more  frequent  and  painful  in 
the  daytime  than  at  night,  occasional  interruption  in  the  stream  of  urine 
from  the  impediment,  pus,  perhaps  blood  and  an  increased  amount  of  mucus, 
in  the  urine,  indicate  the  presence  of  a  stone.  Fortunately,  the  calculus  is 
easily  detected  by  sounding,  and  by  the  present  improved  instruments  it  can 
be  crushed  and  removed,  or  it  can  be  removed  by  lithotomy,  which  in  the 
opinion  of  some  is  less  dangerous,  and  is  preferable  to  crushing  when  the 
patient  is  a  child. 

As  we  have  stated  above,  the  physician  should  always  examine  parts  con- 
tiguous to  the  bladder,  as  the  genital  organs  and  rectum,  in  order  to  ascer- 
tain if  there  be  any  source  of  irritation  in  them  which  may  produce  irrita- 
bility of  the  bladder  by  reflex  action.  In  some  instances,  as  we  have  seen, 
enuresis  rebellious  to  ordinary  treatment  ceases  when  the  irritation  in  parts 
contiguous  to  the  bladder  is  removed.  Phimosis,  preputial  adhesions,  the 
accumulation  of  smegma  between  the  foreskin  and  glans,  with  more  or  less 


DISEASES  OF  THE  GENITO-URINABY  ORGANS.  933 

balanitis  produced  by  the  foul  products,  and  vulvitis,  or  ascarides,  should,  if 
present,  receive  treatment,  and  with  the  removal  of  the  irritating  cause  the 
enuresis  will  probably  cease. 

Cases  in  which  preputial  irritation  produces  an  irritable  state  of  the  blad- 
der are  not  infrequent  among  the  poor  of  New  York,  whose  habits  are  fre- 
quently degraded  and  filthy,  and  the  treatment  consists  in  dividing  adhesions 
of  the  glans  to  the  foreskin,  cleaning  away  the  smegma,  and  using  a  sooth- 
ing ointment.  The  foreskin  can,  with  few  exceptions,  be  sufficiently  stretched 
for  this  purpose,  so  that  incision  (or  circumcision,  which  is  frequently  per- 
formed in  these  cases)  is  unnecessary. 

If  the  enuresis  be  due  to  atony  of  the  sphincter,  a  remedy  is  required 
which  acts  very  difi"erently  from  belladonna.  If  weakness  of  the  sphincter 
be  the  cause,  the  indication  is  obviously  to  increase  its  tonicity,  and  the  two 
medicines  which  have  been  most  successfully  employed  for  this  purpose  are 
nux  vomica  (or  its  active  principle  strychnia)  and  ergot.  We  have  stated 
that  the  sphincter  is  more  abundantly  supplied  with  nerves  than  is  the  mus- 
cular coat  of  the  bladder,  so  that  those  agents  which  restore  innervation,  and 
thereby  increase  muscular  tonicity,  act  upon  the  sphincter  more  powerfully 
than  upon  the  muscular  coat.  Ergot  appears  to  exert  a  similar  action, 
though  perhaps  less  in  degree,  upon  the  sphincters  of  the  bladder  and  anus, 
to  that  which  it  exerts  upon  the  uterine  muscular  fibres. 

We  can  obtain  a  clearer  idea  of  the  efi'ect  of  therapeutic  agents  upon 
paresis  of  the  sphincter  vesicae  by  observing  their  action  in  paresis  of  the 
sphincter  ani,  for  these  two  sphincters  suffer  a  loss  of  power  from  the  same 
causes,  and  recover  it  by  the  use  of  the  same  agents. 

In  a  very  instructive  paper  on  incontinence  of  feces,  published  by  Dr. 
George  B.  Fowler  in  the  American  Journal  of  Obstetrics  for  October,  1882, 
two  cases  are  detailed,  showing  unmistakably  the  beneficial  action  of  ergot  in 
increasing  the  tonicity  of  the  sphincter  ani ;  and  the  same  treatment  is  indi- 
cated for  urinary  incontinence  when  it  arises  from  a  similar  cause.  A  child 
of  seven  years,  in  the  practice  of  Dr.  Fowler,  had  been  closely  confined  to 
his  studies,  with  probably  some  deterioration  of  his  health,  when  fecal  incon- 
tinence commenced.  The  tonicity  of  the  sphincter  ani  on  examination  with 
the  finger  did  not  seem  much  impaired.  Nevertheless,  it  was  so  increased  by 
ten-drop  doses  of  the  fluid  extract  of  ergot  that  the  incontinence  was  relieved. 
The  second  patient,  an  anaemic  girl  of  thirteen  years,  had  been  under  treat- 
ment with  iron  and  other  tonics  without  benefit  to  the  fecal  incontinence. 
Her  flesh  was  flabby  and  surface  cool,  and,  which  is  interesting  to  remark  as 
throwing  light  on  the  condition  of  the  vesical  sphincter  when  it  lacks  toni- 
city, a  lack  of  resistance  in  the  anal  outlet  was  very  apparent  to  the  touch. 
A  mixture  containing  15  minims  of  the  fluid  extract  of  ergot  and  grain  yl^ 
of  strychnia  was  given  three  times  daily.  At  the  end  of  the  first  week  she 
had  only  two  recurrences  of  the  trouble,  and  in  three  weeks  was  cured. 
Four  months  afterward,  although  she  had  been  taking  quinine  and  iron  after 
the  discontinuance  of  the  ergot,  a  partial  relapse  occurred,  and  a  suppository 
of  five  grains  of  ergotin,  with  butter  of  cocoa,  was  employed  morning  and 
evening.  Immediate  relief  followed,  the  tonicity  of  the  sphincter  was 
restored,  and  the  suppositories  were  discontinued  after  two  weeks.  The 
beneficial  effects  of  ergotin  in  weakness  of  the  sphincters  is  shown  by  these 
cases.  Enuresis  from  weakness  of  the  sphincter  vesicae  could  not  have  been 
better  treated  than  by  the  same  remedies  which  relieved  the  fecal  inconti- 
nence in  these  two  patients. 

A  considerable  number  of  medicines  which  are  now  seldom  used  have 
been  employed  with  more  or  less  success  for  enuresis.  According  to 
Bouchut,  M.  Ribes  was  the  first  who  prescribed  nux  vomica.     The  patient 


934  LOCAL  DISEASES. 

was  a  soldier  who  had  both  urinary  and  fecal  incontinence,  and  was  cured  of 
the  weakness  of  the  bladder  in  five  days.  Nux  vomica  is  employed  instead 
of  strychnine,  as  its  use  involves  less  danger.  Mondiere  prescribed  this 
agent  in  combination  with  the  black  oxide  of  iron  in  the  following  formula : 

R.  Extractis  nucis  vomicse,  gr.  vj  ; 

Ferri  oxidi  magnetici,  3J. 

Ft.  pil.  No.  xxiv. 
Take  one  pill  three  times  daily. 

Although  we  accept  the  statement  of  Bouchut  that  strychnia  is  an 
"  extremely  dangerous "  remedy  for  enuresis  if  the  patient  be  under  the 
age  of  four  or  five  years,  yet  over  that  age  it  can  be  safely  prescribed  as 
an  adjuvant  to  the  ergot  in  proper  dose  and  with  proper  precautions.  A 
small  dose,  repeated  after  three  hours,  is  obviously  safer  than  a  larger  dose 
at  longer  intervals. 

Among  the  remedies  not  yet  mentioned  which  have  been  successfully 
employed  in  certain  cases,  the  tincture  of  cantharides  requires  notice.  In 
large  doses  this  drug  causes  strangury,  but  in  small  doses  it  produces 
such  irritation  or  stimulation  of  the  surface  of  the  urethra  as  to  increase 
the  contraction  of  the  sphincter  and  awaken  the  patient  when  the  urine 
presses  upon  the  urethral  orifice,  which  is  rendered  sensitive  by  this  agent. 
Cantharides  is  an  unpleasant  remedy,  and  it  is  not  much  employed  of  late 
years ;  probably  the  benefit  from  its  use  is  not  usually  permanent.  A  child 
of  five  years  can  take  four  or  five  drops,  largely  diluted  with  water,  three 
times  daily,  and  the  dose  should  be  gradually  increased  until  there  is  some 
evidence  of  its  efi"ect  on  the  outlet  of  the  bladder. 

Cubebs,  recommended  by  M.  Dieters,  the  various  vegetable  tonics  and 
astringents,  iron,  creasote,  and  many  other  remedies,  have  fallen  into  dis- 
repute and  are  now  seldom  used.  Sometimes  certain  combinations  of  rem- 
edies give  prompt  and  entire  relief.  Eustace  Smith  says:  "I  have  lately 
cured  a  little  girl,  aged  four  years,  who  had  resisted  all  other  treatment,  with 
the  following  draught,  given  three  times  daily : 

"R.  Tinct,  bellad.,  5J  ; 

Potas.  bromidi,  gr.  x  ; 

Infus.  digitalis,  zij  ; 

Aquae,  ad  ^ss. — Misce. 
Ft.  haustus." 

The  tincture  of  belladonna  of  the  British  Pharmacopoeia  has  about  half 
the  strength  of  that  employed  in  the  United  States ;  but  even  with  this 
allowance  I  would  not  dare  to  prescribe  so  large  a  dose  of  this  agent, 
unless  smaller  doses  were  first  used  and  tolerance  of  the  remedy  demon- 
strated. Of  the  tincture  of  belladonna  of  the  U.  S.  Pharmacopoeia  ten  min- 
ims would  be  a  large  dose. 

Local  treatment  has  been  attended  by  a  degree  of  success.  The  neck  of 
the  bladder  and  the  urethra  have  been  cauterized  by  the  nitrate  of  silver 
applied  by  the  porte-caustique  of  Lallemand,  with  some  relief  of  the  enure- 
sis, at  least  so  long  as  the  soreness  remained.  Baths  and  douches  of  cold 
water  have  also  been  used  by  many  physicians,  some  of  whom,  as  Under- 
wood, Baudelocque,  Gruersant,  and  Dupuytren,  state  that  they  have  obtained 
good  results.  This  treatment  is  most  beneficial  in  those  cases  in  which  the 
sphincter  is  relaxed. 

Since  the  causes  of  enuresis  are  numerous,  and  in  many  instances  cannot 
be  fully  recognized  at  first,  the  following  prescription  has  been  found  useful 
in  the  Out-door  Department  at  Bellevue,  especially  in  the  beginning  before 


DISEASES  OF  THE  GENITO- URINARY  ORGANS.  935 

an  exact  diagnosis  of  the  cause  is  made.     The  prescription  is  for  a  child  of 
five  years : 

R.  Sodii  benzoat., 

Sodii  salicylat,  da.  gij  ; 

Tine,  belladonnse,  fjij  ; 

Aqnse  purse,  ^Siij- 

Give  one  teaspoonful  two  or  three  times  daily.  For  a  child  of  five  years. 

In  certain  patients  the  advice  of  Trousseau  may  he  followed,  that  the 
patient  in  the  daytime  resist  the  inclination  to  pass  urine  so  long  as  it  does 
not  greatly  increase  his  or  her  discomfort ;  by  this  means  greater  tolerance 
of  the  presence  of  urine  in  the  bladder  is  produced. 

Calculi;  Dysuria;  Cryptorchia. — We  have  seen,  in  our  remarks  on  Uric- 
acid  Infarctions,  how  calculi  may  form  in  the  pelvis  of  the  kidney,  first  as 
small  concretions,  and  how,  descending  to  the  bladder,  they  may  become 
nuclei  which  gradually  increase  by  accretions  to  their  surfaces,  or  they  may 
form  primarily  in  the  bladder.  A  vesical  calculus  is  not  very  infrequent, 
even  in  the  young  child.  Its  presence  is  manifested  by  dysuria  and  increase 
of  mucus,  and  the  occurrence  of  pus  and  sometimes  of  blood-cells  in  the 
urine.  Occasionally  the  flow  of  urine  is  obstructed  by  the  presence  of  the 
calculus,  and  the  consequent  tenesmus  causes  prolapsus  ani.  Prolapsus  ani 
and  dysuria  are  important  symptoms  of  stone  in  the  bladder.  Sometimes  the 
bladder  becomes  greatly  distended  with  urine,  and  there  may  be  trickling  of 
it,  with  oedema  and  soreness  of  the  prepuce  and  adjacent  parts.  Now  and 
then  a  calculus  lodges  in  the  urethra,  producing  more  or  less  retention  of 
urine,  with  oedema  of  the  prepuce  and  adjacent  parts.  The  treatment  for 
calculus  must  be  entirely  surgical,  and  will  be  considered  hereafter. 

Dysuria  occurs  from  various  causes.  It  not  only  results  from  calculus, 
but  also  from,  urine  concentrated  and  acid.  We  have  stated  above  that  urine 
containing  uric  acid  and  the  urates,  if  they  are  abundant,  is  highly  irritating, 
and  while  this  acid  and  its  salts  increase  the  frequency  of  micturition,  they 
are  likely  to  render  it  painful.  They  sometimes  cause  colicky  pain  from 
spasmodic  contraction  of  the  muscular  fibres  in  the  urinary  tract,  and  even 
transient  albuminuria  has  been  noticed.  Dysuria  from  this  cause  is  best 
treated  by  alkaline  and  mucilaginous  drinks. 

Dysuria  not  infrequently  arises  from  a  morbid  state  of  the  external  gen- 
itals, and  they  should  always  be  examined  when  micturition  is  painful  or 
obstructed  to  ascertain  their  condition.  In  the  first  two  or  three  years  of 
life  the  prepuce  is  usually  adherent  to  the  glans  through  epidermal  cells, 
which  appear  to  arise  from  the  rete  3Ialpighii,  and  instead  of  becoming  horny 
remain  soft  and  filled  with  protoplasm.  This  adhesion  is  so  common  that  it 
must  be  considered  normal,  especially  as  it  does  not  give  rise  to  symptoms. 
But  occasionally,  even  in  young  boys,  a  pathological  state  sometimes  occurs 
which  gives  rise  to  symptoms,  among  which  is  dysuria.  Phimosis  may  be 
present,  retarding  the  flow  of  urine,  some  of  which  is  retained  under  the 
foreskin,  where,  decomposing,  it  excites  balanitis,  causes  adhesions,  and  ren- 
ders urination  painful.  Stretching  the  foreskin  so  as  to  expose  the  glans, 
break  up  the  adhesions,  and  remove  the  balanitis,  or  circumcision,  which  has 
the  same  efi"ect,  gives  relief  to  the  local  disease  and  the  dysuria. 

In  young  girls  the  labia  minora  are  often  adherent,  apparently  through  a 
catarrhal  inflammation.  They  can,  for  the  most  part,  be  readily  separated  by 
traction,  when  minute  drops  of  blood  appear  upon  the  exposed  surfaces,  show- 
ing that  a  vascular  connection  has  already  occurred.  Henoch  ^  says  :  "  In  a 
few  cases  this  adhesion  appears  to  me  to  be  the  cause  of  dysuria,  which  dis- 

1  Diseases  of  Children,  1882. 


^36  LOCAL  DISEASES. 

appeared  after  the  separation  of  the  labia  from  one  another ;  in  others  exam- 
ination showed  inflammatory  redness  of  the  introitus  and  meatus,  with 
increased  secretion  of  mucus,  which  renders  the  excretion  of  urine  pain- 
ful." Separating  the  adherent  parts  and  covering  the  surface  with  aristol 
or  a  simple  ointment  to  prevent  readhesion  suffice  to  eifect  a  cure  of  the 
dysuria  when  it  depends  upon  this  cause. 

In  the  first  mouths  of  foetal  life  the  testes  lie  in  the  abdominal  cavity  in 
front  of  and  a  little  below  the  kidneys,  behind  the  peritoneum,  and  attached 
to  the  base  of  the  scrotum  by  a  long  cord,  the  gubernaculum  testes.  Between 
the  fifth  and  sixth  months  the  testes  descend  to  the  iliac  fossa,  with  corre- 
sponding shortening  of  the  gubernaculum.  At  the  end  of  the  eighth  month 
they  have  descended  into  the  scrotum,  surrounded  by  a  pouch  of  the  perito- 
neum which  becomes  detached  from  the  peritoneum  "just  before  birth" 
(Gray),  forming  a  closed  sac,  the  tunica  vaginalis.  It  is  estimated  that  in 
one  case  in  five  the  descent  of  the  testicle  is  delayed  from  a  few  months  to  a 
year  after  birth.  Astley  Cooper  states  that  the  descent  does  not  occur  in 
some  cases  until  between  the  thirteenth  and  seventeenth  years.  When  there 
is  this  late  descent  intestine  is  apt  to  follow  the  testicle,  causing  inguinal 
hernia.  In  about  one  case  in  one  thousand,  it  is  estimated,  the  testicle 
does  not  descend,  but  remains  in  the  abdominal  cavity,  either  on  account  of 
adhesions  to  the  abdominal  viscera,  the  small  size  of  the  ring,  or  some  defect 
in  the  gubernaculum.  Occasionally,  a  retained  testicle  has  the  normal  struc- 
ture and  development,  but,  as  a  rule,  it  is  imperfect  and  small,  like  the  tes- 
ticle of  the  infant,  and  it  is  prone  to  fatty  or  fibrous  degeneration.  If  both 
testicles  are  retained,  impotence  may  result  on  account  of  the  non-develop- 
ment or  degeneration.  Xo  treatment  is  required  for  the  retained  testicle, 
unless  it  become  inflamed  when  lying  in  the  inguinal  canal,  when  it  should 
be  treated  by  poultices  and  other  soothing  remedies. 

Vulvitis. — Inflammation  of  the  vulva  is  common  in  girls  under  the  age  of 
five  years.  Like  most  other  inflammations,  it  varies  in  severity  in  diff"erent 
cases,  from  a  mild  and  transient  attack  to  one  attended  by  tumefaction  and 
excoriation  or  ulceration  of  the  labia,  pain,  and  abundant  discharge.  Ordi- 
narily, when  the  physician  is  consulted,  the  disease  has  continued  a  few  days, 
and  he  finds  the  vulva  moist  from  a  muco-purulent  discharge,  which  dries  into 
light-yellow  crusts  and  produces  greenish  or  yellowish  stains  on  the  under- 
clothes. The  vulva  and  lower  part  of  the  vagina  are  sensitive  and  red,  and 
the  acrid  secretions  sometimes  cause  redness  of  the  skin  over  which  they  flow. 
Frequently  the  labia  are  swollen  and  tender,  the  patient  may  complain  of 
soreness  from  friction  in  walking,  and  sometimes  dysuria  occurs  from  exten- 
sion of  the  inflammation  into  the  urethra.  In  severe  cases  ulcerations  or 
erosions  upon  the  labia  result,  increasing  the  distress  of  the  patient. 

Vulvitis  is  sometimes  aphthous.  Small  rounded  elevations  appear  upon 
the  vulva  and  ulcerate,  and  the  adjacent  surface  is  red  and  more  or  less 
swollen.  The  ulcers  are  sensitive  and  painful,  but  under  ordinary  circum- 
stances they  progressively  heal.  Rarely,  in  those  who  are  markedly  cachec- 
tic, the  ulcers  become  gangrenous  and  recovery  is  tedious  and  uncertain. 

Etiology. — The  most  common  cause  of  vulvitis  appears  to  be  uncleanli- 
ness,  and  hence  its  frequency  in  the  families  of  the  poor  and  degraded  in 
cities.  The  collection  of  dirt  and  sebaceous  matter  upon  the  vulva,  and  the 
irritation  to  which  it  gives  rise,  which  prompts  the  patient  to  rub  or  scratch 
the  parts,  cause  inflammation.  Struma  strongly  predisposes  to  this  inflamma- 
tion, so  that  slight  irritating  causes  develop  it  in  those  who  possess  this 
diathesis.  A  considerable  proportion  of  those  who  have  vulvitis  have  or 
have  had  other  manifestations  of  scrofula  and  present  the  strumous  aspect,  so 
that  it  seems  proper  to  consider  the  inflammation  of  the  vulva  occurring  under 


niSEASES  OF  THE  GENITO-UBINABY  ORGANS.  937 

sucli  circumstances  as  possessing  a  strumous  character  or  as  a  local  manifesta- 
tion of  tlie  strumous  diathesis.  We  therefore,  with  Dr.  West,  regard  struma 
as  an  important  predisposing  cause  of  vulvitis  in  the  child.  Ascarides  in  the 
rectum  have  long  been  recognized  as  a  cause,  producing  this  effect  by  the 
intense  itching  which  prompts  the  patient  to  rub  the  parts  and  thereby  inflame 
them.  It  is  said  that  ascarides  sometimes  crawl  to  the  vulva,  and  produce 
inflammation  by  their  presence  upon  the  sensitive  surface.  A  last  and  most 
important  cause  is  infection  by  gonorrhoeal  pus.  Every  physician  who  sees 
cases  in  the  dispensaries  or  tenement-houses  of  our  large  cities  meets  cases, 
even  girls  of  three  or  four  years,  in  whom  vulvitis  has  this  cause.  Sometimes 
the  gonorrhoea  is  communicated  criminally  ;  in  other  instances  it  is  contracted 
from  the  infected  seat  of  a  privy  or  from  soiled  towels  or  linen.  A  young 
man  whom  I  attended  was  under  treatment  for  gonorrhoea,  when  his  two 
nieces  of  about  four  and  six  years  were  infected  by  the  same  disease,  probably 
from  soiled  towels.  The  anatomical  characters  do  not  enable  us  to  discrimi- 
nate between  gonorrhoeal  and  non-specific  vulvitis,  but  the  differential  diagno- 
sis may  be  made  by  observing  the  gonorrhoeal  microbe  in  the  secretions  of  the 
one  and  its  absence  in  those  of  the  other.  In  both  forms  of  vulvitis  the 
muco-purulent  secretion  and  the  inflammatory  lesions  are  identical.  The 
danger  of  infecting  the  conjunctiva  and  producing  purulent  ophthalmia  from 
inoculation  with  the  secretion  of  vulvitis  is  well  known.  On  the  other  hand, 
it  is  believed  by  some  that  vulvitis  is  occasionally  caused  by  inoculating  the 
vulva  with  the  muco-pus  of  ophthalmia. 

Treatment. — The  parts  should  he  frequently  bathed  with  the  following 
lotion,  used  warm  to  ensure  cleanliness,  and  the  same,  also  warm,  should 
be  injected  three  or  four  times  a  day: 

R.  Acidi  borici,  3ij  » 

Sodii  borat.,  Kj  ; 

Glycerin  i,  ^  ; 

Aquse  pura,  Oj. — IMisce. 

Then,  after  delaying  a  few  minutes,  the  parts  should  be  dried  with  borated 
cotton,  and  the  following  powder  should  be  dusted  on  the  internal  surface  of 
the  labia : 

R.  Pulv.  zinci  stearat., 

Pulv.  acidi  borici,  da.  ,^ij  ; 

Pulv.  amyli,  ^. — Misce. 

If  the  vulvitis  have  a  gonorrhoeal  origin,  bichloride  of  mercury  (1  :  5000) 
or  carbolic  acid  (1  :  200)  should  be  used  once  or  twice  daily  as  a  wash. 

Preputial  Dilatation. — The  celebrated  French  psediatrist  Saint-Germain, 
surgeon  to  the  Hopital  des  Enfants,  Paris,  presented  a  paper  on  preputial 
dilatation  before  the  section  of  Diseases  of  Children  at  the  Ninth  Inter- 
national Medical  Congress,  held  in  Washington  in  1887.  From  this  paper 
the  following  is  extracted : 

"  Since  circumcision  is  sometimes  followed  by  accidents,  such  as  hemor- 
rhage difficult  to  control,  partial  gangrene,  diphtheria  of  the  wound,  I  have 
almost  entirely  given  it  up,  and  reserve  it  for  those  cases  in  which  dilatation 
is  impracticable  (these  cases  are  in  the  proportion  of  1  in  300). 

"  I  employ  dilatation.  This  operation,  devised  by  Nelaton  and  since 
adopted  by  the  majority  of  surgeons,  consists  of  the  introduction  into  the 
preputial  orifice  of  a  dilator  of  two  branches,  and  not  three,  as  employed  by 
Nelaton,  and  in  the  gradual  and  slow  dilatation  of  the  orifice.  This  opera- 
tion, which  is  completed  by  separating  the  adhesions  by  the  aid  of  a  grooved 
director  and  by  daily  movement  of  the  prepuce,  by  which  the  glans  is  alter- 


938  LOCAL  DISEASES. 

nately  uncovered  and  covered,  has  given  me  the  most  satisfactory  and  durable 
results." 

During  the  last  ten  years  preputial  dilatation  has  been  largely  practised 
in  certain  institutions  in  Nevs^  York  as  a  substitute  for  circumcision,  and 
almost  invariably  with  a  good  result.  The  closed  blades  of  the  thumb- 
forceps  of  the  surgeon's  pocket-case,  making  a  probe  which  can  be  forced 
through  even  a  pinhole  preputial  orifice,  are  introduced  half  an  inch  to  one 
inch  between  the  prepuce  and  glans,  and  allowed  to  expand.  The  separated 
blades  in  a  few  minutes  stretch  the  foreskin  sufficiently  to  allow  the  tip  of  the 
glans  to  be  seen  ;  the  glans  itself,  then  acting  as  a  wedge,  will  enable  the 
operator  to  bring  in  view  not  only  the  glans,  but  the  corona,  from  which, 
the  smegma  should  be  gently  removed  by  oiled  cotton,  and  the  adhesions 
resulting  from  the  balanitis  broken  up.  After  applying  oil  the  foreskin 
should  be  returned.  With  the  exception  of  the  use  of  the  forceps,  which 
will  be  unnecessary,  this  treatment  should  be  employed  daily.  I  have  not 
seen  a  child  under  the  age  of  six  months  in  which  preputial  dilatation  could 
not  be  readily  and  advantageously  performed,  but  in  older  children,  in  whom 
the  repeated  balanitis  has  caused  thickening  of  the  foreskin,  circumcision  is 
preferable,  and  it  will  always  be  performed  as  a  religious  rite  by  the  Jewish 
population. 

The  Kidney. 

Abscess  of  the  kidney  (pyonephrosis)  in  children  is  very  rare.  It  may 
follow  an  injury,  as  rupture,  or  may  result  from  interstitial  nephritis  or  em- 
bolism. The  kidney  is  markedly  enlarged  ;  its  capsule  and  the  adipose  tissue 
in  which  it  lies  are  congested  and  oedematous.  Beginning  as  a  superficial 
affection,  it  extends  to  the  renal  parenchyma  and  involves  all  the  connective 
tissue  of  the  kidney,  which  culminates  in  suppuration  at  various  points.  The 
diagnosis  of  traumatic  nephritis  rests  upon  the  history  of  the  injury,  and  the 
passage  at  first  of  blood  and  afterward  of  pus  in  the  urine,  to  which  are 
added  great  local  tenderness,  chills  with  fever,  dull  or  sharp  pains  through 
the  part  afi'ected.  and  finally  a  tumor  perceptible  on  examination.  Pus  must 
be  evacuated  by  incision  in  the  loin.  The  opening  should  be  free,  and  the 
walls  of  the  abscess  should  be  stitched  to  the  margins  of  the  wound  ;  a  drain- 
age-tube should  be  inserted.  Even  if  nephrectomy  is  performed  subse- 
quently, nephrotomy  renders  the  former  less  dangerous. 

Case. — A  boy,  aged  nine  years,  received  a  blow  over  the  right  kidney  from  a 
ball.  He  suffered  for  several  days  from  the  contusion,  and  his  urine  contained 
blood  in  small  quantities,  A  chill  occurred  on  the  tenth  day,  followed  by  fever  and 
pus  in  the  urine.  On  the  fifteenth  day  a  well-defined  swelling  in  the  anterior  part 
of  the  loin  was  detected.  A  hypodermic  syringe  with  a  long  needle  withdrew  pus. 
A  vertical  incision  was  made  in  the  loin,  and  a  large  quantity  of  pus  was  evacuated. 
An  exploration  showed  that  the  abscess  formed  in  the  kidney.  The  cavity  was  dis- 
infected and  drained,  and  the  patient  made  a  good  recovery. 

Perinephric  abscess  may  result  from  injury,  abscess  of  the  kidney,  or 
from  unknown  causes.  It  consists  in  the  formation  of  pus  in  the  connective 
tissue  around  the  kidney.  The  symptoms  are  pain  in  the  vicinity  of  the 
kidney,  rapid  pulse,  fever,  swelling  in  the  lumbar  and  iliac  regions,  which 
have  a  doughy  feeling.  As  the  disease  progresses,  the  tumor  enlarges,  fre- 
quently filling  up  the  iliac  fossa  and  protruding  under  Poupart's  ligament  or 
along  the  edge  of  the  ilium  ;  it  may  also  pass  upward  behind  the  perito- 
neum, and,  penetrating  the  diaphragm,  form  connections  with  the  lung,  and 
finally  discharge  through  it,  or  it  may  find  an  outlet  for  its  contents  into  the 
bowels,  rectum,  bladder,  or  vagina.     The  early  treatment  must  aim  to  subdue 


DISEASES  OF  THE  GENITO-UBISAEY  ORGANS.  939 

the  inflammation  by  absolute  rest ;  laxatives  or  enemata  ;  leeching,  opium  to 
relieve  pain,  with  quinine  and  nourishing  food ;  auscultation  of  the  lung 
should  be  frequently  practised,  especially  in  obscure  cases,  to  anticipate  any 
tendency  of  the  pus  to  find  its  way  out  in  that  direction.  Constant  attention 
must  be  given  to  the  formation  of  the  characteristic  enlargement  in  the 
lumbar  region  ;  when  this  appears  and  the  nature  of  the 
disease    becomes    manifest,    an    early    operation    is     de-  Fig.  253. 

manded  ;  for  a  premature  opening,  in  anticipation  of  the 
formation  of  matter,  is  better  than  that  any  delay  should 
occur  in  giving  exit  to  the  pus. 

The  point  of  operation  should  be,  as  a  rule,  in  the  renal 
region,  in  order  to  avoid  the  peritoneum,  and  where  fluctua- 
tion is  most  distinct,  unless  the  abscess  point  below,  as  along 
the  ilium  or  at  Poupart"s  ligament ;  if  the  swelling  is  de- 
fined, and  the  abscess  shows  no  sign  of  pointing,  select  the 
margin  of  the  quadratus  lumborum,  or  a  point  midway  be- 
tween the  last  rib  and  ilium,  on  a  line  vertical  to  the  centre  of  incision  for  perine- 
the  ilium  (1,  Fig.  253)  ;  introduce  an  aspirating  needle,  and  if  phritic  abscess. 

pus  is  found,  make  this  the  guide  to  a  sti-aight,  narrow- 
bladed  knife,  and  open  the  swelling  freely  ;  if  pus  is  not  found,  carefully  dis- 
sect by  transverse  incisions  through  the  skin,  fascia,  and  connective  tissue,  until 
the  abscess  is  reached,  when  it  should  be  freely  opened ;  if  no  pus  is  found,  the 
wound  should  be  kept  open  for  the  purpose  of  securing  its  early  escape.  The 
escape  of  pus  once  secured,  the  cavity  should  be  thoroughly  washed  out  with  dis- 
infecting fluids,  and  maintained  in  an  open  condition  until  the  cavity  closes  by 
granulation. 

Tuberculous  kidney  appears  in  its  early  stages  as  a  pyelitis,  with  few 
marked  symptoms,  but  as  it  advances  there  is  pain  in  the  loins,  tenderness  on 
pressure  in  the  lumbar  region,  increased  area  of  dulness,  and  often  a  tumor 
can  be  felt ;  the  urine  may  not  be  altered  or  may  be  excessive,  and  contain 
albumin,  blood,  and  debris  of  renal  tissue.  The  diagnosis  must  be  between 
scrofulous  and  calculous  disease,  and  the  constitutional  condition  of  the 
patient  must  determine  the  former  aifection.  The  chief  indications  of  scrof- 
ulous kidney  are  a  poor  and  weakly  physique,  with  existing  or  threatening 
lung  symptoms,  suppurative  pyelitis,  glandular  swellings  of  the  neck,  with 
an  irregular  and  occasionally  high  temperature,  and  with  vesical  irritation. 
The  treatment  should  at  first  be  palliative.  If  the  disease  progress,  nephrot- 
omy should  be  performed  with  a  view  to  evacuate  and  drain  one  or  more 
abscesses  in  the  kidney  if  the  disease  is  limited.  If  the  kidney  is  generally 
involved,  or  if,  after  nephrotomy,  the  disease  extend,  nephrectomy  may  be 
performed. 

Tumors  of  the  kidney  are  of  great  variety,  but  the  sarcomatous  form  is 
most  frequent  in  children.  The  following  features  are  important  in  diagnosis  : 
1.  The  large  intestine  is  usually  in  front  of  the  tumor,  to  the  inner  side  on 
the  right  and  to  the  outer  side  on  the  left.  2.  Tumors  do  not  project  or 
protrude  backward,  like  abscesses,  but  expand  in  front.  3.  They  have  the 
rounded  form  and  outline  of  the  kidney.  4.  They  move  slightly  or  not  at 
all  in  respiration.  5.  When  the  tumor  enlarges  so  as  to  press  the  abdominal 
wall,  the  most  anterior  point  at  which  it  comes  in  contact  is  commonly  about 
the  level  of  the  umbilicus  or  a  little  higher.  There  are  occasional  excep- 
tions to  these  rules,  but  rarely  to  the  rounded  outline  of  a  renal  tumor. 
Little  or  no  reliance  can  be  placed  on  the  absence  of  changes  in  the  urine, 
but  pyuria  and  haematuria  are  valuable  adjuncts  in  forming  a  diagnosis, 
when  present. 

Removal   of  the   kidney  is   the    proper  method    of   treatment,  and  has 


940  LOCAL  DISEASES. 

resulted  favorably.  Abbe'  reports  two  cases  in  children;  both  recovered 
and  remained  well  for  upward  of  a  year.  He  took  the  precaution  to  place 
his  patients  in  the  Trendelenberg  position,  with  the  body  inclined  at  an  angle 
of  30°,  and  retained  them  in  this  position  for  two  days.  He  prevented  shock 
by  warmth  and  enemata  of  hot  black  coffee. 

Nephrectomy,  excision  of  the  kidney,  may  be  performed  in  the  lumbar 
or  abdominal  region. 

(a)  Lumbar  nephrectomy  is  as  follows  : 

Make  a  transverse  or  slightly  oblique  incision  as  in  nephrotomy,  and  somewhat 
nearer  the  last  rib  than  in  lumbar  colotomy  ;  with  this  should  be  conjoined  a  second 
incision  running  longitudinally  downward  from  the  first,  and  starting  from  it  about 
one  inch  in  front  of  its  posterior  extremity.  The  first  incision  should  be  about  four 
and  a  half  inches  in  length,  and  not  nearer  the  twelfth  rib  than  half  an  inch,  for 
fear  of  wounding  the  pleura,  which  sometimes  descends  a  little  below  it.  The 
second  incision  may  be  left  until  the  kidney  has  been  reached  and  explored,  and 
can  then  be  made  by  cutting  from  within  outward  with  a  probe-ended  bistoury 
steadied  by  the  index  finger  of  the  left  hand.  The  kidney  being  reached,  separate 
it  from  its  surroundings ;  Avhen  no  perirenal  inflammation  has  existed,  the  colon, 
peritoneum,  and  fatty  tissue  will  easily  be  detached  from  their  connection  with  the 
kidney  by  the  index  finger  of  one  hand  Avorked  close  against  the  capsule  of  the  organ. 
A  double  ligature  of  plaited  silk  is  next  passed  through  the  pedicle  between  the 
ureter  and  the  vessels  by  means  of  an  aneurysm-needle  fixed  in  a  long  handle, 
whilst  the  kidney  is  dragged  well  up  into  the  wound  by  the  operator's  left  hand, 
one  of  the  fingers  of  which  can  at  the  same  time  be  acting  as  a  guide  for  the  needle  ; 
the  needle  passed  and  withdrawn,  divide  the  ligature  silk,  and  tie  one-half  tightly 
around  the  vessels,  and  the  other  half  around  the  ureter,  pressing  the  ligatures 
well  inward  toward  the  front  of  the  spine,  so  as  to  leave  plenty  of  room  between 
them  and  the  hilus  for  dividing  the  pedicle.  Now  draw  the  kidney  quite  out  of  the 
wound,  aiding  the  manoeuvre  by  dragging  the  lower  ribs  forcibly  upward  with 
the  fingers  of  the  left  hand  dipped  into  the  wound.  Another  ligature  should  be 
thrown  around  the  whole  of  the  pedicle,  and  securely  and  tightly  tied  before  cutting 
the  kidney  free,  which  is  now  safely  done  by  snipping  through  the  ureter  and 
vessels  with  a  pair  of  blunt-ended  scissors.  All  bleeding  vessels  should  be  securely 
tied,  and  all  of  the  ligatures  cut  off  short,  and  the  pedicle  dropped  into  the  wound. 
A  drainage-tube  should  be  inserted,  the  edges  brought  together  with  waxed-silk 
or  fishing-gut  sutures,  and  antiseptic  external  dressings  applied.  The  patient 
should  be  kept  in  the  recumbent  position  until  healing  is  complete,  and  the  drain- 
age should  be  kept  up  for  four  or  five  days. 

(b)  Abdominal  nephrectomy  is  preferred  in  cases  of  large  tumors. 

Operate  as  follows :  Make  an  incision  along  the  outer  border  of  the  rectus  ab- 
dominis muscle  on  the  side  of  the  kidney  to  be  removed  ;  the  middle  point  will  proba- 
bly correspond  with  the  umbilicus,  but  this  will  depend  upon  the  size  and  outline 
of  the  tumor.  All  bleeding  being  arrested,  open  the  peritoneal  cavity,  and  first 
ascertain  the  presence  and  condition  of  the  opposite  kidney.  Keep  the  intestines 
aside  from  the  kidney  to  be  removed  by  a  flat  aseptic  sponge  introduced  into  the 
abdomen.  Now,  open  the  outer  layer  of  the  mesocolon  sufficiently  to  allow  of  the 
introduction  of  two  or  three  fingers  behind  the  peritoneum  and  into  the  fat  in  front 
of  the  kidney,  and  the  fingers  should  then  gently  tease  their  way  toward  the  renal 
vessels,  around  which  ligatures  should  be  secured. 

The  Urinary  Bladder. 

In  infancy  the  bladder  is  pyriform  in  shape,  and  it  is  situated  higher 
than  in  the  adult,  being  rather  in  the  abdomen  than  in  the  pelvis.  The 
base  of  the  organ  does  not  sink  in  the  pelvis,  but  is  more  nearly  on  a  plane 
with  the  orifice  of  the  neck. 

Foreign  bodies  are  occasionally  introduced  into  the  bladder  through  the 
^Annals  of  Surgery,  vol.  xix. 


DISEASES  OF  THE  GENITO-UBINARY^ ORGANS.  941 

urethra,  and  may  be  of  every  variety  of  structure  and  consistency.  What- 
ever may  be  their  nature,  they  tend  to  form  nuclei  for  the  deposit  of  the 
urinary  salts,  and  either  by  themselves  or  by  the  concretions  formed  become 
sources  of  severe  irritation  of  the  bladder.  The  symptoms  are  those  of 
vesical  irritation  from  stone — namely,  pain,  obstruction  to  the  free  passage 
of  urine,  and  evidences  of  cystitis.  The  presence  of  a  foreign  body  may  be 
acknowledged  by  the  patient  or  discovered  by  exploration  of  the  bladder. 
The  foreign  body  must  be  removed,  and  in  such  manner  as  to  create  the  least 
possible  injury  to  parts.  The  most  serviceable  instrument  for  general  use, 
as  in  the  removal  of  a  portion  of  catheter,  pin,  bead,  slate-pencil,  small  stone, 
is  the  lithotrite  (Fig.  254).     It  may  be  laid  down  as  a  rule  that  rigid  and 

Fig.  254. 


^^^  -i  ^^  riEAI/lNN.  CO.N.  Y 

Lithotrite. 

elongated  foreign  bodies  tend  to  assume  a  transverse  position,  but  if  their 
dimensions  exceed  six  or  eight  centimetres,  they  cannot  rest  in  this  position, 
but  must  lie  obliquely. 

In  searching  for  a  body  in  an  empty  bladder  it  may  be  impossible  to  move  the 
.  instrument  save  in  a  lateral  direction,  and  if  this  cannot  be  done  the  operator  may 
be  sure  that  the  bladder  has  not  been  entered.  When,  however,  the  bladder  is  dis- 
tended, as  by  an  injection,  these  conditions  immediately  change  ;  the  foreign  body 
becomes  movable,  and  its  position  is  no  longer  regulated  by  physiological  but  by 
physical  laws  ;  distention  of  the  bladder  by  injection,  therefore,  so  far  from  favor- 
ing the  search  for  and  extraction  of  the  body,  really  hinders  these  manoeuvres. 

The  lithotrite  is  made  of  two  halves,  one  sliding  within  the  other,  and  is  like  an 
ordinary  catheter  when  closed  ;  it  is  introduced  into  the  bladder  by  the  urethra  ; 
then,  by  means  of  a  screw  or  rack  and  pinion  worked  on  the  outer  extremity,  the 
movable  part  is  made  to  slide  back  within  the  bladder,  now  forming  two  jaws,  by 
which  the  body  is  seized  ;  by  turning  the  screw  or  handle  the  blade  is  propelled 
onward,  and  the  substance  is  firmly  held  and  compressed,  if  possible,  so  as  to 
admit  of  being  removed  readily  by  the  urethra. 

It  is  desirable  to  seize  the  body  with  the  jaws  of  the  lithotrite  in  such 
manner  as  will  present  its  long  axis  to  the  long  axis  of  the  urethra.  The 
exact  position  of  the  foreign  body  having  been  determined,  place  the  beak  of 
the  instrument  in  immediate  contact  with  it;  now  open  the  jaws  by  turning 
the  screw,  and  when  sufficiently  separated  give  the  beak  a  slight  lateral 
movement,  and  turn  the  screw  so  as  to  close  the  jaws ;  if  the  object  is  seized, 
the  position  of  the  screw  will  indicate  its  size.  If,  on  attempting  its  with- 
drawal, the  body  cannot  be  engaged  in  the  urethra,  the  instrument  must  be 
loosened  and  the  body  seized  again  with  a  view  to  change  its  diameter.  If 
all  efforts  at  extraction  fail,  the  bladder  must  be  opened  by  median  lithotomy 
and  the  body  removed. 

Urinary  calculi  occur  as  frequently  in  children  as  in  adults.  The  cen- 
tral body  is  either  a  crystalloid  deposited  from  solution  in  the  presence  of 
colloids  or  a  solid  body  introduced  from  without,  as  a  pin.  These  stones 
vary  in  composition  according  to  the  constituents  of  the  urine  in  each  case. 
The  symptoms  are  pain  at  the  neck  of  the  bladder,  along  the  urethra,  and 
under  the  glans  penis ;  increased  frequency  of  desire  to  void  urine,  with 
spasmodic  pain  at  the  close  of  the  act;  blood  in  the  urine  at  the  close  of 
urination  or  after  severe  exercise  ;  sudden  arrest  of  the  stream  of  urine  while 
in  full  flow,  with  strong  spasmodic  contractions  at  the  neck  of  the  bladder 


942  •  LOCAL  DISEASES. 

attended  by  severe  pain.  But  tlie  diagnosis  must  finally  rest  upon  the  detec- 
tion of  the  stone  by  the  sound. 

The  first  exploration  should  be  made  with  soft  bulbous  bougies  to  esti- 
mate the  calibre  of  the  urethra  and  its  sensitiveness ;  the  second  examination 
should  be  made  with  a  searcher  of  abrupt  curve  and  short  beak  (Fig.  254). 
When  the  sound  enters  the  bladder  it  must  be  moved  to  and  fro,  to  the  right 
and  left,  and  then  reversed ;  large  stones  usually  lie  close  to  the  vesical  neck 
and  are  readily  felt,  but  medium  and  small-sized  calculi  are  more  apt  to  be 
found  in  the  posterior  part  of  the  bas-fond  on  either  side  of  the  median  line ; 
the  contact  of  the  instrument  with  a  calculus  will  determine  by  the  note 
whether  it  is  hard,  soft,  or  encysted. 

Removal  of  stone  from  the  bladder  must  be  effected  by  litholapaxy,  by 
which  the  stone  is  crushed  in  the  bladder  and  removed  through  the  natural 
passages  without  cutting ;  or  by  lithotomy,  by  which  the  stone  is  removed 
through  an  artificial  opening  made  into  the  urethra  or  bladder.  The  opera- 
tion of  crushing  the  stone  to  facilitate  removal  is  now  generally  regarded  as 
the  best  procedure  when  the  calculus  does  not  exceed  60  grains  or  the  size 
of  a  Spanish  nut.  Keegan  reports  a  case  of  the  removal  of  a  stone,  by  crush- 
ing, weighing  703  grains,  from  a  boy  twelve  years  old. 

Gouley  truly  remarks :  "  There  is  no  exclusively  best  method  of  dealing  with 
these  foreign  bodies,  and  there  is  no  particular  method  applicable  to  all  cases  even 
of  a  kind,  for  experience  teaches  that  one  patient  will  bear  immediate  surgical  ope- 
ration, be  it  lithotomy  or  lithotripsy,  while  another  of  the  same  age  and  apparently 
in  the  same  state  will  be  killed  by  precisely  the  same  treatment;  the  judicious  sur- 
geon, therefore,  will  select  from  among  the  many  known  operative  procedures  the 
one  which  is  indicated  after  due  consideration  and  study  of  all  the  peculiarities  of 
the  individual  case." 

Litholapaxy  and  lithotomy  are  never  emergency  operations,  and  as  the 
procedures  require  special  instruments  and  considerable  dexterity  on  the 
part  of  the  operator,  it  will  be  advisable  for  the  general  practitioner  to  obtain 
the  assistance  of  a  competent  surgeon.  For  the  full  description  of  these 
operations  works  on  operative  surgery  should  be  consulted. 

Stone  in  the  bladder  of  female  children  occasionally  occurs.  It  is 
attended  by  symptoms  of  local  irritation,  cystitis,  sudden  arrest  of  urine. 
If  the  diagnosis  is  not  correctly  made  out,  the  stone  may  cause  ulceration  of 
the  bladder  and  escape  into  the  anterior  part  of  the  vagina. 

Case. — A  girl  aged  six  years  had  suffered  eighteen  months  from  all  of  the  cha- 
racteristic symptoms  of  calculus  of  the  bladder.  No  exploration  of  the  bladder 
had  been  made,  as  the  presence  of  a  stone  had  not  been  suspected  by  the  medical 
attendant,  though  the  suffering  of  the  patient  was  extreme.  At  length  the  stone 
made  its  appearance  just  below  the  opening  of  the  urethra,  and  surgical  advice 
was  sought.  A  slight  enlargement  of  the  opening  already  existing  was  sufficient 
to  permit  the  removal  of  a  calculus  weighing  110  grains. 

Exploration  of  the  bladder  with  a  probe  or  sound  should  at  once  be  made 
in  all  cases  of  female  children  having  symptoms  of  irritation  of  the  bladder 
and  sudden  arrest  of  the  flow  of  urine.  The  examination  is  readily  made 
while  the  patient  is  under  an  anaesthetic,  and  the  presence  of  a  stone  can  be 
positively  determined.  The  treatment  should  be  prompt  removal  of  the  stone 
by  the  method  of  crushing. 

The  Urethra. 

Simple  incised  wounds  of  the  urethra  are  dangerous  in  proportion  to  their 
depth,  as  regards  their  direction,  and  the  tissues  involved.     The  indications 


DISEASES  OF  THE  QENITO-UBINABY  ORGANS.  943 

are  to  prevent  extravasation  of  urine  by  enlargement  of  the  wound  if  neces- 
sary or  the  introduction  of  a  catheter. 

Contused  and  lacerated  wounds  of  the  urethra  occur  in  children  as  the 
result  of  falls  astride  of  hard  bodies,  and  are  more  frequently  located  in  that 
portion  related  to  the  deep  perineal  fascia ;  and  it  is  in  this  part  that  there  is 
the  greatest  risk  to  life,  owing  to  the  tendency  to  urinary  infiltration  and  the 
liabilty  to  intrapelvic  suppuration  and  peritonitis.  The  rupture  is  usually 
due  to  the  forcible  pressure  of  the  urethra  against  the  triangular  ligament. 
The  tube  may  be  torn  partially  or  completely  across.  The  symptoms  may 
be  very  slight,  but  generally  there  are  contusions,  inability  to  pass  water, 
and  bleeding  from  the  urethra.  At  first  an  efibrt  should  be  made  to  pass  a 
flexible  catheter,  but  the  utmost  gentleness  must  be  used  in  order  not  to 
engage  the  point  in  the  rent ;  if  the  rent  is  longitudinal,  the  catheter  may 
pass  without  much  difiiculty ;  if  it  is  transverse  and  involves  only  the  lower 
portion,  the  extremity  of  the  catheter  may  be  passed  along  the  roof;  in  some 
cases  the  stilette  may  be  carried  in  the  flexible  bougie,  and  when  the  obstruc- 
.  tion  is  met  with  by  withdrawing  the  stilette  an  inch  the  end  of  the  catheter 
is  suddenly  raised  and  passes  the  obstruction.  The  catheter  should  rarely 
be  retained,  owing  to  the  liability  to  extravasation  by  its  side.  If  there  is 
hemorrhage,  ice  must  be  applied.  If  the  catheter  cannot  be  passed  or  there 
is  a  distinct  hard  tumor  at  the  seat  of  injury,  perineal  section  must  be  per- 
formed to  give  free  escape  to  the  urine.  Pass  a  sound  down  to  the  rupture 
and  make  the  incision  upon  its  extremity.  Delay  in  the  performance  of 
this  operation  causes  imminent  risk,  and  probably  an  aggravation  of  the  local 
mischief.  These  lesions  always  render  the  patient  liable  to  subsequent  stric- 
tures, often  of  an  intractable  kind,  and  hence  the  importance  of  restoring 
and  maintaining  the  full  capacity  of  the  canal  in  the  subsequent  treatment. 

Foreign  bodies  introduced  into  the  urethra  from  without  include  every 
variety  of  materials,  as  pins,  pencils,  stones,  beads.  They  tend  to  advance 
into  the  bladder,  but,  if  arrested,  they  cause  retention  and  finally  ulceration. 
Immediate  removal  is  necessary.  The  most  useful  instrument  is  forceps  with 
a  long  handle  which  separates  only  at  the  blades  (Fig.  255)  ;  for  bodies  in  the 

Fig.  255. 


Long  urethral  forceps. 

anterior  part  of  the  urethra,  slender  forceps,  with  suitable  blades  are  neces- 
sary (Fig.  256)  ;  pressure  must  be  made  behind  the  body,  if  possible,  to  pre- 
vent its  being  forced  backward  by  the  forceps.  If  the  body  be  long  and  soft, 
as  leather,  rubber,  or  a  piece  of  wood, 
it  may  be  transfixed  with  a  stout  needle  _         Fig.  256. 

through  the  floor  of  the  urethra  and      "' 

the  canal  pushed  back  over  it,  like  a       

glove  over  a  finger,  as  far  as  possible.  Short  urethral  forceps. 

when  it  may  be  transfixed  again,  and 

so  urged  forward  until  it  can  be  seized  at  the  meatus.     If  the  body  cannot 
be  dislodged,  it  must  be  removed  by  a  longitudinal  incision. 

Calculus  or  an  angular  fragment  of  a  crushed  stone  may  lodge  in  the 
urethra  in  its  passage  from  the  bladder.  The  points  where  it  is  most  liable 
to  lodge  are — (1)  the  membranous  portion  at  the  triangular  ligament ;  (2)  in 


944 


LOCAL  DISEASES. 


Fig.  257. 


the  middle  of  the  penile  portion ;  (3)  at  the  meatus.  If  the  calculus  is  pos- 
terior to  the  triangular  ligament,  push  it  back  into  the  bladder  with  a  large 
catheter.  If  it  is  immovable  without  great  force,  which  must  be  avoided,  it 
may  be  forced  back  by  injections  through  the  catheter  of  warm  water,  olive 
oil,  or  flaxseed  tea.  If  the  body  is  anterior  to  the  ligament,  it  should  be 
withdrawn  through  the  meatus  by  means  of  the  forceps  mentioned. 

Imperforate  urethra  may  consist  of  a  closed  meatus,  which  must  be 
opened  by  puncture  or  incision.  Or  the  closure  may  be  due  to  a  diaphragm 
lower  down  in  the  urethra,  which  must  be  perforated  by  a  trocar.  If  the 
tube  is  deficient  for  a  considerable  extent,  a  new  urethra  must  be  con- 
structed. 

The  Penis. 

Phimosis  is  such  a  contraction  of  the  prepuce  that  the  glans  cannot  be 
uncovered  ;  in  the  normal  condition  of  the  infant  the  prepuce  is  adherent  to 
the  glans,  but  later  these  adhesions  are  broken  down  and 
the  prepuce  becomes  free.  If,  however,  there  is  inflamma- 
tion excited  by  irritants,  as  accumulations  of  filth  under  the 
prepuce,  these  adhesions  may  become  firm  ;  or  the  orifice 
may  become  inflamed  and  so  dense  that  it  will  not  yield, 
even  to  allow  the  free  passage  of  urine  (Fig.  257).  The 
afiiection  may  be  a  source  of  great  discomfort  in  children, 
resulting  in  spasms  of  the  muscles  of  diff"erent  parts  of  the 
body,  and  in  adults  of  collections  of  filth  and  foul  matters. 
In  performing  this  operation  it  is  important  to  seize  the 
orifice  of  the  prepuce  for  the  purpose  of  making  suitable 
traction  on  the  mucous  membrane,  which  is  but  slightly 
elastic  compared  with  the   skin. 

Irritated  eonsenital  ^^'^®*'   ^°^^^*   ^  well-oiled   probe   under   the   prepuce,  and 

phimos^.  sweep  the  surface  oi  the  glans  to  break  up  adhesions ;  seize  the 

prepuce,  including  the  mucous  membrane,  with    sharp-toothed 

forceps,  and  draw  it  forward  (Fig.  258) ;  grasp  the  prepuce  firmly  just  in  front  of 

the  glans  with  forceps,  and  with  the  bistoury  cut  away  the  portion  anterior  to  the 

Fig.  258. 


Circumcision  in  the  adult. 


clamp ;  the  prepuce  readily  retracts  ;  now  with  blunt  scissors  slit  up  the  mucous 
membrane  on  the  dorsum,  trim  its  edges,  and  unite  the  mucous  and  skin  flaps 
by  a  number  of  fine  sutures ;  if  the  prepuce  is  not  free,  all  tightness  must  be 


DISEASES  OF  THE  GENITO-URINARY  ORGANS. 


945 


relieved  by  an  incision  on  the  dorsum,  or,  in  infants,  by  tearing  the  tissues  ;  the 
cut  mucous  membrane  must  be  attached  to  the  skin  by  numerous  fine  sutures, 
beginning  at  the  raphe  ;  rest  and  water  dressings  only  are  required  in  the  after- 
treatment.  In  slight  cases  it  may  be  sufficient  to  slit  up  the  prepuce  on  the  dorsum 
and  attach  the  edges  as  before.  If  there  is  a  contracted  prepuce  after  the  excision, 
slit  up  the  skin  three  to  six  lines  on  the  dorsum  of  the  penis  (Fig.  259),  trim  the 
corners  round,  5,  4,  6  (Fig.  260),  incise  the  mucous  membrane  2,  1,  3  (Fig.  260), 
adjust  the  point  1  to  4,  2  to  5,  and  3  to  6,  with  sutures,  and  the  rest  of  the  circum- 
ference by  a  sufficient  number  to  hold  them  in  position. 

Paraphimosis  occurs  when  the  prepuce  is  withdrawn  behind  the  glans 
and  cannot  be  brought  forward  :  the  prepuce  forms  a  constricting  band 
around  the  corona,  which  is  followed  by  swelling  of  the  glans  and  oedema  of 


Fig.  259. 


Fig.  260. 


Preparation  of  flaps. 


the  prepuce.  The  treatment  is  prompt  reduction.  If  the  swelling  is  slight 
and  without  strangulation,  reduction  may  be  effected  by  the  methods  given 
below,  or  by  strips  of  rubber  plaster  applied  longitudinally  from  the  middle 


Fig.  261. 


Reduction  of  paraphimosis. 

of  the  penis  on  one  side  over  the  apex  of  the  glans  to  the  middle  of  the  penis 
opposite,  the  meatus  being  left  uncovered  until  the  organ  is   covered.     If 
there    is    dangerous    strangulation,    shown    by  the  dark  color  of  the  glans 
60 


946 


LOCAL  BISEASES. 


and  great  oedema  of  the  prepuce,  reduction  is  more  difficult,  but  may  be 
aided  by  employing  cold  and  puncture  of  cedematous  parts.  Reduction  is 
effected  as  follows : 

Give  an  ansesthetic ;  seize  the  penis  behind  the  strictured  prepuce,  between  the 
index  and  middle  fingers  of  both  hands,  placed  on  either  side  (Fig.  261),  make 
pressure  with  the  thumbs  on  both  sides  of  the  glans,  in  such  direction  as  to  com- 
press the  glans  laterally  rather  than  from  before  backward,  and  at  the  same  time 
pull  the  strictured  portion  of  the  prepuce  forward ;  the  manipulation  is  designed  to 
reduce  the  glans  by  compression  and  pull  the  stricture  over  the  glans,  and  not  to 
push  the  glans  through  the  stricture. 

Or  the  penis  may  be  encircled  with  one  hand  (Fig.  262)  while  compression  is 
made  with  the  thumb  and  finger  as  before.     Or  place  the  index  and  middle  finger 

Fig.  262. 


Reduction  of  paraphimosis. 

of  the  right  hand  longitudinally  along  the  lower  surface  of  the  penis,  and  the  pulp 
of  the  thumb  on  the  dorsum  of  the  glans  and  the  cedematous  ridge  in  front  of  the 

point  of  stricture ;   by  firm  pres- 
FiG.  263.  sure,  crowding  down  the  swollen 

mucous  membrane  of  the  prepuce, 
endeavor  to  insinuate  the  end  of 
the  thumb-nail  under  the  stric- 
ture ;  succeeding  in  this,  grasp 
the  penis  and  the  two  fingers  of 
the  right  hand  beneath,  in  a  cir- 
cular manner,  with  the  left  hand, 
and  draw  the  strictured  point  up 
over  the  thumb-nail,  and  by  sim- 
ultaneous traction  of  both  hands 
replace  the  prepuce.  If  a  pro- 
longed and  careful  attempt  at  re- 
duction fails,  the  strictured  point 
must  be  divided  as  follows  :  Intro- 
duce a  bistoury  knife  flat-wise 
along  the  sheath  of  the  penis, 
subcutaneously,  under  the  stricture,  and  cut  outward  until  all  tension  is  removed 
(Fig.  263) ;  or  a  simple  incision  may  be  made  down  to  the  sheath  of  the  penis. 


Mode  of  dividing  prepuce  in  paraphimosis. 


DISEASES  OF  THE  GENITO-UBINABY  ORGANS. 


947 


The  after-treatment  consists  of  cleanliness  and  syringing  the  preputial  cavity  with 
carbolized  water. 

The  Scrotum. 

Varicocele  is  due  to  a  varicose  state  of  the  veins  of  the  spermatic  cord, 
resulting  in  an  enlargement  of  its  tissues,  forming  a  pendulous  mass,  which 
becomes  a  source  of  inconvenience.  The  early  treatment  is  support  by 
means  of  a  suspensory  bag.  If  the  scrotum  becomes  very  large  and  trouble- 
some, the  spermatic  veins  must  be  ligated,  with  careful  attention  to  all  of 
the  antiseptic  details. 

Hydrocele  is  an  accumulation  of  fluid  in  the  sac  of  the  tunica  vaginalis, 
and  is  caused  by  any  condition  which  stimulates  that  membrane  to  over- 
secretion.  It  commences  at  the  lower  part  of  the  scrotum  and  gradually 
extends  upward,  and  when  well  marked  the  tumor  is  tense,  transparent,  and 
fluctuating,  has  a  smooth  and  uniform  surface  ;  the  testicle  is  not  defined,  but 
the  spermatic  cord  can  be  traced  to  the  swelling ;  if  the  hydrocele  is  old,  the 
walls  may  be  so  thick  that  the  transparency  is  lost.  The  methods  of  treat- 
ment most  frequently  adopted  are  as  follows:  1.  Tapping  for  temporary 
relief:    grasp  the  tumor  in  the  left  hand  (Fig.  264),  the  anterior  surface 

Fig.  264. 


Tapping  a  hydrocele. 

being  uncovered  ;  avoiding  veins,  puncture  directly,  withdraw  the  trocar,  and 
pass  the  canula  in  the  cavity,  inclined  slightly  upward  and  backward ;  care 
must  be  taken  not  to  penetrate  so  deeply  as  to  wound  the  testicle.  2.  Injec- 
tions often  cure  :  the  best  are  tincture  of  iodine  and  carbolic  acid.  Of  iodine 
use  gj  to  ^iij  pure  tincture,  with  platinum  canula,  and  rub  the  testicle  to  diff'use 
the  fluid ;  leave  the  fluid  all  in ;  the  inflammation  will  be  quite  severe,  but 
curative. 

The  Testicles. 

Tubercles  of  the  testis  consist  of  certain  cheesy  nodules  of  considerable 
bulk  and  more  or  less  globular  shape,  commonly  multiple  for  a  time,  but 
finally  they  coalesce  to  form  a  single  mass  remarkable  for  its  peculiar  elas- 
ticity, which  it  retains  until  a  central  softening  leads  to  an  abscess  ;  this 
tends  to  burst  and  give  rise  to  the  well-known  fistula,  which  is  distinguished 
by  extreme  chronicity  and  occasional  discharge  of  sodden  shreds  of  seminif- 
erous tubuli  through  it.  Suppuration  rarely  occurs  in  children.  The  treat- 
ment should  be  largely  hygienic,  as  exercise  in  the  open  air  and  nutritious 
food ;  quinine,  iron,  and  cod-liver  oil  are  the  most  useful  I'emedies  ;  the  testis 
must  always  be  supported.  Castration  is  required  to  prevent  general  gland- 
ular infection  if  the  disease  involves  the  organ  extensively. 

Sarcoma  in  all  its  principal  varieties  finds  a  favorite  seat  in  the  testicle  ; 
the  tumor  almost  always  contains  not  only  all  the  chief  varieties  of  sarcoma, 


948  LOCAL  DISEASES. 

but  all  the  liistioid  formations  which  are  met  with  in  the  sarcomata  as  well  ; 
cartilage,  mucous  and  connective  tissue,  striped  and  unstriped  muscle,  enter 
more  or  less  into  the  composition  of  the  sarcomata  of  this  organ  ;  these  fre- 
quent combinations  introduce  an  element  of  great  variety  into  the  structure 
of  the  sarcomata  of  the  testicle,  and  this  is  rendered  more  manifold  by  the 
frequent  occurrence  of  cysts  in  their  interior.     The  growth  is  slow,  usually 

I  painless,  oval,  and  smooth.     The  treatment  is  removal  of  the  gland. 

,  The  congenital  malformations  epispadias  and  hypospadias  should  not  be 

'operated  upon  before  the  patient  has  reached  adult  life. 


SEOTIO]^  VII. 
DISEASES   OF   THE   SKIN. 


As  in  all  other  diseases  of  infancy  and  childhood,  those  pertaining  to  the 
skin  in  the  first  years  of  life  have  been  so  fully  investigated  clinically  and 
microscopically  in  the  last  decade  that  they  are  much  better  understood  and 

Fig.  265. 


Vertical  section  through  the  skiu  (after  Heitzmann).    Diagrammatic. 

more  successfully  treated  than  formerly.    At  the  commencement  of  the  study 
-of  these  diseases  the  physician  should  have  a  clear  idea  of  the  nomenclature 


950  LOCAL  DISEASES. 

of  the  cutaneous  eruptions.     I  will  therefore  briefly  present  it  in  detail  in 

the  clear  and  concise  manner  employed  by  Crocker : 

Maculse  "  are  discolorations  level  with  the  skin,  of  various  sizes,  shapes, 

and  tints." 

Papidse.  "  are  small  elevations  of  the  skin,  not  exceeding  a  split  pea  in 

size,  nor  visibly  containing  fluid." 

Nodidse.  "  are  elevations  of  the  skin,  from  a  split  pea  to  a  hazelnut  in 

size." 

Tumors  are  '•  new  growths,  from  a  pea  and  upward  in  size." 

Yesicidse,  "  are  elevations  above  the  surface  of  the  skin,  from  a  pin's  head 

to  a  hempseed  in  size,  with  free  contents  of  serous  fluid." 

Bullse,  or  Blehs,  "  are  vesicles  which  are  as  large  as,  or  larger  than,  a  pea." 
Pustidse  "  differ  from  vesicles  and  blebs  only  in  containing  pus." 
Pomphi^  or  Wheals,  are  caused  by  "  a  circumscribed  oedema  of  the  corium, 

producing  a  flat  elevation  of  the  epidermis  at  that  point." 

Sqiiamse,  or  Scales,  "  are  dry,  laminated  exfoliations  of  the  epidermis." 
Crustse,  or  Crusts,  "  are  irregular,  dried  masses  of  exudation  or  other  eff"ete 

products  of  disease." 

Excoriations  "  are  lesions  in  which,  as  a  rule,  the  surface  is  denuded  only 

as  far  as  the  stratum  mucosum.  They  heal,  therefore,  without  leaving  scars." 
Rhagades  "  are  linear  cracks  in  the  skin,  whether  due  to  injury  or  disease." 
Ulcers  "  are  losses  of  substance  of  the  skin  extending  into  the  corium  and 

and  produced  by  disease." 

Cicatrices,  or  Scars,  are  "  new  formations  replacing  losses  of  substance, 

which  extend  as  far  as  the  corium." 

In  a  treatise  relating  to  the  diseases  of  infancy  and  childhood  want  of 

space  prevents  a  full  description  of  the  cutaneous  diseases  which  are  liable 

to  occur  in  these  periods.     We  will  only  describe  those  which  are  the  most 

frequent  and  most  important. 

Erythema,  or  Rose  Rash,  is  a  term  applied  to  a  disease  of  the  skin  whose 
clinical  character  is  simple  congestion,  which  disappears  on  pressure.  Its 
color  varies  from  a  bright-red  hue  to  a  dusky  tinge,  according  as  arterial  or 
venous  hyperjemia  predominates.  As  the  skin  of  the  child  is  delicate  and  has 
an  active  circulation,  and  is  exposed  to  many  irritating  agencies,  erythema  is 
common  at  this  age. 

1.  Erythema  produced  by  external  agents; 

2.  Erythema  produced  by  internal  causes. 

The  CAUSES  of  the  first  group  are  very  numerous,  among  which  may  be 
mentioned  friction  or  undue  pressure  upon  the  skin  ;  heat,  solare  or  ah  igne, 
sufl&cient  to  cause  erythema ;  cold  of  a  certain  degree  produces  the  same 
result  upon  the  skin,  as  do  numerous  irritants  of  an  animal  and  vegetable 
nature  applied  to  the  surface. 

The  first  group  also  includes  intertrigo,  which  in  its  milder  forms  is  an 
erythema,  but  if  severe  may  present  the  clinical  characters  of  eczema.  It 
often  occurs  in  infants  in  folds  of  the  skin  around  the  neck  and  on  parts 
covered  by  the  diaper  which  are  irritated  by  the  excretions. 

In  the  second  group  certain  internal  causes,  among  which  are  the  eruptive 
fevers,  particularly  scarlet  fever,  measles,  rotheln,  and  beriberi,  produce  a 
cutaneous  hyperaemia  which  has  the  anatomical  characters  of  erythema. 
In  many  children,  as  well  as  adults,  having  an  idiosyncracy,  erythema  is 
caused  by  drugs,  as  quinine  administered  for  disease.  Under  the  term 
idioj^atliic  roseola  Crocker  describes  a  form  of  erythema  which  all  will  recog- 
nize who  are  familiar  with  diseases  of  children.  It  "occurs  mainly  among 
infants  and  young  children.     Its  onset  is  generally  attended  with  constitu- 


DISEASES  OF  THE  SKIN.  951 

tional  symptoms — a  transitory  elevation  of  temperature,  sometimes  amount- 
ing to  three  or  four  degrees,  restlessness,  quickened  pulse,  furred  tongue,  and 
perhaps  some  redness  of  the  palate  and  fauces,  but  there  are  no  catarrhal 
symptoms.  After  a  short  but  variable  period  the  eruption  appears  :  it  may 
be  general  or  partial,  aifecting  the  whole  body  or  only  a  limb,  the  face,  or 
neck ;  the  form  and  shape  of  the  eruption  vary  much,  at  one  time  in  patches 
of  the  size  of  the  end  of  the  finger,  at  another  faintly  papular,  or  it  may  be 
in  rings  or  gyrate  figures.  It  may  come  at  one  place  and  go  at  another,  and 
so  last  several  days." 

Symptomatic  erythema  occurs  suddenly  in  a  variety  of  febrile  attacks, 
the  rash  having  sharply-defined  borders,  with  areas  of  skin  not  hyperaemic, 
and  even  white.  In  erythema  presenting  a  scarlatiniform  appearance,  but 
without  any  relation  to  scarlet  fever,  the  rash  usually  disappears  in  two  to 
six  days,  and  sometimes  with  a  furfuraceous  desquamation.  The  occurrence 
of  this  rash  shows  that  there  has  been  some  constitutional  disturbance,  having 
its  seat  often  in  the  digestive  system.  When  the  erythema  occurs  after  the 
use  of  certain  drugs,  as  quinine  and  copaiba,  the  irritation  of  the  alimentary 
canal  probably  has  a  reflex  action  on  the  vasomotor  centres. 

Diagnosis. — Erythema  is  liable  to  be  mistaken  for  certain  diseases  that 
are  more  severe  and  protracted  and  that  more  urgently  demand  treatment. 
Scarlet  fever  is  the  most  noteworthy  of  these,  but  this  dangerous  disease  has 
the  following  characters,  which  in  ordinary  cases  serve  for  correct  diagnosis : 
Eedness  and  swelling  of  the  fauces,  strawberry  tongue,  vomiting — an  initial 
symptom  in  about  nine-tenths  of  the  cases  of  scarlet  fever.  To  these  may  be 
added,  as  indicative  of  scarlet  fever,  efilorescence,  general  instead  of  limited  to 
certain  areas  with  sharply-defined  borders,  prolonged  desquamation,  following 
a  longer  duration  of  symptoms  than  in  erythema. 

Measles  is  distinguished  from  erythema  by  the  presence  of  coryza,  the 
commencement  of  the  rash  upon  the  forehead  after  three  or  four  days,  nasal 
and  faucial  catarrh,  and  its  gradual  extension  over  the  entire  body,  and  the 
constant  occurrence  of  fever  from  the  beginning  of  the  catarrh  until  the  dis- 
appearance of  the  eruption.  In  certain  cases  it  will  be  necessary  to  observe 
the  efilorescence  and  course  of  the  disease  two  or  three  days  before  making  a 
positive  diagnosis. 

Rotheln  is  in  some  instances  with  difiiculty  diagnosticated  from  erythema, 
but  it  is  accompanied  by  the  enlargement  of  certain  glands  about  the  neck, 
which  is  lacking  in  erythema.  Rotheln  also  occurs  as  an  epidemic  and  feebly 
contagious  disease,  characters  which  are  lacking  in  erythema. 

Treatment. — This  is  simple,  consisting  of  regulating  the  digestive  system 
and  the  application  of  a  simple  dusting  powder,  as  equal  parts  of  subnitrate 
of  bismuth,  stearate  of  zinc,  and  powdered  starch,  or  oxide  of  zinc  1  part  and 
powdered  rice  or  corn  starch  3  parts. 

ErytJiema  multiforme  is  preceded  and  attended  by  malaise  and  slight 
pains  in  the  head,  back,  and  limbs,  and  sometimes  gastric  derangement  and 
enlarged  spleen.  In  some  cases  these  symptoms  are  absent.  If  they  be 
present,  after  their  continuance  a  few  hours  or  days  the  eruption  appears  on 
the  backs  of  the  hands  and  feet,  upon  the  face  and  limbs,  and  it  is  abundant 
around  the  most  painful  articulations.  It  is  rare  upon  the  body.  The  tem- 
perature, rising  from  100°  to  104°  in  the  beginning  of  the  sickness,  may  fall 
to  normal  when  the  eruption  appears,  or  it  may  not  fall  until  the  eruption 
disappears.  The  extent  of  the  eruption  is  variable,  but,  in  whatever  other 
places  it  occurs,  it  is  seldom  absent  from  the  back  of  the  hands.  It  begins 
in  groups  of  deep-red  papules,  from  the  size  of  pin's  head  to  a  small  split 
pea  (e.  papulatiim).  Some  of  the  papules,  enlarging,  may  unite,  forming 
nodules  or  tubercles  (e.  tuberculatum  or  tuherosimij,  or  by  depression  of  the 


952  LOCAL  DISEASES. 

centre  a  ring  forms  (e.  circinatum  or  e.  annulare).  By  absorption  in  the 
centre  colored  zones  of  purple  or  pink  may  be  produced  (e.  iris  or  e. 
ffyratum^. 

The  above  forms  of  erythema,  as  is  seen,  have  been  designated  by  their 
appearance,  and  some  other  forms  of  this  disease  might  be  mentioned  which 
have  also  received  their  appellation  from  their  shape. 

The  usual  duration  of  exudative  erythema  appears  to  be  from  two  to 
four  weeks. 

Pathology.  —  Cocci  have  been  found  in  the  blood  and  eruptions  of 
patients  with  exudative  erythema.  Manssurow  found  bacilli  and  spores  in 
four  cases  of  erythema  multiforme.  Many  European  observers  regard  this 
disease  as  specitic  on  account  of  the  fever,  its  definite  course,  and  its  occa- 
sional endemic  character.  The  fact  that  the  eflPused  fluid  makes  its  way 
between  the  rete-cells  and  forms  vesicles  or  bullse  in  which  leucocytes  occurs 
shows  its  inflammatory  nature. 

Since  the  various  forms  of  exudative  erythema,  as  of  simple  erythema, 
tend  to  recovery  in  from  two  to  four  weeks,  those  in  good  general  health  do 
not  require  internal  remedies.  Nevertheless,  conditions  of  the  system  arise 
in  some  cases  which  are  benefited  by  certain  kinds  of  internal  medication,  as 
iodide  of  potassium,  iron,  quinine,  salicylate  of  sodium. 

The  following  lotion  relieves  the  itching  when  the  skin  is  not  broken : 

R.  Acidi  carbolici,  ,^j  ; 

Zinc  camphor,  ^ij  ; 

Aquae  purse,  Oj. — Misce. 
To  be  applied  as  a  wash. 

Urticaria. — This  eruption  appears  without  premonition,  or  with  a  sting- 
ing and  burning  sensation  resembling  that  caused  by  the  nettle  (Urtica 
iirens).  from  which  its  name  is  derived.  The  eruptions  are  flatly  convex, 
firm  on  pressure,  of  the  average  size  of  the  finger-nail,  but  some  of  them 
larger  from  the  coalescence  of  two  or  more.  At  first  they  are  red,  but  in 
developing  they  become  white  in  the  centre.  Sometimes  the  wheal,  espe- 
cially if  small,  remains  red.  The  burning  and  itching  of  the  eruption  may 
be  slight,  but  commonly  are  so  great  that  the  patient  scratches  vigorously, 
which  causes  an  increase  in  the  wheals  and  in  the  extent  and  intensity  of  the 
burning  and  itching. 

The  eruption  of  urticaria  continues  a  few  hours  or  even  a  day  or  more,  and 
disappears  without  desquamation.  It  does  not  occur  symmetrically.  Only 
a  few  wheals  may  appear,  or  they  may  be  numerous,  covering  the  entire 
body  as  well  as  the  mucous  membrane  of  the  mouth,  tongue,  fauces,  and 
probably  the  surface  of  the  air-passages  and  stomach.  The  occasional  occur- 
rence of  spasmodic  asthma  during  an  attack  of  urticaria  suggests  the  presence 
of  wheals  along  the  air-passages,  and  their  occurrence  in  the  stomach  is  ren- 
dered probable  by  the  nausea  and  vomiting. 

Varieties. — In  urticaria  papulosa  the  wheals  are  small,  not  more  than 
one  inch  in  diameter ;  in  urticaria  tuberosa  or  urticaria  gigans  they  are  of 
longer  duration  than  usual,  and  some  of  them  as  large  as  a  walnut  or  hen's 
egg ;  in  urticaria  cedematosa  the  afi"ected  tissue  is  lax  and  (edematous.  If 
it  occur  on  the  face  and  extend  to  the  eyelids,  the  latter  may  be  cjuite  closed. 
If  the  tongue  be  the  seat  of  the  wheal,  the  swelling  may  seem  to  threaten 
suff"ocation,  but  it  usually  begins  to  abate  in  a  few  hours  without  the  neces- 
sity of  an  incision.  In  exceptional  instances  the  subjective  symptoms  occur, 
but  the  wheals  do  not  appear,  unless,  as  sometimes  happens,  they  are  brought 
out  by  rubbing  or  scratching.  This  form  of  urticaria  is  designated  suhcu- 
tanea,  and  its  usual  location  is  on  the  lower  extremities. 


DISEASES  OF  THE  SKIN.  953 

Hemorrhage  may  take  place  into  the  wheals,  producing  urticaria  hsemor- 
rhagica  ov  imrpura  urticans.  An  over-abunclance  of  the  serum  which  elevates 
the  skin  into  a  wheal  may  force  its  way  through  the  rete,  and,  raising  the 
upper  layers,  produce  a  bulla  {urticaria  bullosa). 

Other  varieties  of  urticaria  are  described  by  writers,  as  urticaria  jactitia, 
designated  also  "  dermagraphia  "  and  "  aixtographism,"  when  letters  can  be 
brought  out  in  two  or  three  minutes  by  inscribing  with  the  finger-nail  or  a 
pointed  instrument  upon  the  skin.  The  term  urticaria  acuta  is  employed  to 
designate  the  disease  when  attended  by  acute  symptoms,  as  nausea,  vomiting, 
pain  in  the  epigastrium  or  head,  and  a  copious  eruption  soon  appears.  Urti- 
caria chronica  is  applied  when  successive  crops  of  wheals  appear  at  longer  or 
shorter  intervals. 

Urticaria  papulosa  is  the  form  of  this  malady  which  is  most  common  in 
children.  Bateman  designates  it  lichen  urticatus.  Instead  of  mere  serum, 
un  inflammatory  exudation  occurs,  and  therefore  after  the  serum  disappears 
a  papule  remains.  Usually  when  the  physician  is  summoned  pale  red  pa- 
pules of  the  size  of  hempseed,  with  incrusted  tops,  are  observed,  the  itching 
of  which  resembles  that  of  scabies.  Urticaria  papulosa  occurs  especially  in 
the  infant  about  the  loins  and  buttocks,  on  parts  which  it  is  enabled  to  reach 
and  scratch  with  its  finger-nails.  The  wheals  have  often  disappeared  when 
the  physician  is  summoned.  If  present,  they  are  likely  to  have  a  pink  color, 
and  are  of  the  usual  size  or  small,  and  may  be  in  some  places  linear  from 
the  scratching. 

Etiology. — Urticaria  papulosa  is  likely  to  be  protracted.  Hutchinson's 
opinion  that  it  is  produced  by  the  bites  of  fleas  and  bugs  is  believed  to  be 
applicable  to  only  certain  cases.  A  more  probable  explanation  of  its  etiology 
is  that  which  refers  the  cause  to  derangement  of  the  digestive  system. 

Urticaria  is  more  common,  especially  the  papular  foi'm,  in  infancy  and 
childhood  than  in  adult  life.  It  is  also  more  common  in  summer  than  in 
winter.  Its  causes,  as  we  have  seen,  are  numerous,  and  may  be  grouped  as 
follows  : 

1st.  Local  irritants  which  act  by  immediate  contact,  as  the  nettle,  insect- 
bites  or  stings,  as  of  fleas,  mosquitoes,  the  wasp,  or  bee ;  scratching  the  sur- 
face, as  in  pruritus  or  scabies  ;  irritating  plasters  or  poultices  ;  sudden  changes 
of  temperature. 

2d.  Indirect  irritation.  Numerous  irritants,  acting  through  the  digestive 
system,  cause  urticaria.  Several  kinds  of  food  have  this  efiect,  as  certain 
kinds  of  meat ;  shellfish,  as  crabs  and  lobsters  ;  and  in  certain  persons  fruits, 
as  strawberries,  fungi,  and  mushrooms.  Certain  kinds  of  medicines  admin- 
istered to  children  also  cause  urticaria,  as  quinine,  turpentine,  and  valerian. 
Chronic  intestinal  catarrh,  occasionally  associated  with  worms,  is  also  a 
recognized  cause,  as  is  also  indigestion.  The  tapping  and  removal  of  an 
hydatid  cyst  and  of  a  pleuritic  exudate,  asthma,  neuralgia,  and  strong  and 
sudden  emotions,  have  been  mentioned  among  the  causes. 

Pathology. — The  symptoms  and  history  of  urticaria  indicate  that  it  is 
due  to  disorder  of  the  vasomotor  nerves,  direct  or  reflex,  central  or  peripheral. 
Probably  a  spasmodic  contraction  first  occurs,  followed  by  dilatation  of  the 
vessels.  The  consequent  retarded  circulation  causes  exudation  of  serum  and 
<]edema,  which  raises  the  epidermis  into  the  wheal.  The  wheal  is  at  first 
pink,  but  the  blood  is  then  pressed  out  of  the  centre,  which  becomes  white, 
while  the  peripheral  part  is  hyperEemic. 

An  excision  of  the  wheal  made  by  Vidal  showed  that  the  superficial  and 
deep-seated  vessels  were  engorged  with  blood,  and  the  vessels  and  lymphatics 
were  surrounded  by  leucocytes,  which  abounded  through  the  whole  section 


954  LOCAL  DISEASES. 

of  the  cutis  and  were  in  masses  in  places.  Pieces  were  excised  from  the 
wheal  in  which  the  epidermis  had  been  raised  so  as  to  produce  a  vesicle. 

Diagnosis. — The  eruption  of  urticaria  occurs  suddenly  after  the  ope- 
ration of  the  cause,  and  is  white  or  pink,  or  of  both  colors,  the  white,  as 
before  stated,  being  the  central  part.  This  wheal,  from  the  characters  given, 
is  readily  diagnosticated  from  any  other  eruption.  Erythema  papulatum, 
which  resembles  urticaria,  is  more  symmetrical,  seldom  itches  severely,  and 
often  enlarges  by  extension  of  its  border,  in  which  respects  it  differs  from 
this  disease. 

Prognosis. — Urticaria  usually  subsides  in  a  few  days  or  hours,  but  it 
may,  if  untreated,  become  chronic.  It  may  disappear  in  winter  and  reappear 
in  the  hot  months.  Still,  in  most  instances  the  disease  can  be  cured  with 
proper  remedies,  and  will  not  reappear  if  suitable  preventive  measures  be 
employed. 

Treatment. — If  the  urticaria  be  apparently  due  to  irritating  and  poorly- 
digested  food,  an  alkaline  laxative,  as  ten  to  twenty  grains  of  magnesium 
carbonate  or  Carlsbad  salt,  repeated  if  necessary,  and  aided  perhaps  by  an 
enema,  will  be  found  useful.  With  an  open  state  of  the  bowels  and  removal 
of  the  irritating  substance  the  wheals  and  pruritus  will  sometimes  disappear 
at  once.  But  if  they  do  not,  care  should  be  taken  in  the  selection  of  the 
food,  and  it  should  be  given  at  proper  intervals  and  in  proper  quantity.  In 
such  cases  bismuth  and  pepsin  taken  at  each  feeding  will  often  be  useful. 

In  cases  of  obstinate  urticaria  the  whole  system  should  be  carefully 
examined,  and  if  any  aberration  occurs  it  should  be  corrected,  but  in  most 
cases  of  obscure  origin  the  digestive  function  is  in  fault,  and  by  using  the 
following  prescription  it  usually  improves : 

R.  Bismuth,  subnitrat.,  ^ij  ; 

Liq.  pepsin,  gj  ; 

Aquse  destillat.,  giv. — Misce. 

Dose  :  One  teaspoonful  after  the  feeding  for  a  child  of  one  or  two  years. 

In  infantile  urticaria  associated  with  chronic  intestinal  catarrh  the  above 
prescription  is  especially  beneficial.  A  careful  selection  of  the  diet  in  these 
infants  is  especially  required.  Starch  in  the  food  should  be  predigested  by 
the  action  of  diastase  ;  a  fair  amount  of  the  predigested  meat  preparations  in 
the  shops  should  be  allowed.  I  have  seen  benefit  from  Fairchild's  panopep- 
tone  or  the  liquid  peptonoids  of  the  Arlington  Chemical  Works,  although  I 
seldom  recommend  the  commercial  foods.  The  following  remedies  in  pro- 
tracted and  obstinate  urticaria  have  advocates :  bromide  of  potassium,  qui- 
nine, galvanism  along  the  spine,  ichthyol,  strophanthus,  sodium  salicylate, 
iodide  of  potassium. 

Scratching  the  irritated  surface  with  the  finger-nails  always  has  an  inju- 
rious effect,  and  the  itching  should  be,  so  far  as  possible,  prevented  by  other 
means.     Dusting  with  the  following  powders  will  be  found  useful : 

R .  Bismuth,  subnitrat.,  ^ij  ; 

Zinci  stearat.,  gj  ; 

Pulv.  amyli,  ^ss ; 

Pulv.  camphorse,  3J. — Misce. 
To  be  dusted  over  surface. 

R.  Lycopodii,  *ss ; 

Pulv.  bismuth,  subnit.,  ^iss. — Misce. 

Prurigo. — This  disease  is  characterized  by  papules,  slightly  raised,  dis- 
crete, inflammatory,  of  a  pale-red  or  white  color,  and  accompanied  with  a 


DISEASES  OF  THE  SKIN.  955 

severe  itching.  Two  varieties  have  been  described,  according  to  the  severity 
of  the  symptoms — the  mitis  and  ferox. 

Symptoms. — The  papules  are  at  first  of  the  color  of  the  skin,  and  may 
be  felt  before  they  are  seen.  By  scratching  they  become  more  red,  and 
blood-crusts  may  form  at  their  apices.  They  are  most  abundant  and  highly 
developed  upon  the  extensor  surfaces  of  the  limbs,  but  they  occur  upon  the 
thorax,  back  and  front,  the  sacral  region,  buttocks,  and  abdomen,  and  other 
places  besides  those  mentioned.  The  eruption  occurs  rarely  and  scantily 
upon  the  face,  and  the  palms,  soles,  neck,  and  scalp  are  nearly  always  free. 
The  hair  is  dry,  dusty-looking,  and  dull. 

The  itching  is  severe,  and  rubbing  of  the  irritated  part  causes  thickening 
of  the  skin.  When  the  disease  is  so  intense  as  to  be  properly  designated 
prurigo,  the  papules  and  scales  are  more  numerous  and  of  greater  size,  and 
other  eruptions  may  appear,  obscuring  somewhat  the  diagnosis,  as  eczema, 
urticaria,  ecthyma,  and  glandular  enlargements  in  the  lymphatic  system. 

Etiology. — Bad  hygiene,  and  especially  the  lack  of  proper  food,  are 
important  causes.  It  usually  begins  early  in  life,  even  in  the  first  year.  It 
is  not  until  between  the  second  and  fifth  year  that  the  disease  is  fully  devel- 
oped, the  papules  becoming  more  numerous  than  at  first.  If  it  be  not 
actively  and  properly  treated  from  the  beginning,  it  is  likely  to  become 
chronic  and  troublesome.  Sometimes  children  well  nourished  and  in  good 
general  condition  are  affected. 

Pathology. — This  disease  is  probably  primarily  an  urticaria,  although 
Ehlers  regards  the  urticaria  as  a  mere  coincidence.  A  microscopic  examina- 
tion of  the  skin  shows  an  inflammatory  exudation  of  leucocytes  and  serum 
into  the  papillary  bodies  and  the  derma.  The  fluid  infiltrates  the  rete,  and 
by  destroying  the  cells  of  the  latter  elevates  the  stratum  lucidum  and  forms 
a  papule,  and  in  time  by  absorption  a  depression  or  pit  occurs.  The  second- 
ary changes  which  may  take  place  are  like  those  in  other  forms  of  chronic 
dermatitis. 

Diagnosis. — Itching  papules,  scabbed  at  the  top  and  dating  back  to 
infancy,  are  characteristic  of  this  disease.  They  have  a  pale-red  color,  occur 
chiefly  on  the  extensor  aspect  of  the  limbs,  and  are  accompanied  by  excoria- 
tions. Enlarged  glands,  secondary  eruptions  from  the  pruritus,  are  charac- 
ters upon  which  the  diagnosis  is  based.  Severe  chronic  eczema  lacks  the 
papules  and  secondary  lesions  of  prurigo.  Chronic  urticaria,  eczema,  ec- 
thyma, and  the  pruritus  from  pediculi,  acari,  or  from  other  causes  can  be 
diagnosticated  by  a  careful  examination  of  the  characters  present  and  the 
history  of  the  eruption. 

Prognosis. — The  prognosis  is  better  in  the  young  than  in  the  adult. 
Apparent  improvement  often  occurs  after  treatment,  but  the  appearances  of 
convalescence  are  likely  to  be  deceitful,  aggravation  of  symptoms  following 
their  decline. 

Treatment. — Measures  are  required  to  remove  the  eruptions,  those  per- 
taining to  the  disease  as  well  as  those  acquired  by  scratching,  and  also  to 
relieve  the  troublesome  pruritus  and  improve  the  health.  According  to 
Kaposi,  "  sulphur,  tar  soap,  and  naphthol  are  the  most  effective  agents  against 
the  itching  and  the  papular  eruptions ;  "  and  he  especially  recommends  naph- 
thol, which  during  the  last  ten  years  he  has  employed  in  all  cases  of  prurigo. 
When  applied  too  freely  this  remedy  may  produce  dangerous  symptoms  by 
absorption,  and  Kaposi  employs  only  a  1  to  2  per  cent,  of  naphthol  in  an 
emollient  ointment  for  children  under  the  age  of  ten  years.  Every  evening 
the  ointment  is  rubbed  into  the  extensor  surface  of  the  affected  limb,  and 
followed  by  a  dusting  powder.  Every  second  night  the  ointment  may  be 
washed  off  by  the  naphthol-sulphur  soap.     This  treatment  is  continued  until 


956  LOCAL  DISEASES. 

the  prurigo  disappears.  K  the  pruriginous  eruption  becomes  watery  and 
covered  with  scabs,  salicylic-acid  plaster  or  Wilkinson's  ointment,  modified 
by  Hebra  according  to  the  following  formula,  should  first  be  used  to  remove 
the  crusts,  before  the  naphthol  treatment  is  commenced : 

R.  Sulphuris  sublimati, 

01.  cadini,  da.  ^iv  ; 

Saponis  viridis, 

Adepis,  da.  ^j  ; 

Cretse  prseparata,  giiss. — IMisce. 

At  night. 

Eczema. — This  term  is  applied  to  a  catarrhal  inflammation  of  the  skin 
which  is  acute  or  chronic.  It  is  attended  by  itching,  often  severe,  and  by 
many  lesions,  including  papules,  erythema,  vesicles,  pustules,  scales,  and 
scabs,  while  a  discharge  of  serum  or  pus  commonly  occurs  upon  certain  parts 
during  the  progress  of  the  disease.  Four  forms  of  eruption  can  be  recog- 
nized during  the  course  of  most  cases — to  wit,  the  erythematous,  vesicular, 
papular,  and  pustular.  This  malady  is  very  common,  constituting,  it  is  be- 
lieved, as  much  as  one-fourth  of  the  cases  of  skin  disease.  Certain  forms  of 
it  are  very  persistent  notwithstanding  well-applied  treatment.  The  squamous 
form  of  eczema  is  regarded  as  a  subvariety  of  the  erythematous. 

Whatever  the  form  which  eczema  presents,  its  beginning  is  usually  acute, 
and  it  may  occur  upon  any  part  of  the  surface,  although  it  is  most  common 
in  certain  locations.  Vesicles,  erythema,  papules,  and  pustules  may  occur 
simultaneously  on  different  parts  of  the  body  or  upon  the  same  parts. 

Eczema  Vesiculosum. — This  is  most  common  where  the  skin  is  thin,  as 
behind  the  ears  and  between  the  fingers.  Pruritus  and  burning  occur,  fol- 
lowed by  erythema,  and  soon  after  by  minute  transparent  vesicles,  which 
enlarge,  and  some  of  which  unite  and  some  rupture,  allowing  the  escape  of 
a  liquid  which  stiffens  and  stains  linen.  The  vesicles  rupture  either  by 
scratching  or  spontaneously,  with  some  relief  to  the  itching,  but  the  burning 
remains,  making  the  child  restless,  especially  at  night.  After  the  rupture  of 
the  primary  vesicles  the  burning  and  itching  continue  from  the  raw  surface 
or  from  fresh  vesicles.  It  is  at  this  stage,  when  the  vesicles  are  mostly 
broken,  that  the  physician  is  usually  summoned.  If  there  be  but  little  dis- 
turbance of  the  inflamed  surface,  yellow  crusts  form  in  the  site  of  the  vesi- 
cles, and  they  are  renewed  when  removed. 

In  favorable  cases  the  exudation  and  redness  soon  begin  to  diminish,  and 
gradually  disappear,  or  the  affected  surface  may  remain  red  and  thickened, 
and  become  covered  with  scales,  producing — 

Eczema  Squamosum. — In  this  form  of  eczema  the  intensity  of  the  inflam- 
mation has  diminished.  It  most  frequently  appears  after  eczema  erythema- 
tosum.  It  occurs  when  the  inflammation  is  of  so  low  a  grade  that  but  little 
exudation  takes  place,  but  hyperplasia  of  the  rete-cells  is  present.  This  form 
of  eczema  appears  in  patches  of  variable  size ;  coarse  or  fine  scales  cover  the 
thickened  and  hyperaemic  cuticle,  which  can  be  readily  detached.  It  occurs 
especially  on  the  neck  and  limbs,  and  in  a  mild  form  on  the  face,  as  thin 
scaly  eruptions,  with  no  marked  redness  or  infiltration.  This  was  formerly 
designated  pityriasis  simplex,  and  it  may  apparently  be  produced  by  applica- 
tions of  soap,  and  is  sometimes  accompanied  by  seborrhoea.  Instead  of  a 
diminution  of  the  exudation,  hyperaemia,  and  other  symptoms,  these  may 
increase,  and 

Eczema  rubrum  is  then  developed.  Eczema  rubrum  is  most  frequently 
a  sequel  of  the  vesicular  or  pustular  form,  although  it  may  result  from  the 
other  varieties.     The  inflammation  is  severe,  and  the  skin  is  denuded  of  the 


DISEASES  OF  THE  SKIN.  957 

upper  layer  of  tlie  epithelium,  has  a  bright  or  dusky-red  hue,  is  moist,  and 
discharges  a  clear  or  glairy  fluid,  which  may  form  yellowish  or  brownish 
crusts.  This  form  of  eczema  is  not  common  in  children,  but  in  adults  the 
crusts  may  cover  a  considerable  part  of  a  limb,  and  when  their  borders  are 
detached  they  come  off  easily.  The  surface  underneath  is  very  moist,  and 
sometimes  blood  exudes  from  it  on  pressure  or  slight  friction.  The  infiltra- 
tion and  induration  in  eczema  rubrum  are  greater  than  in  other  forms  of 
eczema.     In  the  flexures  they  produce  sometimes  painful  fissures. 

Eczema  Pustulosum  or  Impetiginodes. — Instead  of  vesicles,  pustules  occur, 
due  to  the  irritating  action  of  cocci.  They  may  appear  primarily,  or  the 
vesicles  may  increase  in  size  and  become  pustules.  It  is  more  common  in 
children  than  in  adults,  and  in  the  cachectic  than  in  those  in  good  health. 

Eczema  pajntlosum,  formerly  designated  lichen  simplex,  is  the  term 
applied  to  that  form  of  the  disease  in  which  papules  are  produced  by  inflam- 
mation in  the  hair-follicles.  They  are  discrete  or  in  groups,  or  even  con- 
fluent, and  are  seated  usually  upon  the  back  or  extensor  aspect  of  the  limbs, 
accuminate,  and  not  larger  than  a  pin's  head ;  they  have  a  bright  or  dull 
red  color.  They  may  remain  papules,  or  with  a  lens  a  minute  quantity  of 
fluid  may  be  observed  at  the  top  of  the  papules,  being  the  disease  formerly 
designated  lichen  agrius. 

Eczema  erythetnatosnm  occurs  in  its  typical  form  on  the  face,  and  is 
attended  with  heat  and  swelling.  It  begins  in  patches  of  an  erythematous 
appearance,  which  may  extend  and  coalesce  or  remain  discrete.  The  color 
is  bright  or  dull  red,  and  the  surface  has  slight  scaliness,  but  no  discharge. 
The  disease  gradually  abates,  but  periods  of  recrudescence  are  common  until 
the  final  cure. 

Several  other  forms  of  eczema  are  described  by  dermatologists,  according 
to  the  anatomical  character  of  the  eruption  or  regions  aff"ected,  as  eczema 
acutum,  eczema  chronicum,  eczema  sclerosum,  eczema  spargosiforme,  eczema 
verrucosum,  eczema  papillomatosum,  eczema  capitis,  eczema  genitalium,  ecze- 
ma palmare,  capitis  et  faciei,  eczema  rimosum,  etc. 

In  children,  especially  in  those  under  the  age  of  five  years,  the  erythema- 
tous eruption  is  much  more  likely  to  become  pustular  than  in  those  who  are 
older.  The  tendency  of  diseases  to  become  pustular  is  indeed  exhibited  in 
other  forms  of  inflammation  in  childhood.  Irritants,  whether  acting  externally 
on  the  skin  or  internally  through  the  digestive  system  and  in  a  reflex  manner, 
produce  an  eczema  upon  some  part  of  the  cutaneous  surface  much  more 
readily  in  children  than  in  adults.  Frequently  in  children  the  disease  occurs 
upon  the  head,  cheeks,  and  behind  the  ears.  In  children  having  the  strumous 
cachexia  the  inflammation  sometimes  extends  more  deeply,  causing  subcuta- 
neous abscesses,  and  the  adjacent  cervical  and  occipital  glands  frequently 
undergo  hyperplasia. 

Age. — Crocker  states  that  the  statistics  in  a  large  number  of  cases 
observed  by  him  show  that  one-third  of  all  those  occurring  in  children  com- 
mence in  the  first  year :  in  the  second  and  third  years  the  numbers  were 
about  equal ;  and  after  the  third  year  the  number  gradually  declined  until 
the  sixth  year,  and  from  that  age  until  the  thirteenth  year  the  numbers  each 
year  were  about  the  same. 

According  to  Unna,  the  eczema  of  the  face  and  head  in  children  arises 
from  three  different  causes  :  First,  the  seborrhoeic,  commencing  perhaps  as  a 
seborrhoea  of  the  scalp.  It  extends  to  the  ears,  forehead,  and  eyebrows.  It  may 
extend  to  the  shoulders  and  upper  part  of  the  arms.  Secondly,  the  nervous 
form,  which  is  believed  to  be  due  in  some  cases  to  gastro-intestinal  irritation. 
It  occurs  especially  on  the  lower  part  of  the  arm  and  back  of  the  forearm. 
Third,  the   tubercular  form,   which  is  found  chiefly  in  strumous   children 


958  LOCAL  DISEASES. 

poorly  fed  and  eared  for,  and  is  often  connected  with  strumous  conjuncti- 
vitis, rhinitis,  or  otorrhoea.  Crocker  regards  it  as  a  dermatitis  produced  hy 
"  contagious  pus."  If  the  conjunctivitis  or  rhinitis  be  cured  by  appropriate 
treatment,  this  form  of  eczema  disappears  by  antiseptic  applications. 

Etiology. — The  causes  are  very  numerous.  Irritants  which  by  their 
effect  upon  the  surface  produce  eczema  are  chemical,  thermal,  or  mechanical. 
Among  the  substances  that  produce  eczema  by  their  chemical  properties  are 
the  dilute  acids,  the  soaps  containing  too  much  alkali,  irritating  medicinal 
agents,  as  turpentine,  tartar  emetic,  croton  oil,  and  other  substances  which 
are  highly  irritating  when  applied  to  the  skin.  The  thermal  causes  occur 
from  the  heat  of  the  sun  or  artificial  heat,  and  we  therefore  observe  it  espe- 
cially in  those  who  by  their  occupations  are  exposed  to  a  high  temperature, 
as  laundry-women,  blacksmiths,  and  cooks.  Cold  and  wet  also  operate  as 
causes.  Among  the  mechanical  causes  are  friction  from  tight  or  rough  and 
irritating  clothing,  scratching  to  relieve  itching,  and  dust  occurring  in  various 
occupations. 

The  constitutional  causes  of  eczema  must  not  be  overlooked.  The  general 
health  is  very  likely  to  be  impaired  when  eczema  supervenes.  The  patient 
is  languid,  and  no  longer  has  the  clear  and  ruddy  complexion  of  health.  He 
is  lacking  in  energy,  and  his  nervous  system  is  probably  exhausted  or  in  the 
state  known  in  America  as  neurasthenia. 

Among  the  external  causes  of  eczema,  derangement  of  the  digestive 
system  has  a  prominent  place.  Diarrhoea  or  constipation  is  so  frequently  a 
concomitant  of  eczema  in  children  as  well  as  adults  that  it  probably  sustains 
a  causal  relation  to  this  disease.  Improper  feeding  of  infants,  causing  irri- 
tation and  perhaps  catarrh  of  the  intestinal  surface,  is  also  regarded  as  a 
common  cause  of  eczema.  It  is  known  that  the  rachitic  are  very  liable  to 
catarrhal  inflammations  of  the  various  surfaces,  and  Crocker  and  others  regard 
rachitis  as  a  cause  of  eczema.  Certain  dermatologists  also  regard  struma  as 
a  cause  of  pustular  eczema. 

Pathology. — Eczema  is  a  catarrhal  inflammation  of  the  skin,  and 
many  leading  dermatologists  regard  it  as  a  peripheral  or  central  tropho- 
neurosis when  not  caused  by  local  irritation.  Unna  believes  that  eczema 
is  caused  by  an  undetermined  micrococcus,  but  the  opinion  expressed  by 
Crocker  seems  to  be  more  plausible,  ••  that,  while  a  limited  number  of  local 
eczemas  are  parasitic,  in  most  the  dermatitis,  however  caused,  only  opens  the 
door  to  parasites,  whose  presence  keeps  up  local  irritation,  and  that  their 
destruction  is  an  important  step  in  the  restoi'ation  of  the  skin  ad  integrum^ 

The  following  remarks  relating  to  the  anatomy  of  eczema,  together  with 
the  illustrations,  have  been  kindly  furnished  by  Dr.  A..  R.  Robinson,  the  dis- 
tinguished professor  of  dermatology  at  the  Xew  York  Polyclinic  : 

"  Anatomy. — Regarding  the  term  '  eczema '  as  equivalent  to  catarrhal 
dermatitis,  a  term  having  a  pathological-process  significance  more  than  rep- 
resenting a  special  disease,  a  clinical  entity — for  the  catarrhal  dermatitis  or 
so-called  eczematous  inflammation  can  be  caused  by  many  different  factors — 
it  follows  that,  as  in  other  inflammatory  processes,  the  histological  changes 
will  vary  as  regards  intensity  and  character  in  different  cases  depending  upon 
the  vulnerability  of  the  tissues  affected,  the  kind  of  agent  causing  the  changes, 
and  the  quantity  and  duration  of  action  of  the  injurious  agent.  As  the  ma- 
jority of  the  cases  of  eczema  in  children  are  local  diseases  caused  by  micro- 
organisms, the  nature  of  the  ground  and  the  kind  of  organism  are  the  deter- 
mining factors  in  the  tissue-changes. 

'■  In  the  erythematous  form  all  the  vessels  of  the  papillary  layer  of  the 
affected  area  are  changed,  as  in  any  mild  inflammatory  process.  The  blood- 
vessels are  dilated,  the  walls  are  chanaed.  there  is  abnormal  transudation  and 


DISEASES  OF  THE  SKIN. 


959 


emigration  into  the  surrounding  tissue,  probably  in  consequence  of  the  leuco- 
toxic  and  serotoxic  action  of  the  toxines  from  the  organisms  lying  within  or 
upon  the  epidermis,  and  the  epidermis  itself  is  more  or  less  flooded  and  in- 
vaded by  this  exudation  and  emigration.  As  a  consequence,  the  rete-cells 
are  slightly  swollen  from  imbibition  of  serum,  the  intercellular  spaces  are 
dilated,  and  besides  serum  contain  an  occasional  emigrant  corpuscle.  The 
corneous  layer  also  suffers  from  the  transudation.  The  normal  cohesion  of 
the  cells  is  interfered  with  and  lessened,  and  slight  desquamation  resiilts. 

'•  When  the  lesions  are  papular  in  character,  they  are  usually  situated  in  a 
hair-follicle  or  sweat-gland  area,  especially  the  former,  as  the  orifices  of  these 
structures  make  favorable  camping-ground  for  organisms,  and  the  blood-vessel 
supply  is  comparatively  large  in  these  areas.  The  vascular  changes  need  not 
be  described,  as  their  discussion  belongs  to  general  pathology.  There  are  exu- 
dation and  emigration,  with  secondary  changes  in  the  corium  and  epidermis. 
The  exudation  causes  swelling  of  the  papillar  and  upper  part  of  the  corium. 
A  portion  of  the  exudation  passes  into  the  rete,  causing  oedema  of  the  rete- 
cells,  with  disordered  molecular  constitution  or  complete  destruction.  The 
spaces  between  the  cells  are  enlarged  by  the  serum,  the  connecting  spindles 
are  lengthened  or  torn,  and  individual  cells  may  become  isolated.  The  normal 
coherence  of  the   corneous  cells  is  disturbed  and  desquamation  follows. 

"  If  the  process  is  more  intense  as  regards  transudation  of  serum,  the  col- 
lection of  the  liquid  within  the  rete  gives  rise  to  a  vesicle.  In  this  ease  a 
clear  space  forms  in  the  upper  part  of  the  rete,  usually  just  below  the  granu- 
lar layer  or  stratum  lucidum,  containing  serum  and  more  or  less  detached 
rete-cells  suspended  in  the  serum.  The  walls  are  iisually  ill  defined,  and 
the  rete-cells  much  deformed  as  well  as  changed  chemically.  The  corneous 
layer  is  more  broken  up  than  in  the  papular  form.     In  Fig.  266  is  shown  a 

Fig.  266. 


Vertical  section  of  a  recent  vesicle  of  parasitic  eczema :  a,  corneous  layer ;  b,  rete ;  c,  corium ;  d, 
vesicle  ;  e,  dilated  blood-vessel  (after  A.  K.  Robinson). 

section  of  a  recent  vesicle,  the  result  of  the  action  of  a  local  agent.  The  cells 
of  the  rete  do  not  take  any  active  part  in  the  early  changes  that  lead  to  the 
formation  of  the  vesicle,  and  in  eczema  there  are  no  reasons  for  assuming  a 


960  LOCAL  DISEASES. 

primary  patliologieal  condition  of  the  rete  causing  the  vascular  changes.  It 
seems  more  correct  to  regard  the  exudation  and  emigration  and  their  conse- 
quences as  the  result  of  a  chemotoxic  action — a  leucotaxis  and  serotaxis 
caused  by  the  toxine  in  all  the  cases  of  parasitic  eczema. 

''  The  vesicle  at  first  consists  of  clear  serous  fluid  and  a  few  isolated  or 
broken-down  rete-cells,  but  later  pus-corpuscles  are  usually  present  and  con- 
tinue to  increase  the  longer  the  vesicle  exists.  The  pustular  character  de- 
pends generally  upon  secondary  infection  by  pus-organisms.  As  long  as  the 
rete  is  thus  injured  by  the  inflammatory  process  normal  epithelium  cannot 
form.  The  organisms  must  be  destroyed  and  the  circulatory  disturbance 
corrected  by  appropriate  treatment. 

"  In  neurotic  eczema  (toxic  eczema)  the  vesicles  are  frequently  more  or 
less  grouped,  and,  I  think,  often  deeper-seated  than  when  the  primary  cause 
is  a  local  one.  The  disorganization  of  the  rete  is  not  so  great ;  the  vesicle  is 
formed  by  serum  that  makes  a  vesicle-area  by  pushing  aside  and  compressing 
the  rete-cells  more  than  by  causing  rvipture  of  the  connecting  spindles.  For 
quite  a  distance,  however,  beyond  the  clear  vesicle  the  rete-cells  that  are  not 
flattened  out  show  an  oedematous  condition  from  serum  imbibition  interfer- 
ing with  normal  epidermis  cell-formation  and  change.  The  lower  rows  of 
rete-cells  are  not  so  changed  as  in  the  parasitic  form,  neither  does  the  serous 
transudation  into  the  corium  and  papillary  layers  appear  to  be  so  great. 
Perivascular  round-cell  collection  is  more  prominent  than  the  transudation. 
The  corneous  layer  is  also  less  aff"ected,  and  the  vesicles  as  a  consequence  are 
less  liable  to  rupture. 

"  In  Fig.  267  is  shown  a  section  of  a  group  of  vesicles  from  the  palm  of 
the  hand.  The  eruption  was  symmetrical  and  the  lesions  grouped.  In  these 
cases  the  lesions  do  not  tend  to  form  around  a  hair-follicle,  and  may  remain 
limited  to  a  small  area  for  a  long  period. 

"  In  cases  of  eczema  in  which  there  is  a  difiiise  surface  (catarrhal  derma- 
titis) the  exudation  is  not  so  liable  to  form  papules  or  vesicles,  but,  apart 
from  that,  the  histological  characters  do  not  call  for  special  description.  If 
there  is  a  mixed  infection  from  pus-organisms,  the  serous  exudation  becomes 
purulent  in  character — a  condition  often  justifying  the  use  of  the  term  sup- 
purative catarrhal  dermatitis  or  impetiginous  eczema. 

"  The  seborrhoeal  form  of  eczema  is  always  caused  by  organisms  which 
reside  in  the  epidermis  and  cause  a  subacute  dermatitis,  in  which  it  is  rare 
to  find  vesicles  or  pustules.  In  this  form  of  disease  the  corneous  layer  is 
disturbed,  and  the  cells  are  thrown  ofi"  in  lamellar  form  ;  the  rete  shows  en- 
larged intercellular  spaces,  and  the  prickle-cells  undergo  various  degrees  of 
degeneration.  In  the  corium  the  blood-vessels  are  dilated ;  there  is  a  mod- 
erate amount  of  serous  transudation  and  a  marked  perivascular  round-cell 
infiltration. 

''  In  chronic  eczema  rubrum  the  corium  is  thickened  from  exudation  and 
round-cell  infiltration  and  plasma-cell  formation.  The  papillae  are  enlarged 
from  the  same  cause.  The  boundary  between  the  corium  and  the  rete  is 
often  dif&cult  or  impossible  to  recognize,  on  account  of  the  round-cell  col- 
lection and  inflammatory  changes  on  the  one  side,  and  the  changes  in  the 
rete  on  the  other  side  destroy  the  characteristic  boundary-line.  In  the  rete 
the  lower  rows  of  cells  are  separated  from  each  other  and  intermingled  with 
serum  and  lymphoid  cells.  The  rete-cells  are  swollen,  oedematous,  and  ex- 
hibit various  degrees  and  forms  of  degeneration.  The  shape  is  also  distorted, 
and  may  be  roundish,  oval,  or  spindle-form,  with  even  or  irregular  outline. 
Vacuolation-areas  are  frequently  present,  and  the  vesicles  may  be  the  only 
part  to  color  with  staining  dyes.  The  granular  layer  is  generally  imperfectly 
formed,  and  hence  an  abnormal  corneous  layer,  many  cells  of  which  still  show 


DISEASES  OF  THE  SKIN. 


961 


a  nucleus.  This  corneous  layer  is  more  or  less  thinned,  the  surface  irregular, 
and  the  normal  union  of  the  cells  disturbed  or  destroyed.  The  lymph-spaces 
between  the  rete-cells  are  enlarged,  as  already  mentioned ;  the  rete-cells  are 
oedematous,  the  granular  layer  is  changed,  the  corneous  layer  partly  de- 
stroyed ;  hence  in  chronic  eczema  of  this  form — the  clinically  chronic,  but 


Fig.  267. 


.  \ 


hi 

-a 


,'ii  \\\ 


Section  of  a  group  of  vesicles  in  a  case  of  neurotic  (toxic)  eczema  of  the  palms  :  a,  corneous 
layer ;  6,  stratum  lucidum ;  c,  rete ;  d,  corium ;  e,  dilated  blood-vessel ;  /,  vesicle  (after  A.  R. 
Robinson). 

histologically  acute — the  above-described  changes  greatly  favor  a  continuance 
of  the  disease.  The  indications  in  treatment  would  be  astringents  for  the 
circulatory  disturbance  and  oedema  of  the  rete,  and  keratoplastie  applications 
for  the  epidermis,  together  with  treatment  for  the  direct  cause,  which  is 
usually  a  microbe. 
61 


962 


LOCAL  DISEASES. 


"  The  longer  an  eczema  lasts,  the  deeper  are  the  inflammatory  changes,  and 
the  thicker  the  skin  as  a  consequence.  In  long-continued  inflammations  the 
hair-follicles  and  sebaceous  glands  may  be  destroyed,  but  that  is  an  unusual 
occurrence. 

"  Occasionally  as  the  result  of  an  eczematous  condition  a  hyperplastic 
process  takes  place,  by  which  the  corium,  including  the  papillae,  is  hyper- 
trophied  from  new  connective-tissue  formation,  giving  the  affected  area  a 
warty  appearance,  which  has  been  described  as  eczema  verrucosum.  In 
Fig.  268  is  shown  a  section  of  chronic  eczema  rubrum  with  the  changes  just 


Section  from  a  patch  of  chronic  eczema  of  the  leg :  o,  corneous  layer ;  6,  stratum  lucidum  stri- 
atim;  c,  papillae ;  d,  interpapillary  rete  ;  e,  deep  part  of  corium  (after  A.  R.  Robinson). 


described.  The  round  cells  and  nuclei  should  have  been  drawn  as  deeply- 
stained  objects  to  bring  out  the  drawing.  The  broken-up  corneous  layer  is 
well  shown,  as  well  as  the  merging  of  the  rete  and  subepidermal  tissues  into 
each  other. 

"  In  chronic  eczema  squamosum  the  corium  and  papillae  show  dilated 
blood-vessels  and  round-cell  collection,  with  more  or  less  disappearance  of 
the  ground-substance.  The  epidermis  is  not  much  changed  ;  there  is  slight 
enlargement  of  the  intercellular  spaces  in  the  rete  and  also  in  the  corneous 
layer,  with  consequent  cell-desquamation — scale-formation — in  macroscopi- 
cal  quantity." 

Diagnosis. — This  may  be  difficult  or  easy.  It  is  comparatively  easy  if 
the  case  be  one  of  the  four  typical  forms  of  eczematous  eruption — to  wit,  the 
vesicular,  pustular,  papular,  and  erythematous — or  if  there  be  the  history  of 
a  continuous  discharge,  whether  serous  or  pustular,  which  stains  or  stiffens 
linen.  Vesicles  or  pustules  not  eczematous  dry  without  rupture,  or  if  rup- 
tured dry  as  soon  as  the  liquid  escapes. 

The  following  mistakes  in  diagnosis  may  occur : 

Vesicular  eczema  and  scabies  may  be  mistaken  for  each  other.  Both 
have  itching  and  produce  vesicles,  pustules,  crusts,  and  scales.     The  history 


DISEASES  OF  THE  SKIN.  963 

of  contagion  of  course  indicates  scabies.  The  presence  of  this  disease  between 
the  fingers,  upon  the  wrists,  and  the  flexures  generally  is  also  characteristic 
of  scabies,  although  eczema  may  occur  in  these  situations.  In  doubtful 
cases  the  treatment  for  scabies  will  quickly  determine  the  nature  of  the 
malady,  and  the  use  of  remedies  which  destroy  the  acarus  is  justified  as  a 
means  of  diagnosis. 

Syphilitic  pustules  on  the  scalp  often  resemble  the  pustules  of  eczema, 
but  they  diifer  from  the  latter  in  the  occurrence  of  ulcers  and  scars,  in  the 
presence  of  a  peculiarly  offensive  odor,  and  in  being  more  circumscribed. 

There  is  a  considerable  number  of  other  diseases  which  might  by  careless 
examination  be  mistaken  for  certain  forms  of  eczema,  and  vice  versa,  and 
to  make  accurate  diagnosis  in  many  instances  requires  a  careful  examination 
and  frequently  more  than  one  visit. 

Prognosis. — Eczema  is  usually  a  chronic  disease  if  correct  treatment  be 
not  employed,  but  with  correct  treatment,  perseveringly  applied,  a  gradual 
cure  is  usually  effected.  Fortunately,  certain  causes  of  eczema  which  render 
it  obstinate  in  the  adult  do  not  exist  or  are  rare  in  the  child,  as,  for  example, 
varicose  veins  or  gout. 

Treatment. — The  general  condition  of  the  child  should  be  carefully 
investigated,  so  as  to  ascertain  if  there  be  any  injurious  influence,  dietetic, 
iygienic,  or  other,  which  impairs  the  general  health.  This  if  present  should 
be  removed,  or  so  far  as  possible  modifled.  The  condition  of  the  digestive 
system  must  especially  receive  attention.  Constipation  is  common  in  the 
eczematous,  and  must  be  removed  as  preliminary  treatment.  If  the  consti- 
pation be  chronic,  a  few  drops  (according  to  the  child's  age)  of  the  liquid 
extract  of  cascara  sagrada  should  be  given  once  or  twice  daily.  In  some 
cases,  especially  in  robust  children,  a  mineral  water,  as  Carlsbad,  may  be 
advantageously  given  two  or  three  times  weekly,  or  magnesia  calcinat.  in 
lemon-water. 

Infants  of  one  or  two  years  are  very  liable  to  intestinal  catarrh,  especially 
after  weaning,  and  such  infants  are  prone  to  eczema.  These  infants  should 
receive  the  treatment  which  is  recommended  in  another  part  of  this  book. 
The   diet  should  be  selected  and  prepared  with  great  care. 

Local  Treatment. — The  eczematous  surface  should  not  be  washed  with 
plain  water,  since  it  is  irritating  and  retards  convalescence,  and  it  should  not 
be  exposed  to  the  air  or  winds.  The  exception  may  be  in  strumous  cases, 
when  out-door  life  may  be  of  service  in  improving  the  general  health.  In 
the  first  place,  the  crusts  and  scales  should  be  entirely  removed  if  possible, 
so  that  the  remedy  subsequently  applied  will  reach  the  surface.  Commonly 
a  poultice  is  applied  for  three  or  four  hours.  A  better  plan  is  to  apply  strips 
of  flannel  soaked  with  sweet  oil  until  the  crusts  are  softened  by  the  oil,  so  that 
they  can  be  detached.  Or  the  application  may  consist  of  two  drachms  of 
bicarbonate  of  sodium  added  to  one  quart  of  the  decoction  of  marshm allow 
or  thin  gruel.  The  oil  or  poultice  should  be  applied  night  and  morning,  and 
the  softened  and  detached  crusts  removed  at  each  dressing. 

Eczema  presents  so  many  difl^erent  forms  that  the  proper  external  remedy 
varies  in  different  cases.  Generally  in  acute  or  subacute  forms  of  the  disease 
the  applications  should  be  constant.  Intermissions  in  treatment  should  not 
occur  except  in  the  chronic  or  dry  forms  of  the  malady.  It  is  necessary  for 
successful  treatment  to  protect  the  surface  from  the  air,  so  as  to  exclude  the 
microbes  which  it  contains,  for  microbes,  especially  in  the  foul  air  of  a  city, 
irritate  the  diseased  surface  and  tend  to  keep  up  the  inflammation. 

Ordinarily,  dusting  powders  or  lotions  should  be  preferred.  Ointments  are 
preferable  if  the  discharge  is  light,  and  hard  pastes  over  dry  surfaces.  When 
there  is  much  hyperasmia  and  discharge  non-irritating  antiseptic  applications 


964  LOCAL  DISEASES. 

are  the  most  useful.  It  is  better  ordinarily  to  employ  mild  applications  in 
the  beginning  of  the  treatment  of  a  case  until  we  ascertain  how  tolerant  the 
skin  is  of  remedies.  Keratolytic  treatment,  or  such  as  softens  or  loosens  the 
skin,  is  required  if  the  eruption  be  indolent  and  scaly  or  much  thickening  and 
itching  be  present.  The  astringent  preparations  used  in  the  treatment  of 
skin  diseases  are  mainly  the  preparations  of  zinc,  lead,  bismuth,  boric  acid,  and 
alum.  Among  the  important  antiseptics  are  resorcin,  salicylic  acid,  ichthyol, 
and  its  equivalent,  thiol.  Lotions  containing  powders  in  suspension,  like 
bismuth,  applied  to  the  diseased  surface  and  allowed  to  dry  leave  a  deposit 
which  protects  the  surface.  They  are  useful  when  the  discharge  is  slight  or 
absent.  They  should  not  be  applied  on  parts  covered  by  hair.  They  relieve 
the  itching  of  a  papular  eczema,  and  often  will  abridge  this  disease  or  prevent 
its  recurrence  if  healed.  In  cases  requiring  strong  lotions,  as  nitrate  of  silver, 
permanganate  of  potassium,  or  tar,  the  surface  should  be  painted  from  one  to 
three  times  daily. 

Soothing  applications  in  the  form  of  liniments  or  ointments  should  be 
thickly  spread  on  strips  of  lint  and  linen,  and  they  may  be  reapplied  twice 
daily.  Stimulating  antiseptic  ointments,  unless  quite  weak,  seldom  require 
constant  use.  They  may  be  applied  once  or  twice  daily,  and  the  skin  should 
be  protected  from  the  air  when  they  are  not  in  use. 

In  subacute  eczema  the  following,  known  as  Lassar's  soft  paste,  is  useful : 

R.  Zinci  oxidi     I  .-      .. 
Pulv.  amyli,  J  '-'•'' 

Petrolati,  ^ss ; 

Acidi  salicylici,  gr.  x. — Misce. 

Ten  or  twenty  grains  of  the  boric  acid  may  be  substituted  for  the  salicylic 
acid. 

A  similar  paste  is  Ihle's,  having  the  following  formula : 

R.  Lanolin,  "1 

Petrolati,  I  ""    ^'i  • 

Zinci  oxidi,  f  •  6  J  > 

Pulv.  amyli,  J 
Eesorcin,  gr.  x. 

These  pastes  should  be  spread  thickly  on  the  part  and  covered  by  a  many- 
tailed  bandage  of  porous  cloth. 

The  pastes  which  become  firm  contain  gelatin,  glycerin,  and  zinc.  Unna's 
is  one  of  the  best  of  them.     It  has  the  following  formula : 

R.  Gelatini,       1  ..    „. 

Zincioxk,  I  ««•  3iss; 
Glycerini,  ^iij  ; 

Aquae,  ^iv. — Misce. 

Unna  usually  adds  2  per  cent,  of  ichthyol,  but  if  this  kind  of  medicine  is 
required,  thiol,  which  is  the  chemical  equivalent  of  ichthyol,  may  be  substi- 
tuted for  it,  and  other  antiseptics  may  be  added  if  needed.  These  pastes  are 
properly  used  upon  surfaces  that  are  dry  or  with  little  discharge.  The  paste 
is  heated  in  a  spoon  or  convenient  vessel  until  it  is  liquid,  when  it  has  the 
consistence  of  cream.  It  may  be  applied  with  a  stiff  brush  or  with  the  side 
of  the  finger,  and  cotton  wool  daubed  upon  it  to  prevent  adhesion  to  the 
clothing. 

If  the  discharge  of  an  eczematous  eruption  be  considerable,  desiccating 
powders  are  required,  as  the  following : 


DISEASES  OF  THE  SKIN.  965 

R .  Zinci  oxidi,  1  part ; 

PuIy.  amyli  (rice  or  maize),  3  parts. — Misce. 


R.  Zinci  oxidi,  ~)  . 

Lycopodii,   ri^^lP^^'t^- 


R,  Bismuthi  subnitrat.,  3J  ; 

Zinci  stearat.,  ^ij. — Misce. 

In  eczema  that  is  extensive,  and  not  profuse,  the  surgeon's  lint  soaked 
with  calamine  liniment  (prepared  calamine,  9ij  ;  zinci  oxidi,  gss ;  lime-water 
and  olive  oil,  da.  §ss)  makes  a  soothing  and  effectual  application.  When  the 
discharge  is  profuse  the  glycerole  of  the  subacetate  of  lead  1  :  10,  applied 
warm,  is  one  of  the  best  applications.  The  ammoniated  or  yellow  oxide  of 
mercury,  gr.  10  to  60,  rubbed  up  with  glycerin  1  ounce,  is  useful  for  scaly 
patches  and  for  the  scalp  when  the  acute  stage  has  abated.  Some  derma- 
tologists, when  the  inflammation  has  considerably  abated,  add  a  small  amount 
of  a  mercurial  to  the  soothing  ointment  employed,  as  1  or  2  per  cent,  of  the 
oleate  of  mercury  upon  localized  patches. 

In  pustular  eczema  iodoform  or  aristol  is  the  most  eflicient  agent  for  local 
use.  From  5  to  10  grains  of  this  added  to  any  astringent  ointment,  such  as 
zinc  or  lead,  quickly  destroy  the  cocci  of  pus,  so  that  the  eruption  soon 
becomes  serous  or  dry.  I  have  obtained  benefit  by  applying  sweet  oil  over 
the  pustular  patches  and  dusting  aristol  over  the  oil. 

Tar  is  a  useful  remedy  if  applied  at  the  right  stage  or  in  the  right  form 
of  eczema.  Its  use  is  not  indicated,  and  it  may  do  harm,  in  acute  eczema. 
It  is  most  useful  in  the  squamous  and  papular  forms,  effectually  relieving  the 
irritation,  as  in  the  following  formula  : 

R.  Olei  picis  liquidse,  ^ss-^j  ; 

Olei  cadini,  vi\jv  ; 

Ung.  aquae  rosse,  ^ij . — Misce. 
Apply  tliree  or  four  times  daily. 

Eczema  is  so  common  that  it  will  aid  the  physician  to  call  to  mind  the 
mode  of  treating  different  forms  of  it  by  prominent  dermatologists.  White 
of  Boston  and  Duhring  of  Philadelphia  employ  for  acute  eczema  the  lotio 
nigra,  either  of  the  full  strength  or  diluted  with  an  equal  quantity  of  water. 
It  is  applied  with  a  sponge  or  a  wad  of  absorbent  cotton  for  a  quarter  of  an 
hour.  The  black  powder  is  allowed  to  remain  on,  and  then  a  little  zinc  oint- 
ment is  smeared  over  it,  and  this  is  repeated  every  three  or  four  hours. 

Unna  of  Hamburg  strongly  recommends  ichthyol,  applied  externally,  in 
eczema.  As  an  ointment  or  lotion  of  the  strength  of  5  to  50  per  cent,  it  is 
applied  on  the  moist  obstinate  patches  which  often  occur  on  the  hands  and 
arms.  Used  in  the  percentage  mentioned,  a  good  vehicle  for  it  is  Unna's  zinc 
paste  mentioned  above.  Thiol,  which  has  the  same  chemical  characters  as 
ichthyol,  may  be  used  in  place  of  the  latter,  as  it  is  less  offensive. 

A  very  important  part  of  Crocker's  recent  treatise  on  skin  diseases,  which 
two  prominent  New  York  dermatologists  inform  me  is  the  best  book  yet 
published  in  this  branch  of  medicine,  relates  to  the  regional  treatment  of 
eczema.     His  remarks  on  this  subject  I  will  condense,  as  follows : 

Eczema  of  the  Head. — Cut  the  hair  short.  Soften  the  crusts  with  strips 
of  flannel  dipped  in  oil,  and  fasten  them  on  with  a  calico  cap  for  four  to  six 
hours.  The  crusts  may  then  be  removed.  If  the  disease  be  eczema  pustu- 
losum,  gr.  V  of  iodoform  to  §j  of  vaseline  on  strips  of  lint  should  be  kept 
on  with  the  cap,  and  renewed  morning  and  evening.  The  old  ointment 
should  be  wiped  off.     In  a  week  the  eruption  will  be  serous  or  dry. instead 


966  LOCAL  DISEASES. 

of  pustular.  Oleate  of  zinc  or  lead  or  boracic  acid,  ^ss  to  5J,  should  then 
be  substituted  in  place  of  the  iodoform,  with  perhaps  later  the  addition  of  a 
few  grains  of  ammoniated  mercury. 

In  eczema  vesiculosum  these  ointments  should  be  used  at  once.  Where 
there  is  much  irritation  a  few  minims  of  the  oil  of  cade  to  the  ounce  is  a 
good  addition,  and  the  hairs  should  be  extracted  if  there  is  pustular  inflam- 
mation around  them. 

Ecz&nia  of  the  Ears. — Calamine  liniment  (prepared  calamine,  ^ij  ;  zinei 
oxidi,  3SS  ;  lime-water  and  olive  oil,  da.  3ss),  freely  applied  and  painted  inside 
the  meatus  several  times  daily,  gives  most  relief.  The  lactate-of-lead  lotion 
(subacetate  of  lead,  3:],  and  fresh  milk,  gij),  shaken  well  in  the  bottle,  or  the 
glycerole  of  the  subacetate  of  lead  (subacetate  of  lead  1  part,  and  glycerin 
10  parts)  is  also  a  good  application. 

Eczema  0/ the  Face. — In  infants  this  is  common.  The  following  remedies 
are  useful  for  external  treatment :  Lassar's  paste,  described  above,  or  the 
lead,  zinc,  or  boracie-acid  ointment.  (The  lead  ointment  is  made  by  boiling 
together  equal  parts  of  diachylon  and  sweet  oil.)  The  boric-acid  ointment 
consists  of  finely-powdered  boric  acid,  gss,  and  benzoated  lard,  ^j  ;  and  Wil- 
son's "  ung.  zinci  oxidi  benzoat.,"  much  employed  for  eczema,  consists  of 
prepared  lard,  3iij  ;  powdered  benzoin,  ^ss.  Melt  together  at  a. gentle  heat 
for  twenty-four  hours  in  a  closed  vessel,  strain,  and  add  oxide  of  zinc,  3J. 
The  chief  difiiculty  is  to  prevent  scratching,  and  to  accomplish  this  almond 
oil  should  be  applied  under  the  dressing,  and,  if  necessary,  the  hands  secured 
to  the  sides  of  the  patient. 

Eczema  of  the  eyelids  (blepharitis),  common  in  the  scrofulous,  has  long 
been  successfully  treated  by  the  application  of  weak  mercurial  ointments. 
The  crusts  should  be  softened  with  oil  and  removed,  after  which  1  part  of 
the  ung.  hydrarg.  nitratis  and  8  parts  of  vaseline  should  be  smeared  along 
the  edges.  In  the  strumous  the  syrup  of  the  iodide  of  iron  should  be  em- 
ployed. 

Eczema  of  the  lips  sometimes  leads  to  fissures  resulting  from  the  frequent 
motion.  The  liq.  plumbi  subacetatis,  tt\^xv,  mixed  with  white  vaseline  or 
lard,  should  be  prescribed  for  application  over  the  lips,  or,  if  this  be  inade- 
quate, the  following  formula,  recommended  by  Hebra,  may  be  cautiously 
painted  on : 

R.  Acidi  carbolici,  ,^ij ; 

Glycerini,  T  ._    -. 

Athens,    /  "'^-  5J; 
Spts.  vini  recti,  ^vj. — Misce. 

Though  having  the  utmost  confidence  in  Hebra's  opinion,  I  think,  on  account 
of  the  highly  irritating  nature  of  carbolic  acid,  that  it  would  be  judicious  to 
employ  only  §ss  of  this  agent  in  the  above  prescription  for  children,  or  not 
use  it,  but  wait  for  the  slower  action  of  milder  measures. 

Eczema  of  the  Palms. — In  all  instances  it  is  necessary  to  remove  the 
thick  epidermis.  The  hard  and  thickened  skin  may  be  rubbed  by  pumice- 
stone  or  fine  sand-paper.  Unna's  plan  of  employing  salicylic-acid  plaster, 
applied  fresh  every  two  or  three  days,  is  good.  The  thickened  epidermis 
may  be  peeled  off  in  this  manner.  The  disintegration  and  removal  may  also 
be  produced  by  the  constant  application  of  a  pancreatic  emulsion. 

When  the  epidermis  is  removed  salicylic  acid,  gr.  x  to  Ix,  added  to  5J  of 
the  gelatin-zinc  paste,  which  is  useful  as  a  base,  should  be  applied,  and  re- 
newed once  in  twenty-four  hours.  Thiol  and  ichthyol  are  also  said  to  have  a 
good  effect  in  diminishing  the  thickness  of  the  epidermis,  but  if  either  be 


DISEASES  OF  THE  SKIN.  967 

used  it  should  be  witli  the  salicylic  acid,  the  efficacy  of  which  in  diminishing 
the  thickness  of  the  epidermis  is  well  known. 

Eczema  of  the  Nails. — This  disease  is  somewhat  protracted  on  account  of 
the  difficulty  in  applying  remedies  around  the  matrix.     A  useful  remedy  is — 

B  .  Aristol,  5j  ; 

Olei  olivse,  giij  ; 

Lanolin,  ^j. — Misce. 

A  good  remedy  also  is  salicylic  acid,  3J,  mixed  with  sweet  oil,  ^ss,  and 
lanolin,  gj. 

Eczema  genitalia  of  the  scrotum,  genitalia,  and  other  contiguous  parts 
sometimes  occurs.  All  causes  which  might  excite  this  inflammation  should 
be  removed,  and  calamine  liniment  be  applied,  not  by  rubbing,  but  upon  sur- 
geon's lint  soaked  with  it  or  a  thin  layer  of  absorbent  cotton,  which  for  pur- 
poses of  cleanliness  may  be  covered  with  oil-silk.  Bulkley  recommends 
applying,  before  the  liniment  is  used,  a  handkerchief  dipped  in  water  as  hot 
as  can  be  borne  for  two  or  three  minutes. 

The  Pathogenic  Effects  of  Microbes. 

Recent  microscopic  examinations  have  almost  conclusively  demonstrated 
the  fact  that  various  diseases  presenting  diff"erent  clinical  histories  are  pro- 
duced by  the  entrance  of  microbes  into  the  cutaneous  tissue. 

Impetigo  Contagiosa. — This  consists  of  discrete  vesicles  or  pustules  due 
to  contagious  pus,  and  occurs  most  frequently  in  children  of  the  poor  and  in 
those  who  are  cachectic  and  who  live  in  disregard  of  sanitary  requirements. 
Occurring  frequently  in  an  epidemic  form,  crops  of  vesicles  appear  for  several 
days,  with  mild  fever,  the  disease  abating  in  about  two  weeks.  In  some 
instances  this  disease  has  no  fever  and  no  definite  course,  but  the  eruption 
occurs  chiefly  around  the  mouth,  chin,  nostrils,  and  occipital  regions.  Two 
or  more  vesicles  or  pustules  may  unite,  forming  one  of  larger  size,  but  the 
discrete  eruption  is  also  present  in  adjacent  parts.  The  initial  stage  in  this 
disease  is  vesicular.  The  vesicles  are  as  large  as  a  pea  or  larger,  but  they 
soon  become  pustular,  flat,  and  irregular. 

Impetigo  contagiosa  varies  greatly  in  extent  and  severity.  There  may 
be  a  few  distinct  eruptions,  or  they  may  unite  in  extended  patches,  spreading 
over  the  body.     Under  such  circumstances  the  vesicular  form  predominates. 

When  the  disease  occurs  upon  the  limbs,  the  vesicles  or  pustules  are 
liable  to  be  broken  and  become  scabbed,  and  the  surrounding  surface  forms 
an  areola.  This  has  been  designated  ecthyma,  but  the  more  typical  eruption 
on  the  face  shows  that  the  eruption  on  the  limbs  is  an  impetigo  contagiosa 
changed  by  friction. 

Etiology. — The  theory  that  impetigo  contagiosa  is  produced  by  conta- 
gious pus  is  now  accepted  by  dermatologists.  Scratching  readily  produces 
the  transference  of  the  contagious  principle  from  one  place  to  another.  It 
appears  to  be  most  frequently  and  abundantly  produced  in  the  cachectic  and 
poorly  nourished.  Of  four  hundred  children  with  this  disease  observed  by 
the  late  Mr.  Startin,  three-fourths  were  children  under  the  age  of  seven 
years. 

Pathology. — The  fact  that  impetigo  contagiosa  is  undoubtedly  conta- 
gious, as  its  name  implies,  leads  to  the  belief  that  its  cause  is  microbic. 
Crocker  found  in  the  liquid  cautiously  withdrawn  from  unbroken  vesicles 
and  pustules,  chains  of  micrococci  in  twos  and  multiples  of  twos.  They  were 
most  abundant  in  pustules  and  in  the  margins  of  epithelial  cells,  but  not  in 


968  LOCAL  DISEASES. 

the  pus-cells.  The  liquid  was  withdrawn  in  a  capillary  tube  and  blown  upon 
the  cover-glass.  E.  A.  Barton  obtained  pure  cultures  of  staphylococcus 
pyogenes  aureus  from  the  fluid  of  unbroken  vesicles,  and  Bubreuilh  of  Bor- 
deaux and  others  in  independent  examinations  have  discovered  the  same 
organism,  so  that  the  theory  may  be  considered  established  that  this  disease 
is  caused  by  the  streptococcus. 

Diagnosis. — The  absence  of  redness  around  the  eruption  unless  it  be 
rubbed,  and  the  inoculability  of  the  liquid  in  the  vesicles  or  pustules,  are 
diagnostic. 

Prognosis. — The  disease  with  correct  treatment  will  not  continue  more 
than  two  or  three  weeks,  but  if  neglected  the  contagiousness  of  the  eruption 
and  its  inoculability  may  cause  its  continuance  for  an  indefinite  time. 

Treatment. — The  crusts  should  be  soaked  in  sweet  oil  until  they  can  be 
detached.  After  they  are  removed  the  following  ointment  should  be  con- 
stantly applied,  and  the  cure  soon  results : 

R.  Hydi-arg.  ammoniati,  gr.  x  ; 

Cerat.  simplic,  ^j. — ^lisce. 

Seborrhcea. — This  term,  as  the  name  indicates,  is  applied  to  an  increased 
flow  of  the  secretion  from  the  sebaceous  glands.  The  sebaceous  substance 
undergoes  some  alteration  in  consistence  in  difi"erent  instances,  so  as  to  form 
oily,  waxy,  or  scaly  concretions  upon  the  surface.  The  purpose  of  the  seba- 
ceous matter  or  sebum  is  to  lubricate  the  skin,  and  the  glands  which  furnish 
it  occur  upon  nearly  every  part  of  the  surface,  except  the  palms  of  the  hands 
and  soles  of  the  feet.  Although  the  sebaceous  glands  are  so  numerous,  it  is 
difficult  to  collect  sufficient  sebum  for  microscopic  examination.  Lutz  pub- 
lishes the  following  mean  of  eight  analyses  of  this  substance  taken  from  a 
case  of  general  hypertrophy  of  the  sebaceous  system :  ^ 

Water 357 

Oleine 270 

Margarine 135 

Butvric  acid  and  butvrate  of  soda 3 

Casein " 129 

Albumin 2 

Gelatin.. 87 

Phosphate  of  soda  and  traces  of  phosphate  of  lime 7 

Chloride  of  sodium 5 

Sulphate  of  soda 5 

Seborrhcea  sicca  is  a  term  applied  to  the  waxy  and  scaly  forms.  These 
forms  may  be  associated  or  pass  into  each  other,  and  they  are  regarded  as 
the  chief  cause  of  premature  baldness.  The  oleaginous  ingredients  of  the 
sebum  render  the  skin  supple  and  glossy. 

The  waxy  form  varies  according  to  the  location  and  the  age.  The  vernix 
caseosa  of  the  new-born  is  regarded  as  sebum  of  the  waxy  form.  In  the  nor- 
mal state  the  sebaceous  material  is  abundantly  secreted  in  infancy,  and  it 
often  accumulates  upon  the  scalp,  chiefly  at  the  vertex,  where  it  forms  a  yel- 
lowish mass  which  collects  dust  and  dirt.  It  is  sometimes  quite  thick  and  of 
a  caseous  consistence.  The  skin  underneath  has  a  healthy  appearance,  unless 
it  be  irritated  by  decomposition  of  the  oleaginous  matter,  when  it  becomes 
inflamed  and  an  eczema  results. 

The  secretion  which  collects  under  a  narrow  and  long  prepuce  in  the  male 
child,  and  around  the  clitoris  and  between  the  labia  in  the  female,  when  proper 
ablution  cannot  be  or  is  not  performed,  consists  of  epithelial  cells  and  seba- 

^  Flint's  Physiology. 


DISEASES  OF  THE  SKIN.  969 

eeous  matter,  and  its  irritating  property  is  very  likely  to  cause  inflammation, 
a  balanitis,  or  a  vulvitis,  according  to  the  sex.  All  physicians  who  have  per- 
formed the  simple  operation  of  stretching  the  prepuce,  so  as  to  expose  the 
glans  in  order  to  remove  the  irritating  smegma,  or  have  perforined  the  more 
severe  operation  of  circumcision,  know  how  frequently  a  catarrhal  inflamma- 
tion has  been  excited  by  the  smegma,  so  as  to  cause  a  vascular  adhesion  of 
the  prepuce  to  the  glans.  This  inflammation  is  produced  by  the  decomposing 
epithelial  cells  and  smegma. 

The  relation  of  the  sebaceous  glands  and  the  hair-follicles  is  intimate. 
The  sebaeeovis  glands  are  racemose — that  is,  existing  in  distinct  lobules, 
which  discharge  their  contents  into  a  common  duet,  and  this  duct  opens  into 
the  hair-follicle  at  about  the  junction  of  its  upper  third  with  the  lower  two- 
thirds.  From  two  to  five  of  these  racemose  glands  are  arranged  around  each 
large  follicle. 

The  eff"ect  of  the  waxy  form  of  seborrhoea  when  the  secretion  is  sufficient 
to  form  a  crust  of  a  yellow,  dirty  appearance  is  to  distend  and  plug  the  hair- 
follicles.     This  leads  to  atrophy  of  the  hair  and  premature  baldness. 

Seborrhoea  fur/uracea,  or  the  scaly  form,  has  been  designated  by  the  terms 
pityriasis  simplex,  dandruff,  etc.  Many,  more  frequently  adults  than  children, 
have  their  scalp  constantly  covered  with  white,  fine,  shining  crusts  which  are 
readily  detached  by  the  hair-brush,  so  as  to  alight  like  small  flakes  upon  their 
clothes.  When  this  form  of  seborrhoea  occurs  upon  the  scalp  it  occupies 
the  same  position  as  the  waxy  secretion,  and,  like  the  latter,  may  lead  to 
baldness.  The  scalp  underneath  may  be  of  normal  appearance,  but  it  may 
be  red  and  itch  or  burn  from  more  or  less  inflammation  which  has  been  estab- 
lished. In  children  seborrhcea  furfuracea,  exhibiting  small  shining  scales, 
may  occur  over  nearly  the  entire  body  and  limbs.  Such  children  exhibit 
often  symptoms  of  the  strumous  cachexia. 

Seborrhoea  universalis  is  more  rare  than  the  local  disease.  One  form  of  it 
is  the  vernix  caseosa  which  covers  the  body  of  the  new-born,  and  continues 
to  be  secreted  until  the  infant  is  a  few  days  old.  It  sometimes  gives  rise  to 
tension  of  the  skin  and  fissures.  If  the  whole  integument  is  affected,  it  may 
shine  as  if  varnished.  Fissures,  painful  when  moved  or  touched,  arise  from 
the  angles  of  the  mouth,  upon  the  joints,  and  in  the  gluteal  folds.  The 
rigidity  of  the  mouth  and  nose  and  the  pain  of  the  fissures  may  render  trac- 
tion of  the  nipple  insufficient  for  the  infant's  nutrition.  Kaposi  says  :  "  The 
children  die  in  a  few  days  from  inanition  and  loss  of  heat  unless  relief  is 
afforded  by  inunctioD  and  softening  of  the  incrustations  and  by  artificial 
maintenance  of  the  heat  of  the  body.  This  condition  is  correctly  termed 
'  ichthyosis  sebacea  '  or  '  seborrhoea  squamosa  neonatorum.'  "  Although  the 
skin,  when  the  sebaceous  material  is  removed,  appears  normal  or  slightly 
reddened,  we  find  openings  of  the  glands  on  close  inspection,  which  corre- 
spond with  the  hair-follicles,  into  which  thread-like  prolongations  extend. 

Sehorrhoea  of  the  scalp  may  be  mistaken  for  any  of  those  diseases  in 
which  scales  and  crusts  form  upon  this  part.  Especially,  it  may  be  mistaken 
for  eczema  squamosum  or  impetiginosum,  but  in  eczema  the  skin  of  the 
affected  part  is  red  and  moist,  while  in  seborrhoea  it  is  white  and  dry.  More- 
over, the  eruption  which  is  characteristic  of  the  form  of  disease  present  occurs 
also  often  upon  other  parts.  In  psoriasis,  for  which  seborrhoea  may  also  be 
mistaken,  the  eruption  always  presents  a  well-defined  patch,  and  the  scales 
are  abundant,  larger,  and  more  firmly  attached  than  in  seborrhoea,  while  the 
surface  is  very  red.  Psoriasis  occurs  not  only  upon  the  scalp,  but  likewise 
usually  upon  the  exposed  surfaces,  where  this  eruption  can  be  more  easily 
differentiated.  Favus  and  herpes  tonsurans  are  caused  by  fungi  which  the 
microscope  reveals,  and  which  are  never  present  in  seborrhoea. 


970  LOCAL  DISEASES. 

Prognosis. — This  is  favorable  in  seborrhoea,  both  in  its  local  and  general 
forms.  Most  cases  with  correct  treatment  soon  improve,  and  can  be  perma- 
nently cured.  The  disease  has  no  ill  effect  upon  the  constitution,  but  is 
sometimes  painful  from  the  rhagades  and  tension,  and,  besides  the  unsightly 
appearance  which  it  produces,  it  may  be  complicated  by  eczema,  comedoes, 
and  acne  upon  conspicuous  parts  like  the  features. 

Treatment. — We  have  to  deal  with  epidermis,  crusts  of  fat,  scales,  and 
secondary  deposits  of  morbid  products.  First  of  all,  they  must  be  softened, 
detached,  and  removed.  They  are  softened  and  detached  most  rapidly  and 
effectually  by  the  fluid  fats,  and  are  then  removed  by  the  action  of  soap  and 
water.  For  this  purpose  as  domestic  remedies  butter  and  lard  have  been 
used,  and  physicians  have  obtained  the  desired  result  by  rubbing  in  warm 
vaseline,  cod-liver  oil,  or  sweet  oil.  Upon  the  scalp,  which  is  the  most  com- 
mon seat  of  seborrhoea  in  infants,  the  oil  is  best  rubbed  in  by  a  pledget  of 
lint,  a  small  sponge,  or  a  firm  brush,  sufficient  pressure  and  friction  being 
used  to  cause  permeation  of  the  crust,  and  the  head  is  then  covered  by  a  cap 
of  flannel  or  other  suitable  substance.  In  this  manner  the  oil  is  applied  four 
or  five  times  daily,  and  allowed  to  remain  on  over  night.  Within  a  day  or 
two  the  crusts  become  soft,  friable,  and  broken,  so  as  to  be  readily  detached. 
When  this  occurs  they  are  gently  removed  by  washing. 

In  infants  attempts  to  remove  the  sebaceous  matter  should  be  performed 
gently,  and  not  until  the  scabs  are  completely  softened  and  broken ;  in  adults 
the  process  may  be  expedited  by  cutting  the  hair. 

When  the  crusts  are  softened  and  disintegrating,  glycerin  soap  is  prefer- 
able for  cleansing  the  tender  surface  of  infants,  as  it  is  less  irritating  than  the 
ordinary  toilet  soap.  In  older  children,  as  well  as  in  adults,  the  following 
formula  from  Hebra  is  useful  in  cleaning  the  surface  after  it  has  undergone 
the  treatment  mentioned  above : 

K,  Saponis  viridis,  100  grammes ; 

Solve  leni  calore  in  spir.  vini,  200        ' ' 
Filtre  et  adde — 

Olei  lavendulse,  \  /i(7       ^        " 

Olei  bergamoti,  J 
Misce.  Filtra. 

A  coarse  flannel  cloth  or  a  sponge  is  used  for  making  the  application,  with 
an  abundance  of  lukewarm  water.  By  the  thorough  ablution  performed  in 
this  way  affected  parts  are  entirely  cleaned,  when  they  should  be  dried.  By 
this  mode  of  treating  seborrhoea  hairs  that  are  held  together  by  the  crusts 
are  often  detached,  and  patients  sometimes  attribute  the  baldness  which 
results  to  the  treatment.  The  seborrhoeal  process,  however,  caused  the 
detachment  of  the  hair  and  more  or  less  baldness. 

The  skin  when  cleaned  by  the  method  described  appears  red,  but  the 
redness  fades  under  proper  treatment,  and  the  unpleasant  sensation,  fissures 
of  the  thin  corium,  and  reproduction  of  the  sebaceous  deposits  are  prevented 
by  applying  oily  substances.  Kaposi  recommends  the  following  after  the 
skin  has  lost  its  tenderness  and  the  corium  has  regained  its  thickness.  The 
application  must  be  made  for  several  weeks  to  the  scalp  of  spiritus  vini  gallici, 
either  used  pure  or  in  the  following  formula : 

R.  Acidi  carbolici,  0.15 ; 

Acidi  borici,  3.00  : 

or  Acidi  salicylici,  3.00  : 

Spts.  vini  gallici,  qs.  ad  100.00. — Misce. 

Inasmuch  as  the  treatment  of  the  corium  by  soap  and  alcohol  tends  to 


DISEASES  OF  THE  SKIN.  971 

render  it  brittle,  it  is  best  in  the  subsequent  treatment  to  apply  some  bland 
oil  or  fat  for  weeks  or  perhaps  months. 

General  seborrhoea  must  be  treated  in  the  same  manner  as  local  forms 
of  it,  allowance  being  made  for  the  age.  The  cutis  testacea  (ichthyosis 
sebacea  neonatorum)  requires  vigorous  rubbing  of  the  surface  with  sweet 
oil,  or  the  application  of  cloths  soaked  with  a  bland  ointment  and  applied 
over  the  face,  limbs,  body,  fingers,  and  toes,  and  retained  by  a  flannel  binder. 
The  infant  is  kept  in  an  incubator  or  in  a  poor  conductor  of  heat,  as  down  or 
flannel.  It  should  be  washed  daily  in  a  warm  bath  with  glycerin  soap,  after 
which  the  oil  is  applied. 

Parasites  of  the  Skin. 

A  complete  treatise  on  diseases  of  the  cutaneous  system  requires  the 
description  of  a  considerable  number  of  vegetable  and  animal  parasites  which 
grow  upon  or  burrow  in  the  skin.  It  is  our  purpose  to  describe  only  such 
as  occur  most  frequently  in  America.  The  parasitic  diseases  are  observed 
chiefly  among  the  filthy  who  seldom  bathe  or  change  their  clothes.  The 
most  common  of  these  diseases  is — 

Scabies,  or  the  Itch. — This  is  contagious  by  contact  or  transference.  It 
is  caused  by  a  minute  animal  parasite,  and  its  chief  lesions  are  the  burrows 
produced  by  the  female  in  order  to  deposit  her  eggs,  and  such  injuries  as 
result  from  the  scratching  due  to  the  intense  itching  incident  to  the  burrow- 
ing. The  itch-mite,  or  acarus  scabiei,  consists  of  the  male  and  female,  and 
the  symptoms  and  lesions  are  mainly  due  to  the  latter,  which  when  removed 
from  its  burrow  is  barely  visible  to  the  naked  eye  as  a  minute  yellowish- 
white  hemispherical  body.  Viewed  under  the  microscope,  it  is  seen  to  be 
crab-like,  with  legs  and  a  proboscis ;  the  rounded  body  has  wavy  transverse 
furrows,  so  that  the  parts  move  over  each  other  with  facility.  From  obser- 
vations made  by  Eichstedt,  Guddens,  and  others,  the  female  has  been  found 
within  half  an  hour  after  being  placed  upon  the  skin  to  have  concealed  her- 
self in  the  epidermis,  and  the  burrow  which  she  constructs  is  arched,  tortuous, 
and  four  or  five  lines  in  length.  The  young  acarus  has  six,  the  mature  eight, 
articulated  legs,  with  suckers  upon  the  two  anterior  pairs  and  hairs  on  the 
posterior.  The  head,  which  can  be  elongated  or  retracted,  is  provided  with 
two  jaws.  The  upper  surface  is  covered  with  spines  directed  backward  so  as 
to  prevent  retrogression  in  the  burrow.  She  leaves  behind  her  in  the  cunic- 
ulus,  as  she  advances,  her  moulted  skin,  excreta,  and  eggs,  which  hatch  on 
the  eleventh  day.  The  mother-acarus  is  always  found  at  the  remote  end  of 
the  burrow,  where  it  can  be  seen  by  the  unassisted  eye  as  a  minute  whitish 
or  sometimes  brownish  speck,  and  from  which  it  can  be  lifted  by  the  point 
of  a  needle,  to  which  it  clings.  The  cuniculi  can  also  be  seen  by  the  naked 
eye,  looking,  says  Niemeyer,  like  the  "  scars  of  needle-scratches."  and  con- 
taining the  young  acari  in  various  stages  of  growth. 

The  acarus  by  its  burrowing  produces  an  irritation  and  troublesome  itch- 
ing, which  is  the  chief  cause  of  the  suff'ering  of  the  patient.  At  the  point 
where  the  acarus  penetrates  the  cuticle  the  inflammation  gives  rise  to  a  single, 
small,  and  acuminate  vesicular  or  papular  eruption,  the  cuniculus  extending 
away  from  it.  We  often  find  ecthymatous  pustules  and  abrasions  intermin- 
gled with  the  vesicles,  the  result  of  frequent  scratching.  The  itching  is  most 
intense  and  the  acarus  most  active  at  night,  when  the  patient  is  warm  in  bed. 
Scabies  most  frequently  appears,  especially  in  adults,  first  upon  the  hands, 
between  the  fingers,  where  the  skin  is  thin,  and  it  extends  thence  along  the 
forearm  and  over  the  thighs  and  abdomen.  In  children  it  not  infrequently 
occurs  upon  the  buttocks,  thighs,  feet,  etc.,  while  the  hands  and  forearms  escape. 


972 


LOCAL  DISEASES. 


Fig.  270. 


Fig.  269.  The  itch  animalcule,  Acnrus  scabiei,  viewed  upon  the  back,  showing  its  figure  and  the 
arrangement  of  its  spines  and  filaments.  The  female,  which  is  somewhat  larger  than  the 
male,  has  a  length  of  Qne-ei.shtieth  to  one-sixtieth  of  an  inch. 

Fig.  270.    The  foot  and  last  joints  of  the  leg  of  the  itch  animalcule. 

Fig.  271.    Ova  of  the  itch  animalcule. 

Fig.  272.  The  male  itch  animalcule,  viewed  upon  the  under  surface,  showing  its  legs  and 
lobulated  feet.  .as 

Fig.  273.    Burrow  of  the  female  acarus  (after  Kaposi). 

Diagnosis. — Correct    diagnosis    is    important,   because    the    treatment 
required  is   different  from  that  in   any   other    exanthem,   and   because  the 


DISEASES  OF  THE  SKIN.  973 

suspicion  of  liaving  this  disease  always  renders  one  solicitous  to  know  the 
exact  nature  of  the  eruption.  Scabies  can  be  diagnosticated  from  those  dis- 
eases for  which  it  may  be  mistaken  by  the  following  characters :  its  occur- 
rence where  the  cuticle  is  thin  and  delicate,  as  between  the  fingers,  along  the 
anterior  aspect  of  the  forearm,  upon  the  abdomen,  thighs,  and  inside  of  the 
feet ;  small  size,  acuminate  shape,  and  isolated  position  of  vesicles  ;  the  inter- 
mingli^g  with  the  vesicles  of  other  forms  of  eruption,  as  papules  and  pustules, 
and  the  presence  of  linear  scars  and  abrasions  produced  by  the  scratching ; 
itching  most  intense  at  night ;  absence  of  fever ;  absence  of  the  disease  from 
posterior  aspect  of  body  and  arms  and  from  head  and  face.  Scabies  may  be 
distinguished  by  the  vesicular  character  of  the  eruption  from  all  other  exan- 
thematic  affections  except  eczema,  sudamina,  and  herpes.  Eczema  is  most 
common  on  the  scalp  and  face,  where  scabies  does  not  occur,  and  unlike 
scabies  its  vesicles  are  round  and  thickly  aggregated  in  clusters ;  in  eczema 
there  is  a  smarting  or  prickling  sensation  very  different  from  the  intense  itch- 
ing of  scabies.  In  herpes  the  vesicles  are  lai'ge,  rounded,  and  in  clusters, 
and  attended  by  a  burning  or  prickling  sensation,  with  but  little  itching.  The 
eruption  in  sudamina  is  vesicular  and  discrete,  as  in  scabies,  but  it  is  globular 
and  accompanied  by  no  itching  or  other  local  symptoms. 

Treatment. — As  scabies  is  due  to  a  species  of  acarus  which  burrows  in 
the  epidermis,  it  can  only  be  treated  successfully  by  measures  which  destroy 
this  animalcule.  If  it  be  destroyed,  the  disease  gets  well  of  itself.  Sulphur 
has  been  employed  for  a  long  period  for  this  purpose,  since  sulphurous  acid, 
which  is  evolved  from  the  sulphur,  is  destructive  to  the  animalcule.  The 
unguentum  sulphuris,  if  thoroughly  applied,  will  rarely  fail  to  eradicate  sca- 
bies. The  internal  use  of  sulphur  aids  the  external  treatment,  since  a  portion 
of  the  gas  which  is  generated  escapes  through  the  pores  of  the  skin.  The 
chief  objection  to  the  employment  of  sulphur  is  its  exceedingly  unpleasant 
odor,  which  is  noticeable,  however  disguised  by  perfume.  Sulphur  or  any 
other  substance  employed  externally  has  more  effect  if  it  be  preceded  by  a 
bath,  which  softens  the  epidermis,  and  therefore  favors  the  entrance  of  the 
remedy  into  the  pores  of  the  skin  and  the  cuniculi. 

Helmerich's  ointment  is  very  effectual  in  the  treatment  of  scabies.  It 
-consists  of  two  parts  of  sulphur,  one  of  carbonate  of  potassium,  and  eight 
of  lard.  "  M.  Hardy  afterward  perfected  the  method,  so  as  radically  to  cure 
the  disease  in  two  hours.  He  proceeded  in  the  following  manner  :  The  patient 
first  undergoes  a  friction  of  his  whole  body  for  half  an  hour  with  soft  soap, 
in  order  to  cleanse  the  skin  and  break  up  the  burrows ;  a  warm  bath  of  an 
hour's  duration  follows,  during  which  the  skin  is  thoroughly  rubbed,  in  order 
to  complete  the  destruction  of  the  burrows ;  after  which  frictions  for  half  an 
hour  and  upon  the  whole  surface  are  practised  with  Helmerich's  ointment. 
This  completes  the  cure.  Out  of  400  patients  subjected  to  this  treatment 
only  4  returned  to  the  hospital."  ^ 

M.  Albin  G-ras  experimented  with  different  substances  in  order  to  ascer- 
tain their  relative  destructiveness  to  the  acarus.  The  following  table  gives 
some  of  the  results  of  his  experiments : 

Immersed  in  pure  water,  the  acarus  was  alive  after  three  hours. 

"  saline  water,  the  acarus  moved  freely  after  three  hours. 

"  Goulard's  solution,  the  acarus  lived  after  one  hour. 

"  olive,  almond,  or  castor  oil,  the  acarus  lived  more  than  two  hours. 

"  lime-water,  the  acarus  died  in  three-fourths  of  an  hour. 

"  vine2:ar,  "  "  twenty  minutes. 

"  alcohol,  "  "  _  "  ■ 

"  turpentine,        "  "  nine  " 

"  iodide  of  potassium,  the  acarus  died  in  four  to  six  minutes. 

^  Stille's  Therapeutics,  etc.,  vol.  ii.  p.  561. 


974  LOCAL  DISEASES. 

It  is  seen  that  vinegar,  lime-water,  alcoliol,  turpentine,  and  iodide  of 
potassium  destroy  the  acarus  in  a  short  time.  They  may  be  employed  in 
the  same  manner  as  the  sulphur  ointment.  Camphor  is  also  destructive  to 
this  animalcule,  and  the  linimentum  camphorae,  thoroughly  applied,  is  a  good 
remedy  for  uncomplicated  scabies. 

In  order  to  avoid  the  odor  of  sulphur,  which  is  so  offensive,  one  of  the 
following  ointments  may  be  employed  if  the  patient  be  fastidious: 

R.  Unguent,  hydrarg.  ammoniat.,  ^  ; 

Moschi,  gr.  ij  ; 

01.  lavendul.,  gtt.  ij  ; 

01.  amygdal.,  3J. — Misce.^ 

If  scabies  be  extensive,  this  should  not  be  used,  as  its  application  over  a 
considerable  area  might  endanger  salivation,  but  the  following,  which  is  rec- 
ommended by  Bazin,  and  is  said  to  cure  the  disease  with  three  applications, 
may  be  used  instead  : 

R.  Anthemis  pulv. , 
Adipis, 
01.  olivse,  da.  5J. — Misce. 

In  cases  which  have  been  protracted,  and  in  which  ecthymatous  and  other 
secondary  eruption  have  occurred,  the  scabies  can  ordinarily  be  readily  cured, 
while  the  other  eruptions  remain  and  disappear  more  slowly.  A  knowledge 
of  this  is  important,  since  the  sulphur  or  other  ointment  employed  for  the 
cure  of  scabies  should  be  discontinued  when  the  itching  ceases  and  vesicles 
no  longer  appear,  and  tonic  or  other  treatment  appropriate  to  cure  these 
secondary  eruptions  should  be  employed  instead.  The  sulphur  ointment 
continued  after  the  scabies  is  cured  does  harm,  since  it  irritates  the  cuticle.  It 
is  essential  in  the  treatment  of  scabies  that  the  linen  be  frequently  changed. 

Pediculosis. — The  pediculi,  or,  in  common  parlance,  lice,  "  are  wingless 
insects  without  metamorphosis,  with  two  simple  small  eyes.  They  first  bite 
into  the  skin  with  their  mandibles,  and  then  insert  the  head  into  the  wound 
in  order  to  suck  "  (Kaposi).  Three  varieties  of  these  insects  inhabit  the  sur- 
face of  man.  The  one  abides  upon  the  scalp,  the  second  in  the  vestments, 
and  the  third  upon  the  pubes.     Hence  the  classification — 

1.  The  pediculus  capitis  ; 

2.  The  pediculus  vestimenti ; 

3.  The  pediculus  pubis. 

The  piercing  of  the  skin  with  the  mandibles,  the  suction  of  the  blood 
and  serum,  and  the  formation  of  crusts  or  wheals  cause  intense  itching  with 
scratching.  Hence  result  excoriations,  vesicles,  papules,  furuncles,  abscesses, 
crusts,  which  produce  a  resemblance  to  certain  other  eruptive  diseases,  but 
which  are  chiefly  due  to  the  intense  itching  and  unavoidable  scratching.  The 
lesions  of  course  vary  according  to  the  number  and  variety  of  the  pediculi 
and  the  duration  of  the  disease. 

The  three  varieties  of  pediculi  seldom  wander  from  the  regions  which 
they  primarily  occupy.  The  first  variety  rarely  pass  beyond  the  scalp ; 
the  second  variety  occupy  the  folds  of  the  vestments,  to  which  they  suddenly 
retreat  when  the  garments  are  disturbed  ;  and  the  third  variety  seldom  leave 
the  pubic  region. 

The  pediculus  capitis  has  the  length  of  two  millimetres,  and  is  of  a  gray 
color ;  its  head  and  limbs  are  thicker  and  chest  broader  than  are  those  of  the 
pediculus  vestimenti. 

^  From  Wilson. 


DISEASES  OF  THE  SKIN.  975 

Treatment. — In  the  treatment  of  pediculosis  capitis  the  use  of  petro- 
leum according  to  the  following  formula  will  be  found  safe  and  effectual : 


R.  Petrolei, 

100  parts ; 

01.  olivfe, 

50     " 

Bals.  Peru, 

20     " 

Eub  freely  into  the  hair. 

If  there  be  moderate  eczema,  naphthol  oil,  5  per  cent.,  may  then  be 
applied,  and  the  head  wrapped  in  flannel.  In  twenty-four  hours  the  lice  are 
dead,  and  the  nits,  which  are  attached  to  the  hairs  at  different  distances,  are 
incapable  of  growth.  The  scalp  is  then  washed  with  the  spiritus  saponatus 
kalinus,  prepared  according  to  the  following  formula  of  Hebra : 

R.  Saponis  viridis,  100  grammes  ; 

Solve  leni  calore  in  spir.  vini,      200         " 
Filtra  et  adde — 
Olei  lavendulse, 
Olei  bergamoti,  da.      3         " 

The  eczematous  crusts  which  occur  from  the  irritation  and  scratching  in 
pediculosis  are  softened  and  broken  up  by  this  treatment.  Daily  oiling  and 
washing  the  surface  complete  the  cure. 

The  treatment  of  pediculosis  corporis  by  a  complete  change  of  clothing 
and  a  bath  of  the  entire  surface  with  soap  and  water  speedily  cures  the  dis- 
ease, since  the  insect  which  causes  this  form  of  pediculosis  lives  in  the  vest- 
ments.    Of  course  the  worn  clothes  should  be  burnt. 

Pediculosis  pubis  is  cured  by  applications  which  destroy  the  insect,  among 
which  we  may  mention  1  part  of  corrosive  sublimate  to  250  of  water,  and  by 
naphthol;  as  well  as  by  petroleum.  The  nits  are  destroyed  by  carbolic  acid, 
1  part  to  50  of  water. 

FORMULARY. 

Within  the  last  few  years  the  investigations  of  dermatologists  have 
revealed  the  important  causal  relation  of  bacteria  to  the  cutaneous  diseases. 
Unna  believes  that  eczema,  which  is  probably  the  most  common  cutaneous 
malady  of  early  life,  is  parasitic,  "  due  to  some  micrococcus  not  yet  deter- 
mined," and  he  adduces  the  success  of  antiseptic  local  treatment  as  a  proof 
of  this  theory.  Crocker  says:  "  My  own  view  is  this:  that  while  a  limited 
number  of  local  skin  diseases  are  parasitic,  in  most  the  dermatitis,  however 
caused,  only  opens  the  door  to  parasites,  whose  presence  keeps  up  local  irri- 
tation, and  that  their  destruction  is  an  important  step  in  the  restoration  of 
the  skin  ad  integrum.''  Again  Crocker  writes :  "  .  .  .  .  Micrococci  are  so 
ubiquitous  that  their  invariable  presence  may  be  demonstrated  in  any  par- 
ticular disease  "  of  the  skin.  Hence  germicides  are  regarded  as  important 
agents  in  the  initial  treatment,  as  well  as  during  the  progress  of  those  mal- 
adies in  which  the  cuticle  is  so  injured  by  disease  that  it  no  longer  prevents 
the  invasion  of  microbes. 

The  lotio  nigra  is  one  of  the  best,  if  not  the  best,  germicide  wash  employed 
for  this  purpose.  1  drachm  of  calomel  is  mixed  with  1  pint  of  lime-water, 
and  by  double  decomposition  the  very  active  and  safe  germicide  calcium 
chloride  and  the  oxide  of  mercury  are  produced.  The  former  is  the  anti- 
septic required.  By  the  judicious  use  of  this  remedy,  followed  by  an  oint- 
ment like  Lassar's,  many  of  the  acute  eczemas  rapidly  yield. 

The  following  formulae,  most  of  which  have  been  obtained  from  Crocker's 
and  Kaposi's  recent  treatises,  will  be  found  useful  to  the  practitioner : 


976 


LOCAL  DISEASES. 


Baths. 

■  1.  Cold,      40°-  65°  Fahr. 

2.  Cool,      65°-  75°      " 

3.  Tepid,   85°-  95°      " 

4.  AYarm,  95°-100°      " 

Lotions. 

5.  Be.  Hyd.  clilor.  corros.,  gr.  ij  ; 

Tine,  benzoin. ,  ^ss  ; 

Misturffi  amygdalae,  5j. — M. 

For  freckles  (Duhring). 

6.  R-  Hyd.  chlor.  corros.,  gr.  vj  ; 

Acidi  aceti  dilut.,  ^ij  ; 

Sodii  borat.,  Qij  ; 

Aquse  rosae,  5iv. — M. 

For  freckles  (Bulkley ) .  Apply  twice  daily. 

■  7.   R.   Corrosive  sublimate,         gr.  iv  ; 

Dilute  nitric  acid,  3J  ; 

Dilute  hydrocyanic  acid,  3j  ; 
Glycerin,  5^j- — M. 

For  syphilitic  eruptions,  pityriasis  versic- 
olor, chloasma,  freckles  (Startin). 

Soft  Soap. 

8.  R .  Oil  of  cade,  l 

Soft  soap,       >■  da.  gss ; 

Alcohol,       J 

Olive  oil,  §jss ; 

Oil  of  lavender,  3jss. — M. 

For  chronic  eczema,  psoriasis  of  the  scalp 
or  knee. 

9.  R.  Soft  soap  or  green  soap,  alcohol, 

equal  parts. — M. 
To  remove  scales  of  psoriasis  and  sebor- 
rhcea. 

SuLPircB. 

10.  K.  Sulphur  precipitat., 

Alcohol,  da.  §j. — M. 

For  acne. 

11.  R.   Sulphur,  1 

Alcohol, 

Ether,  -        dd.  Qij  ; 

Glycerin, 
Carb.  potash,  J 

Eose-water,  S^j- — ^^• 

For  acne,  or,  without  the  water,  rubbed 
in,  for  comedones. 

12.  R.  Potassium  sulphuret,       ,^ss  ; 

Lime-water,  §^'^.i- — ^^■ 

For  pustular  and  parasitic  diseases  and 
pityriasis  versicolor. 
13.'  R.  Snlphuris  loti,  gj  ; 

Jiltheris,  f  3;iv ; 

Alcoholis,  f  giijss. — M. 

Shake  bottle,  and  apply  with  a  swab  of 
cotton  every  three  or  four  hours. 

For  acne  I  have  used  this  with  a  good 
result. 
14.   R.  Lime-water, 

Olive  or  linseed  oil,  ad. — M. 

For  bums  and  superficial  inflammations 
of  skin. 


15.  R.  Prepared  calamine,  ^ij  ; 

Zinci  oxidi,  ,^ss  ; 

Lime-water,  olive  oil,  dd.  §ss. — M. 
For  eczema  and  acute  dermatitis.     The 
parts  are  wrapped  with  this  lotion. 

16.  R .   Menthol,   chloral,   camphor,  equal 

parts.     Triturated  to  liquefaction. 
Apply  for  pruritus  and  superficial  pains. 

17.  Tar. 

The  liquor  carbonis  detergens  has  recently 
come  into  use  as  an  eligible  preparation  for 
certain  skin  diseases.  It  is  designated  in  one 
of  the  books  as  an  alcoholic  solution  of  coal- 
tar. 

The  following  formulae  are  used  for 
chronic   eczema   and  pruritus : 

18.  R.  Liq.  carb.  detergentis,   f  ^ss  ; 

Acidi  nitrici  dilut.,  5J  ; 

Aqua^  camphorae,         ad  3viij. — M. 

19.  R .  Liq.  carb.  detergentis,     5J-ij  ; 

Liq.  plumbi  subacetatis,  ,^j-ij  ; 
Aqua?  rosae,  §^j- — M. 

20.  Liq.  carbonis  detergentis,  diluted,  1  part 

to  40  or  80  of  spirit  or  water. — M. 

21.  R .  Ung.  picis  (B.  P.). 

22.  R.   {a)  Creosote,       ^    ^j   or  more  of 

(b)  Olei  cadini,  I  either    to   .fj 

(c)  01.  rusci,       J  of  lard. — M. 
L^seful  in  psoriasis  and  chronic  inflam- 
mations. 

Astringent  Lotions. 

23.  Collodion  (non-flesible). 

It  acts  by  mechanical  compression,  and 
is  useful  when  such  is  required,  as  in  acne 
rosacea,  lupus  erythematosus,  and  in  small 
naevi. 

24.  Tincture  of  hamamelis,  1  part  to  4  of 

water. 
For  dilated  capillaries. 

25.  R.  Tannic  acid,  gr.  xl ; 

French  vinegar,        ^ss ; 
Water,  ,l"^ij- — ^i- 

For  seborrhcea  and  hyperidrosis. 

26.  R.  Boric  acid,  a  saturated  solution. 
For  eczema  and  erythema. 

Stimulants  for  the  Scalp,  or  Hair 
Lotions. 
The  following  formulte  are  given  for 
children  of  half  the  strength  which  is 
recommended  by  distinguished  dermatol- 
ogists  for   adults : 

27.  R.  Tine,  of  cantharides,      ^ss: 

Distilled  vinegar,  .liijss ; 

Eose-water,  ad  3viij. — M. 

28.  R.  Hyd.  chlor.  corros.,        gr.  ij  ; 

Ammon.  chloridi,  gr.  x  ; 

Resorcin,  gr.  xx ; 

Eau  de  Cologne,  gij  ; 

Glycerin,  ^ij ; 

Aquae  rosae,  to  Oj. — M. 

For  seborrhcea  capitis  and  alopecia. 


FORMULAE  Y. 


977 


Sedati\t;  Astrestgent  Lotions. 
Zinc  or  Calamine  Lotion. 
Prepared  as  follows  : 

29.  B.  Powdered  calamine  (the  na- 

tive carbonate  of  zincj,    9ij  ; 
Oxide  of  zinc,  ^ss  ; 

Glycerin,  iT^xv ; 

Rose-water,  5J. — M. 

For  erythema  and  eczema  when  little  or 
no  discharge,  and  for  active  hyperamic 
states. 

Bismuth  Lotion. 

30.  R.  Bismuth,  subnitrat.,  gr.  viij  ; 

Oxide  of  zinc,  5ss  ; 

Glycerin,  ^^^j  ; 
Hydrarg.  chlor.  corros.,      gr.  -4- ; 

Rose-water,  ^j. — M. 
For  acne  rosacea  and  other  hypersemic 
states. 

Lead  Lotion. 

31.  R.  Solution  of  subacetate  of 

lead,  TTl^v-xx ; 

Glycerin,  ^_^y ; 

Water,  §j.— M. 

For  erythema,  eczema,  and  excoriations. 

Sedative  Astringent  Ointments. 
Boric  Acid. 

32.  R.  Boric  acid,  ,^ss  ; 

Benzoated  lard,  §j. — M. 

The  boric  acid  should  be  ground  into  an 
impalpable  powder  before  the  admixture. 

Used  in  eczema  and  as  an  antiseptic  in 
wounds  and  excoriations. 

Lead. 


.  R.  Carbonate  of  lead. 

gr.  iv  ; 

Glycerin, 

.^j; 

Simple  ointment, 

5J— M 

For  erythema. 

Zinc. 

Wilson's  benzoated  zinc  ointment,  a  well- 
known  remedy  for  eczema,  is  prepared  as 
follows  : 

34.  R.  Lard,  |vj  ; 

Powdered  benzoin,  5j. — M. 

Melt  together  for  twenty-four  hours  at  a 

gentle   heat   in  a  closed  vessel,   and   then 

strain  and  add  oxide  of  zinc  §j.     Stir  till 

cool  and  strain. 

Antiseptic  Ointments. 

35.  R.  Iodoform,  gr.  iij-v ; 

Vaselin  or  lard,  ^j. — ^M. 

To  cover  the  unpleasant  odor  of  iodo- 
form, creolin  n\,v  to  5J  may  be  added. 

36.  R.   Aristol,  gr.  iij-v  ; 

Vaselin  or  lard,  ^j. — M. 

Aristol,    used   in   powder,    is    also   very 
effectual  in  curing  sores  and  the  surround- 
ing inflamed  tissue. 
62 


Mercury. 

37.  R.  Ammoniated  mercury,        gr.  x  ; 

Lard,  gj. — M. 

A  specific  for  impetigo  contagiosa  after 
the  crusts  are  broken. 

Sulphur. 

38.  R.  Iodide  of  sulphur,    gr.  x   to   ^ss, 
added  to  lard,  3J. — M. 

For  acne. 

Antipruritic  Lotions. 

39.  R.  Borax,  ^\]  ; 

Glycerin,  ^ss ; 

Water,  Oij.— M. 

Use  in  urticaria  and  as  a  head-wash  in 
seborrhcea. 

40.  R.  Borax, 

Carbonate  of  ammo- 
nia, da.  ,^iss ; 
Glycerin,    _        _  ^  ; 
Hydrocyanic  acid, 

dilute,  ,5iij  ; 

Water,  S^^]- — ^^• 

Use  diluted  one  to  four  times. 
For  vesicular  diseases  and  seborrhcea. 

41.  R.  Acidi  carbolici,  ^j  ; 

Tinct.  camphorae,         ^ij  ; 

Aqua?,  Oj.— M. 

An  excellent  application  to  the  surface 
in  pruritus  of  any  kind,  provided  that  the 
skin  be  not  broken. 

42.  R.  Terebene,  .^j  ; 

Water,  .5^iij- — M- 

For  pruritus  and  urticaria. 

43.  R.  Salicylic  acid,  ^i]  ; 

Borax,  _^j  ; 

Glycerin,  q.  s.  for  3J. — M. 

Mix  the  acid  and  borax  with  ^^^iv  of  gly- 
cerin. Heat  gently  until  dissolved:  then 
add  glycerin  to  make  §j.  Tliis  can  be  di- 
luted -with  glycerin,  alcohol,  or  water  to 
any  extent. 

5J  of  the  first  mixture,  .5J  alcohol,  and 
water  to  ^viij  make  a  good  proportion  for 
pruritus  and  urticaria. 

44.  R.  Menthol,  gr.  i]  ; 

Water,  5J-— M. 

For  same. 

45.  R.  Subacetate  of  lead,  .^ij  ; 

Water,  n^iij- — M. 

For  same. 

46.  R.  Benzoic  acid,  ,^ij  ; 

Water,  o'^iJ- — ^^■ 

For  same. 

Pastes. 
Unna's  Gelatin  Paste. 

47.  R.  Oxide  of  zinc, 

Glycerin,  ,^iij  ; 

Gelatin,  dd.  giss ; 

Distilled  water,  ,:^iv. — M. 


978 


LOCAL  DISEASES. 


To  this,  as  a  base,  5  to  10  gr.  of  an  anti- 
septic, as  salicylic  acid,  resorcin,  aristol,  or 
ichthyol,  or  the  chemical  equivalent  of  the 
latter— namely,  thiol — may  be  added.  At 
the  ordinary  temperature  it  is  elastic  like 
rubber,  and  most  be  melted  by  sufficient 
heat  before  its  application.  When  applied 
it  should  be  dabbed  with  a  light  layer  of 
wool  to  prevent  adhesion  to  the  clothes. 

This  is  known  as  Unna'  s  paste,  and  is 
much  used  in  subacute  and  chronic  eczema 
and  whenever  the  discharge  is  slight  or 
absent.  It  is  not  adapted  for  parts  covered 
with  hair  or  for  use  in  hot  weather  unless 
it  be  covered  by  the  light  wool  mentioned 
above. 
48.  Lassai^s  is  another  paste  largely  used. 

It  has  the  following  composition : 
R.  Zinc  oxide  and  pow- 
dered starch,  da.  ,^ij ; 
Vaselin,  ^ss ; 
Salicylic  acid,                 gr.  x. — M. 

Used  for  eczemas  and  other  inflamma- 
tions, whether  moist  or  dry,  if  the  dis- 
charge be  moderate.  It  should  be  spread 
thickly  on,  and  be  covered  with  cheese- 
cloth. If  the  inflammation  be  acute,  it  is 
better  to  leave  out  the  salicylic  acid  for  a 
time. 


Fob  A2sriMAL  Parasites. 

49.  R.  Ung.  sulphuris,  B.  P. 

For  the  vegetable  parasitic  eruptions  and 

scabies. 

50.  Wilson's  Formula  : 

R.  Sulphur,  ,^ss ; 

Carbonate  of  potash,  gj  ; 

Benzoated  lard,  ^ijss  ; 

Oil  of  chamomile,  TT\^xv. — M. 

51.  Wilkinson's  Formula: 

R.  Sulphur,  ] 

Tar,  V  da.   |j ; 

Lard,        j 

Precipitated  chalk,  ,^ss; 

Sulphide  of  ammo- 
nium, iT^xv. — M. 
For  tinea  tonsurans  and  scabies. 
Kaposi   recommends  the  following  oint- 
ment: 

52.  R.  Naphthol,  15  parts  ; 

Prepared  chalk,      10     " 
Lard,  100     " 

Soft  soap,  50     "         — M. 

53.  R.  Iodide  of  sulphur. 

Iodide  of  potas- 
sium, da.  3Jss ; 
Water,  |xxx. — M. 


INDEX  TO   FORMULARY. 


Acne,  Nos.  10,  11,  13,  38. 

Acne  rosacea,  23,  30. 

Alopecia,  27,  28. 

Antiseptics,  32,  35,  36. 

Burns,  14,  48. 

Capillaries,  dilatation  of,  24. 

Chloasma,  7. 

Comedones,  11. 

Dermatitis,  15. 

Eczema,  8,  15,  16,  17,  18,  19,  20,  21,  22, 

26,  29,  31,  32,  34,  47,  48. 
Erythema,  26,  29,  33. 
Excoriations,  31,  32. 
Freckles,  5,  6,  7. 
Hyperemia,  1,  2,  3,  4,  29,  30. 


Hyperidrosis,  Nos.  25. 

Impetigo  contagiosa,  37. 

Lupus  erythematosus,  23. 

Nffivus,  23. 

Parasiticides,  12,  49,  50,  51,  52,  53. 

Pityriasis  versicolor,  7,  12. 

Pruritus,  16,  17,  18,  19,  20,  39,  40,  41,  42, 

43,  44,  45,  46. 
Psoriasis,  8,  9,  22. 
Scabies,  49,  50,  51,  52,  53. 
Seborrhcea,  9,  25,  27,  28,  39,  40. 
Syphilis,  7. 
Tinea  tonsurans,  51. 
Urticaria,  16,  39,  42,  43,  44,  45,  46. 
Wounds,  32. 


INDEX. 


A. 

Abnormalities  in  circulatory  sj^stem,  con- 
genital, 89 
Acrania,  81 

Adenoid  vegetations,  700 
Alveola,  697 
Anaemia,  simple  or  secondary,  507 

etiology,  symptoms,  diagnosis,  509 
treatment,  510 
Primary,  511 

etiology,  morbid  anatomy,  511 
symptoms,  diagnosis,  treatment,  512 
Lymphatic,  512 

etiology,  morbid  anatomy,  512 
symptoms,  diagnosis,  prognosis,  treat- 
ment, 513 
Splenic,  513 

etiologv,  morbid  anatomy,  svmptoms, 

513 
diagnosis,  prognosis,  treatment,  514 
Pernicious,  514 
Idiopathic,  514 

morbid  anatomy,  symptoms,  etiology, 
treatment,  514 
Aneurysm  of  arteries,  923 
Angeioma,  482 
Animal  heat  in  infancy,  75 
Ankle-joint,  diseases  of,  569 
Anus,  absence  of,  imperforate,  488 
Appendicitis,  799 

etiology,  anatomical  character,  799,  800 
symptoms,  800-802 
diagnosis,  802 
prognosis,  803 
treatment,  804 
Arthritis,  acute  suppurative,  551 

treatment,  552 
Artificial  feeding,  53-57 
Atelectasis,  861 
Acquired,  861 
symptoms,  862 
anatomical  characters,  862 
treatment,  863,  864 
Atresia  oris,  476 
Attitude  of  infant,  72 

B. 

Bathing  of  infant,  65 
Bladder,  extroversion  of,  489 
Bones,  injuries  of,  530 

long  bones,  530,  531 

diagnosis,  treatment,  531-533 

clavicle,  533 

humerus,  534 


Bones,  injuries  of, 

ulna,  radius,  epiphysis,  femur,  535 
condyles,  537 
tibia,  fibula,  538 
Inflanmiations  of,  538 
etiology,  538 
periostitis,  539 

symptoms,  539,  540 
treatment,  540,  541 
chronic,  542 
syphilitic,  542 
epiphysitis,  acute,  542 

causes,    symptoms,     treatment, 
542,  543 
osteomyelitis,  acute  (diaphysitis),  543 
treatment,  548 
chronic  diffuse,  548 

symptoms,  pi'ogress,  548 
treatment,  549 
Tuberculosis  of,  549 

diagnosis,  prognosis,  treatment,  550 
Arthritis,  acute,  suppurative,  551 
Bowleg,  496 

Brain,  congestion  of,  578 
causes,  578 
symptoms,  579 

anatomical  characters,  580,  581 
Brain,  incomplete,  83 
Burns,  scalds,  829 
Bronchitis,  851 

causes,  anatomical  characters,  851-853 
symptoms,  854 
duration,  855 
diagnosis,  prognosis,  856 
treatment,  857 

of  mild  bronchitis,  857 

of  bronchitis  affecting  the  tubes,  857, 

858 
internal,  859,  860 

c. 

Calculus  in  genitourinary  organs,  935 

urinary,  941 
Caput  succedaneum,  99 
Caries,  vertebral,  519 
prognosis  520 
treatment,  521 
Spinal  abscesses,  524 
Catarrh,  intestinal,  of  infancy,  730 
etiology,  731 
age,  dentition,  736 
symptoms,  736-739 

anatomical,  739 
diagnosis,  prognosis,  743 

979 


980 


INDEX. 


Catarrhal  laryngitis,  820 
Cephallirematonia,  100 
Cerebral  hemorrhage,  584 
Cerebro-spinal  fever,  421 
history,  421 
etiology,  423 
contagiousness,  424 
secondary,  sex,  age,  427,  428 
mode  of  commencement,  430 
nervous  system,  431 
digestive  system,  435 
pulse,  temperature,  437 
respiratory  system,  438 
cutaneous  surface,  438,  439 
urinary  organs,  439 
special  senses,  440 
symptoms  of  endemic,  441 
prognosis,  diagnosis,  446,  447 
treatment,  448 
curative,  449 
internal,  452-455 
Cerebro-spinal  system,  disease  of,  576 
Chicken-pox,  326 
Childhood,  17 

anatomy,  physiology,  17,  18 
Cholera  infantum,  743 

anatomical  characters,  744 
diagnosis,  prognosis,  treatment,  747 
treatment  medicinal,  749 
antiseptic,  749 

irrigation  of  stomach,  749,  750 
alkalies,  astringents,  750 
stimulants,  750 
Chorea,  anaemia,  653 
rheumatism,  653 
fright,  irritation,  656 
intestinal  irritation,  657 
lesions  of  brain,  657 
anatomical  characters,  658 
symptoms,  659 
prognosis,  course,  660 
diagnosis,  661 

treatment,  medicinal,  661,  662 
Circulatory  system,  abnormalities  of,  89 
Circumcision,  944 
Clavicle,  injuries  of,  533 
Clothing  of  infants,  66 
Club-foot,  hollow  (pes  cavus),  502 
Colitis,  752 
Colostrum,  32 
Condyles,  fracture  of,  537 
Congestion  of  the  stomach,  719 
Conjunctivitis  of  newly-born,  102 

mild  or  catarrhal,  103 
Constipation,  754 

symptomatic,  causes,  754 
idiopathic,  causes,  756 
treatment,  760 

hygienic  measures,  761 
therapeutic  measures,  762 
of  newly-born,  130 

symptoms,  treatment,  131,  132 
Coryza,  anatomical  characters,  818 

symptoms,  prognosis,  treatment,  819 
Cow's    milk,   diseases    communicated    by. 
57 


Craniotabes,  170 
Cretinism,  469 
diagnosis,  471 
treatment,  473 
Croup,  pseudo-membranous,  or  true  croup, 
831 
etiology,  831,  832 
anatomical  characters,  833,  834 
symptoms,  diagnosis,  834,  835 
prognosis,  836 

treatment,  preventive,  837,  838 
surgical,  838,  839 
Cryptorchia,  935 
Curvatures,  lateral,  of  spine,  525 
Cyanosis,  89-99 

D. 

Dactylitis,  strumous,  190 

syphilitica,  237 
Deformities,  476 
Dentigerous  cysts,  697 
Dentition,  691 

pathological  results  of,  691 
diagnosis,  693 
treatment,  694 
Second,  695 
Ranula,  696 

Tonsils,  abscesses  of,  698 
Chronic  inflammation  of  tonsils,  698 

symptoms,  698 
Tonsillitis,  recurrent,  699 

treatment,  700 
Adenoid  vegetations,  700 
treatment,  701 
Diaphysitis,  543 

Diarrhoea  of  the  newly-born,  128 
simple,  726 
causes,  726 

symptoms,  anatomical  characters,  727 
prognosis,  treatment,  728 
choleriform,  743 
Digestive  apparatus,  diseases  of,  680 

Stomatitis,  simple    or    catarrhal, 
680 
ulcerous,  681 
aphthous,  683 
Gangrene  of  the  mouth,  684 
Dentition,  691 
alveola,  697 
Dilatation  of  stomach,  723 
Diarrhoea,  726 
system  in  infanc}',  78 
Digits,  supernumerary,  490 
Union  of,  491 

Flexion  of  phalangeal  joints,  492 
Dilatation  of  the  stomach,  723 
Diphtheria,  328 
etiologv,  331 

Klebs-LoefBer  bacillus,  832 
pseudo-diphtheria,  333 
mixed  infection,  334 
age,  334-345 
incubative  period,  336 
modes  of  propagation,  337 
contracted  from  animals,  338 


INDEX. 


981 


Diphtheria,  diagnosis,  340 

anatomical  characters,  342 
blood,  brain  and  spinal  cord,  344 
tonsils,  lungs,  345 
lymphatic  glands,  heart,  346 
mouth,  stomach,  intestines,  347 
spleen,  liver,  kidneys,  347 
symptoms,  348 
temperature,  349 
nares  and  eye,  350 
ear,  351 
albuminuria,  351 
paralysis,  354 
clinical  history,  355 
time  of  commencement,  356 
loss  of  tendon-retlexes,  357 
palatal  paralysis,  357,  358 
multiple  paralysis,  359 
cardiac  paralysis,  359-363 

its  cause,  363 
prognosis,  365 
treatment,  preventive,  366 
hygienic,  368 
stimulants,  quinia,  370  _ 
tinctura  ferri  chloridi,  371 
potassium  chlorate,  372 
hydrargyri   chloridum    corrosivum, 

373 
hydrargyri       perchloridum       (Br. 

Phar.),  373 
calomel,  374 
trypsin,  papoid,  374 
peroxyde  of  hydrogen,  375 
Diseases,  local,  of  newly-born,  101 

Hajmatoma   of  the  sterno-cleido- 

mastoid  muscle,  101 
Mastitis,  102 
Conjunctivitis,  102 

mild  or  catarrhal,  103 
Ophthalmia    neonatorum,    puru- 
lent, 103 
Gonorrhoea!,  103-108 
Umbilical  vegetations,  108 

hemorrhage,  109 
Icterus,  112 

Septicemia  of  new-born,  115 
first  group,  115-119 
second  group,  119-122 
third  group,  122,  123 
Thrush,  123 
Dysuria,  935 

E. 

Eclampsia,  614 

causes,  615 

premonitory  stage,  symptoms,  bib 

partial,  617 

anatomical  characters,  618 

diagnosis,  prognosis,  symptoms,  619 

treatment,  620 
Eczema,  956-967 
Elbow,  disease  of,  555 
Encephalocele,  83-85 
Endocarditis,  917 
Enteritis,  752 
Entero-colitis,  730 


Epilepsy,  622 

etiology,  predisposing  causes,  622 
age,  exciting  causes,  622 
mental  emotion,  traumatism,  623 
symptoms,  623 

attacks,  minor  and  major,  624 
anatomical  characters,  627 
pathology,  628 
diagnosis,  629 
prognosis,  630 
treatment,  630-634 
Epiphysis,  injury  of,  535 
Epiphysitis,  acute,  542 
Erysipelas,  463 

age,  point  of  commencement,  464 
causes,  465 

premonitory  symptoms,  466 
symptoms,  466  \    ap" 

prognosis,  duration,  modes  of  death,  46/ 
pathological       anatomy,  ^    prophylaxis, 
modes  of  treatment,  467-469 
Erythema,  or  rose-rash,  952 
Exercise  of  infant,  68,  69 


F. 

Feeding,  infantile,  47 
over-feeding,  47 
insufficient,  48 
artificial,  53-57 
Feet,  distortions  of^  497 
Femur,  injury  of,  535 
treatment,  535-537 
Fever,  scarlet,  250 
Intermittent,  399 
Remittent,  405 
Typhoid,  407 
Cerebro-spinal,  421 
Growing,  543 
I  Foot,  amputation  of,  575 

G. 

Gangrene  of  the  mouth,  684 

anatomical  characters,  684 
age,  causes,  685 
symptoms,  diagnosis,  686 
prognosis,  treatment,  687,  688 
efflorescence,   furring,   and  erup- 
tion upon  tongue,  690 
Gastritis,  719 

cause,  age,  720  ^ 

symptoms,  anatomical  characters,  i  Ll 
Follicular,  722 
Diphtheritic,  723 
Gastro-intestinal  bacteria,  723 
Genito-urinary  organs,  diseases  of,  927 
nerves  in,  928 
etiology,  929 

prognosis,  treatment,  931-935  ^ 
Calculi,  dysuria,  cryptorchia,  935 
Vulvitis,  936 
Preputial  dilatation,  937 
Kidnev,  abscess  of  (pyonephrosis), 

938' 
Perinephric  abscess,  93S 


982 


INDEX. 


Genito-urinary  organs,  diseases  of, 

Nephi'ectoniv,  940 

Urinarv  bladder,  940,  941 
calculi,  941,  942 

Urethra,  wounds  of,  942 

Penis,  944 

Scrotum,  947 

Testicles,  tubercles  of,  947 
sarcoma  of,  947,  948 
German  measles,  298 
Glottis,  spasm  of,  634 
Growing  fever,  543 
Growth  of  infant,  26 

H. 

Hsematoma  of  sterno-cleido-mastoid  mus- 
cle, 101 
Hsemophilia,  etiology,  anatomical  appear- 
ance, diagnosis,   prognosis,  treat- 
ment, 515 
Hare-lip,  476 
Heart,  diseases  of,  912 

position  in  childhood,  912 
functional  disorders,  diagnosis,  prog- 
nosis, 912 
.     treatment,  912,  913 
Pericarditis,  913 
Myocarditis,  916 
Endocarditis,  917 
ulcerative,  919 
chronic,  920 
Hemorrhage,  intracranial,  581 
cerebral,  584 
meningeal,  587 
Hernia  of  the  abdomen,  809 
inguinal,  809,  810 
symptoms,  811 
femoral,  811 
umbilical,  811 

treatment,  812-814 
strangulated,  814 
umbilical,  817 
Hip-joint,  diseases  of,  558 
Hodgkin's  disease,  512 
Human  milk,  33 
Humerus,  injuries  of,  534 
Hydrencephalocele,  83-85 
Hydrocephalus,  congenital,  589 
anatomical  characters,  589 
etiology,  symptoms,  592 
diagnosis,  prognosis,  593 
treatment,  594 
acquired,  595 

causes,  anatomical  characters,  595 
symptoms,  treatment,  596 
spurious,  611 

anatomical  characters,  symptoms,  612 
diagnosis,  prognosis,  613 
treatment,  614 

I. 

Icterus  neonatorum,  112 

treatment,  115 
Impetigo  contagiosa,  967 


Incubator,  the,  76,  77 
Indigestion,  714 
symptoms,  715 
prognosis,  diagnosis,  716 
treatment,  717 
Infancy,  attitude,  movements,  voice,  72 
Respiratory  system  in  health,  73 

in  disease,  73,  74 
Circulatory  system,  74 
Pulse  in  health,  74 

in  disease,  75 
Animal  heat,  75 
Digestive  system  in,  78 
Nervous  system  in,  79 
Tlierapeutics  in,  80,  81 
Infant,  care  of,  bathing,  65 
clothing,  sleep,  66,  67 
exercise,  68,  69 
Infantile  feeding,  47 
diseases,  diagnosis,  70 

general  observations,  features,  70,  71 
appearance  of  head,  trunk,  limbs,  71 
Intestinal  catarrh  of  infancy,  730 
Intermittent  fever,  399 
etiology,  400 
symptoms,  402 
treatment,  404 
Intracranial  hemorrhage,  causes,  581 

anatomical  characters,  582 
Intubation,  839 

indications  for,  method  of  operating,  842 
difficulties  of  operator,  844 
accidents  and  dangers  of,  845 
asphyxia,  846 
extraction,  846 
time  of  removal  of  tube,  846  ' 

management  after  intubation,  847,  848 
Intussusception,  779 
without  symptoms,  779,  780 
with  symptoms,  780 

previous  health,  causes,  780 
seat,  pathological  anatomy,  781 
in  small  intestines,  784 
in  large  intestines,  782 
symptoms,  787 
diagnosis,  788 
duration,  prognosis,  789 

J. 

Joints,  diseases  of,  552 

Synovitis,  acute,  serous,  552 
treatment,  552 
suppurative,  553 
Tubercular  affections  of,  553 
cause,  diagnosis,  553 
prognosis,  treatment,  554 
Shoulder-joint,  inflammation,  554 
simple,  acute,  treatment,  554 
tubercular,  treatment,  554,  555 
Elbow-joint,  555 
Wrist-joint,  556 

tubercular  form,  556 
treatment,  557 
Hip-joint,  synovitis,  simple  and  acute, 
treatment,  558 


INDEX. 


983 


Joints,  diseases  of, 

Hip-joint,  tubercular,  558,  559 

symptoms,    diagnosis,    treatment, 
559-567 
Knee-joint,  567 

synovitis,  acute,  567 

clironic,  treatment,  567 
tubercular  disease  of,  568 

progress,  symptoms,  prognosis,  568 
treatment,  568,  569 
Ankle-joint,  synovitis  of,  569 
treatment,  569,  570 
tubercular  disease  of,  570 
treatment,  570-573 
Tarsus, 
synovitis  of  tarsal  joints,  treatment, 

573 
tubercular  disease   of  tarsal  joints, 
573 
symptoms,  treatment,  573-575 

K. 

Keratitis, 

Herpetic  or  phlyctenular,  198 
duration,  prognosis,  199 
treatment,  200 
Parenchymatous  or  diffuse,  201 
treatm'ent,  201,  202 
Kidney,  abscess  of,  938 
tuberculosis  of,  939 
tumors  of,  939 
Knee-joint,  diseases  of,  567 
Knock-knee,  492 

Lactation  of  infant,  27 

rules  in  regard  to,  38-42 
Laryngismus  stridulus,  179,  634 
causes,  635 

anatomical  characters,  636 
symptoms,  636 
diagnosis,  prognosis,  modes  of  death, 

637 
treatment,  638 
Laryngitis,  catarrhal,  820 
Acute,  820 

symptoms.  821 
Chronic,  822 

anatomical  characters,  822 
treatment,  822 
Spasmodic,  822 

causes,  symptoms,  823 

anatomical    characters,    pathology, 

824 
diagnosis,  824 
prognosis,  treatment,  825 
Laryngotomy,  828 

thyrotomy,  burns  and  scalds,  829 
Larynx,  diseases  of,  828 
Leukaemia  (leucocythaemia),  511 
Lockjaw,  132 


M. 


Malformations,  82 
Acrania,  82,  83 


Malformations, 

Incomplete  brain,  83 

Meningocele,     encephalocele,     hydren- 

cephalocele,  83-85 
Spina  biiida,  86-88 
Congenital  abnormalities  in  circulatory 

svstera,  89 
Cyanosis,  89-99 
Caput  succedaneum,  99 
Atresia  oris,  microstoma,  476 
Macrostoma,  476 
Hare-lip,  476_,  477 
fissure  partial,  477 
single,  478 
double,  479 
Hypertrophy  of  mucous  glands  and  of 

lips,  480 
Tongue-tie,  hypertrophy  of  tongue,  481 
Angeioma,  papillomata,  482 
Palate,  congenital  defects  of,  482 
Staphylorraphy,  483 
Urinoplasty,  485 
Contracted  soft  palate,  486 
Rectum,  imperforate,  absence  of,  487 
Anus,  contraction  of,  487 

imperforate,  absence  of,  488 
Bladder,  extroversion  of,  489 
Digits,  supernumerary,  490 

union  of,  flexion  of  phalangeal  joints, 
491,  492 
Knock-knee  (genu  valgum),  492 

treatment,  493 
Out-knee  (genu  extrorsum),  495 

treatment,  495 
Bowleg,  496 
Feet,  distortions  of,  497 
talipes  calcaneus,  499 
varus,  500 
valgus,  501 
hollow,  club  (pes  cavus),  502 
hypertrophy  of  toes  and  foot,  503 
Mastitis,  102 
Measles,  etiology  of,  242 
symptoms,  242-244 
complications,  245,  246 
anatomical  characters,  nature,  247 
diagnosis,  prognosis,  247,  248 
treatment,  248,  249 
Measles,  German,  298 
Meliena  neonatorum,  504 
age,  etiology,  504—506 
diagnosis,  prognosis,  treatment,  507 
Meningitis,  tubercular  and  non-tubercular, 
596  _ 

age,  pathological  anatomy,  598 
causes,  601 

premonitory  stage,  602 
symptoms,  603 
diagnosis,  prognosis,  607,  608 
treatment,  609 
Meningocele,  83-85 
Milk,  human.  33 

modified  by  diet,  34 

by  retention  in  breast,  34 

by  age  and  mental  impressions,  35 

by  the  catamenial  function,  36 


984 


IXDEX. 


Milk,  human,  modified  by  pregnancy,  and 
other  causes,  36 
effect  of  medicine  on,  37 
differences    in   ciuantitv   and   quality, 

38 
rules  in  regard  to  lactation,  38-42 
Milk,  cow's,  diseases  communicated  by,  57 
Mortality  of  early  life,  22 
causes,  24,  25 
prevention,  26 
Mother,  in  pregnancy,  care  of,  19 
Movements  of  infant,  72 
Mumps,  395 

etiology,  incubation,  395 
symptoms,  anatomical  characters,  396 
complications,  sequelce,  396,  397 
diagnosis,  prognosis,  treatment,  397,  398 
Myocarditis,  916 

cause,  symptoms,  916 
diagnosis,  treatment,  917 
Myxcedema,  469 

IS". 

K?evus,  924 

diagnosis,  treatment,  924-926 
I^ecrosis,  545 
Nephrectomv,  940 

lumbar,  940 

abdominal,  940 
Nephritis  in  scarlet  fever,  275,  276 
Nervous  system  in  infancy,  79 
Nose,  iinperfoiate,  827 

hemorrhage  of,  827 

foreign  bodies  in,  827,  828 

o. 

OEdema  neonatorum,  150 
Qi^sophagus,  711 
Stricture  of,  711 
OEsophagitis,  712 

anatomical       characters,      symptoms, 
treatment,  713 
Oidium  albicans,  123 
Ophthalmia  neonatorum,  103-108 
prognosis,  105 
prevention,  106 
treatment,  107,  108 
preventive  treatment,  107 
Purulent  neonatorum,  gonorrhoeal,  103 
Strumous,  198 

Herpetic  or  phlyctenular  keratitis,  198 
duration,  prognosis,  199 
treatment,  200 
Parenchymatous  or  diffuse  keratitis,  201 
treatment,  201,  202 
Osteomyelitis,  acute,  543 
Necrosis,  545 

of  entire  diaphysis,  546 
Chronic  circumscribed,  547 

treatment,  548 
Chronic  diffuse,  548 
svmptoms,  progress,  treatment.  548, 
■  549 
Osteoparesis  imperfecta,  153 


Palate,  congenital  defects  of,  482 
Papillomata,  482 
Paralysis  in  young  children,  664 
facial,  671 

causes,  symptoms,  prognosis,  671 
treatment,  672 
pseudo-hypertrophic,  672 
anatomical  characters,  674 
causes,  prognosis,  treatment,  675 
Eachitic,  180 
in  diphtheria,  363 
Paraphimosis,  945 
Parasites  of  the  skin,  971 
Parotitis,  parotiditis,  395 
Pemphigus  neonatorum,  151 
simplex,  151 
cachecticus,  152 
anatomy,  152 
treatment,  153 
Penis,  944 
Pericarditis,  913 
pathology,  913 
symptoms,  diagnosis,  914 
prognosis,  treatment,  915 
Perinephric  abscess,  938 
Periostitis,  539 
Peripharyngeal  abscess,  704 

anatomical  characters,  symptoms,  705 
diagnosis,  prognosis,  707 
swallowing  foreign  substances,  708 
Peritonitis,  805 
etiology,  805,  806 
symptoms,  807 
diagnosis,  prognosis,  808 
treatment,  808,  809 
Pertussis,  381 

incubative  period,  381 
age,  cause,  382 
pathological  anatomy,  383 
symptoms,  383 

first  and  second  periods,  384 
third  period,  385 
complications,  385-388 
diagnosis,  prognosis,  389 
treatment,  390 

carbolic  acid,  cocaine,  390,  391 
antipyrine,  quinine,  391,  392 
sulphur,  393 
of  complications,  394 
prophylaxis,  395 
Pharyngitis     catarrhal,    anatomical    cha- 
racters, 701 
causes,  symptoms,  prognosis,  702 
diagnosis,  treatment,  703 
Phimosis,  944 
Pleurisy,  876 

frequency,  876,  877 ;  causes,  878-882 
anatomical  characters,  882 
Plastic,  883 
Sero-fibrinous,  884 
Purulent,  884,  885 
Hemorrhagic,  885-888 
symptoms,  889 
physical  signs,  891 


INDEX. 


985 


Pleurisy,  hemorrliagic, 

palpitation,  percussion,  891,  892 
auscultation,  892-894 
diagnosis,  894 
prognosis,  895,  896 
treatment,  897 
internal  remedies,  898 
Second  stage,  899 
Thoracentesis,  901 

indications  for,  901,  902 
mode  of  operating.  903 
for  empyema,  904 
admission  of  air  into  pleural  cavity,  905 
injury  by  instruments,  906 
washing  out  cavity,  906-908 
use  of  tent  and  tube  in  empyema,  908 
Paracentesis  thoracis,  908-911 
Excision  of  the  rib,  911 
Pneumonia,  864 
Catarrhal,  864 
etiology,  864 

anatomical  characters,  865,  866 
Croupous,  867 
etiology,  867 

anatomical  characters,  868 
Septic  or  embolismal,  869 
cheesy  degeneration,  870 
symptoms,  870,  871 
physical  signs,  872 
diagnosis,  873 
prognosis,  874 
treatment,  874 

of  catarrhal  pneumonia,  874 
of  croupous  pneumonia,  874,  875 
local,  875,  876 
Poliomyelitis  acuta  anterior,  664 
symptoms,  664 
progress,  etiology,  666 
diagnosis,  prognosis,  669 
treatment,  670 
Pott's  disease,  519 
Preputial  dilatation,  937,  938 
Prurigo,  954,  955 
Pulse  of  infant,  26 
in  health,  74 
in  disease,  75 
Purpura,  515 

etiology,  anatomical  appearances,  515 
symptoms,    diagnosis,    prognosis,    treat- 
ment, 516 
Pyonephrosis,  938 

R. 

Eachitis,  156 
frequency,  156 
diagnosis,  158 
age  of  occurrence,  159 
etiology,  159 
inheritance,  159 

antihygienic  conditions,  food,  160 
pathology,  161 

changes  in  soft  tissues  (mucous  mem- 
branes, ligaments,  spleen,  liver), 
abdominal  protuberance,  kidneys, 
urine,  brain,  spinal  cord,  162,  163 


Ptachitis,   changes    in    osseous   svstem    in 
health,  163-165 
anatomical  characters : 

1,  in  the   stage   of  proliferation    and 

altered  nutrition,  165 

2,  of  the  rachitic  child,  169 
changes  in  cranial  bones,  169 
craniotabes,  170 

changes  in  the  vertebrae,  171 
in  maxillfe  and  ribs,  172 
in  bones  of  upper  extremities  and 

pelvis,  174 
in  bones  of  lower  extremities,  175 

effect  on  dentition,  176 

3,  of  stage  of  reconstruction,  176 
symptoms,  177 

laryngismus  stridulus  in,  179 
rachitic  paralysis,  180 
acute  rickets,  180 

treatment,  hygiene,  181 
■  medicinal,  183-185 
Radius,  fracture  of,  535 
Eanula,  696 

Kectum,  absence  of,  imperforate,  487 
Remittent  fever,  405 

symptoms,  diagnosis,  treatment,  406 
Respiration  of  infant,  26 
Respiratory  system  in  infants,  72 
Rheumatism,  acute,  455 
causes,  456 
symptoms,  457 
pathology,  459 
duration,  prognosis,  460 
diagnosis,  treatment,  461-463 
Rotheln,  298 

premonitory  stage,  300 
symptoms,  tegumentary  system,  300,  301 
mucous  membrane,  301 
respiratory  and  digestive  system,  302 
pulse,  temperature,  302 
complications,  prognosis,  303 
nature,  incubative  period,  303 
contagiousness,  303-305 
complications,  diagnosis,  prognosis,  treat- 
ment, 306 
Rubeola  (see  Measles). 

S. 

Scalds  and  burns,  829 
Scarlet  fever,  250 

etiology,  250-252 

incubative  period,  252,  253 

contagiousness,  254 

variations  in  type,  254-257 

age,  258 

clinical  facts,  259 

symptoms,  ordinary  form,  260-263 

grave  form,  264,  265 

irregular  form,  265,  266 
complications  and  sequelte,  266-270 

coryza,  270 

inflammation  of  middle  ear,  270 

scarlatinous  rheumatism,  272 

pleuritis,  273 

dilatation  of  the  heart,  273 


986 


IXDEX. 


Scarlet  fever,  complications,  etc. : 

nephritis,  parenchyuiatoiis,  275 
interstitial,  276 
anatomical  characters,  278 
diagnosis,  279 
prognosis,  281 
treatment,  283 

prophylaxis    (care    of   patient,   in- 
fected articles),  283-285 
hygienic,  285 
therapeutic,  in  mild  cases,  286 

in  severe  cases,  287-289 
of  complications  and  sequelae,  289- 
298 
Sclerema  neonatorum,  149 
Scorbutus,  etiology,  516 

morbid    anatomy,   symptoms,  diagnosis, 
prognosis,  treatment,  517,  518 
Scrofula,  186 
causes,  187 

anatomical  characters,  188 
symptoms,  191 
prognosis,  193 
treatment,  prophylactic,  193 

curative,  194 
strumous,  dactylitic,  190 
Scrotum,  947 

Hydrocele,  variocele,  947 
Scurvy  (see  'Scorbutus). 
Septicfemia  of  the  new-born,  115 
first  group,  115-119 
second  group,  119-122 
third  group,  122,  123 
Shoulder,  diseases  of,  554 
Skin,  diseases  of,  949 

Erythema,  or  rose-rash,  950 
diagnosis,  treatment,  951 
duration,  pathology,  952 
Urticaria,  varieties,  952 
papulosa,  953 
etiology,  pathology,  953 
diagnosis,  prognosis,  treatment,  954 
Prurigo,  954 

symptoms,  etiology,  954,  955 
patliology,    diagnosis,     prognosis, 
treatment,  955 
Eczema,  956 

vesiculosum,    squamosum,    rubrum, 

956 
pustulosum,  impetiginodes,  papulo- 

sum,  erythematosum,  957 
age,  957 
etiology,  pathology,  anatomv,   958- 

962  ' 
diagnosis,  prognosis,  treatment,  962, 

963 
treatment,  local,  963-965 
of  the  head,  965,  966 
of   the    ears,    face,    eyelids,    lips, 

23alms,  966 
of  the  nails,  genitalia,  967 
Microbes,  pathogenic  effects  of,  967 
Impetigo  contagiosa,  967 
etiology,  pathology,  967 
diagnosis,     prognosis,    treatment, 
968 


Skin,  diseases  of, 

Seborrhoea,  seborrhoea  sicca,  968 
furfuracea  universalis  of  the  scalp, 

969 
prognosis,  treatment,  970 
Parasites  of  the  skin,  971 

scabies  or  the  itch,  diagnosis,  972 

treatment,  973 
pediculosis,  974 
Skull,  injuries  of,  530 

depression    of,    diagnosis,    treatment, 
fractures,  530 
Sleep  of  infant,  67 
Spina  bifida,  86 

Spinal  cord  and  coverings,  diseases  of,  676 
membranes,  congestion  of,  677 
anatomical  characters,  677 
symptoms,  treatment,  678 
Spine,  lateral  curvature  of,  525 
diagnosis,  526 
treatment,  527 
Staphylorraphy,  483 
St.  Guy's  dance,  650 
Stomach,  719 

congestion  of,  719 
Stomatitis,  680 

simple  or  catarrhal,  680 

symptoms,  appearance,  treatment,  681 
ulcerous,  681 

causes,  symptoms,  prognosis,  treatment, 
682 
aphthous,  683 

causes,  .symptoms,  diagnosis,  683 
prognosis,  treatment,  684 
Strumous  ophthalmia,  198 
St.  Vitus's  dance,  650 
Synovitis,  acute,  serous,  552 

suppurative,  553 
Syphilis,  etiology,  230 
'clinical  history.  232-235 
visceral  lesions,  235 
osseous  lesions,  236 
prognosis,  238 
treatment,  238-241 

T. 

Tarsus,  synovitis  of,  treatment,  573 
Temperature  of  infant,  26 
Testicles,  tubercles  of.  947 

sarcoma  of,  947,  948 
Tetanus  neonatorum,  132 

time  of  commencement,  fatal  cases,  135 
favorable  cases,  136 

period  of  commencement,  136 
symptoms,  141 
mode  of  death,  142 
prognosis,  142 
duration  in  fatal  cases,  143 

in  favorable  cases,  143 
diagnosis,  preventive    treatment,  143, 

144 
treatment,  145-149 
Tetany,  640 
causes,  640 
symptoms,  644 


INDEX. 


987 


Tetany,  pathology,  648 
diaguosis,  prognosis,  649 
treatment,  650 
Therapeutics  of  infancy,  80,  81 
Thoracentesis,  901 
Thrush,  123 

causes,  anatomical  characters,  124,  125 
symptoms,  126 

diagnosis,  prognosis,  treatment,  127,  12S 
Thyrotomy,  829 
Tibia,  fracture  of,  538 
Tongue,  tongue-tie,  hypertrophy  of,  481 
Tonsil,  abscess  of,  698 

chronic  inflammation  of,  698 
Tonsillitis,  recurrent,  699 
Tracheotomy,  848-850 
Tubercular  affections  of  joints,  553 
Tuberculosis,  202 
etiology,  202-205 

anatomical   characters   of   the  tubercle, 
205 
in  infancy  and  childhood,  207 
lungs,  208-211 
abdominal  viscera,  211-214 
encephalon,  214-216 
bronchial  glands,  216 
physical  signs,  217-219 
diagnosis,  219-222 
prophylaxis,  222,  223 
treatment,  224 
high  altitude,  224 
benefit  of  evergreen  forest  and  use  of 

turpentine,  225,  226 
creosote,  226-228 
guaiacol,  228 
tuberculin,  229 
of  bone,  549 

diagnosis,  prognosis,  treatment,  550 
Typhoid  fever,  407 

causation,  407—410 

anatomical  characters,  410 

pathology,  411 

incubative  period,  symptoms,  412 

duration,  413 

relapses,  second  attacks,  414 

complications,  414,  415 

diagnosis,  415,  416 

prognosis,  416 

treatment,  416-420 

U. 

Ulna,  injury  of,  535 
Umbilical  hemorrhage,  109 

etiology,  prognosis,  treatment,  111 
Vegetations,  108 

progress,  treatment,  109 
Uranoplasty,  485 


Urethra,  942 

wounds  of,  943 

foreign  bodies  in,  943 

calculus  of,  943,  944 

imperforate,  944 
Urticaria,  varieties,  952 

V. 

Vaccinia,  316 

appearances,  symptoms,  319 

anomalies,  complications,  sequelse,  320 

vaccination,  subsequent,  322 
protection  from,  323 

virus,  selection  of,  324-326 
Varicella,  326 

symptoms,  326,  327 

complications,  sequelte,  327 

diagnosis,  prognosis,  treatment,  327,  328 
Variola,  306 

etiology,  incubative  period,  stage  of  in- 
vasion, 307 

stage  of  eruption,  308 

of  desiccation  and  desquamation,  309 
Varioloid,  310 

mode  of  death,  310,  311 

anatomical  characters,  311,  312 

prognosis,  diagnosis,  312 

treatment,  314-316 
Vascular  growths,  694 
Vertebral  caries,  519 
Vessels,  diseases  of,  923 
Voice  in  infant,  72 
Vulvitis,  936 

etiology,  936,  937 

treatment,  937 

W. 

Weaning,  46,  47 
AVeight  of  infant,  26 
Wet-nurse,  selection  of,  42-45 
Wet-nursing,  28 

its  advantages  and  hindrances,  28 
physical  conditions,  if  improper,  29-31 
course,  45,  46 
Whooping  cough,  381 
Worms,  intestinal,  765 

Ascaris  lumbricoides,  765 
symptoms,  772 
diagnosis,  prognosis,  774 
treatment,  775 
Oxyurus  vermicularis,  767 
Tape-worm,  Ta2nia  solium,  768 
Taenia  saginata,  769 

elliptica,  or  cucumerina,  770 
Bothriocephalus  latus,  770 
Trichocephalus  dispar,  770 
Wrist-joint,  diseases  of,  556 


LEA  BROTHERS  &  COS 

CLASSIFIED   CATALOGUE  4 

OF  J> 

a 


Medical  m  Surgical 


.2 

N  ASKING  the  attention  of  the  profession  to  the  works  advertised  in  the  follow-  Q, 

ing  pages,  the  publishers  would  state  that  no  pains  are  spared  to  secure  a  0«  C) 

continuance  of  the   confidence   earned  for    the  publications  of   the  house  ^   ^ 

by  their  careful  selection  and  accuracy  and  finish  of  execution.  ^   q^ 

The  printed  prices  are  those  at  which  books  can  generally  be  supplied  by  booksellers  ^^  ^    - ^ 

throughout  the  United  States,  who  can  readily  procure  for  their  customers  any  works  not  "  ^   1> 

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has  been  removed,  no  difficulty  will  be  experienced  in  obtaining  through  the  post-office  ^  g   g 

any  work  in  this  catalogue.      No  risks  however  are  assiuned  either  on  the  money  or  ©   O 

on  the  books,  and  no  publications  but  our  own  are  supplied,  so  that  gentlemen  will  in  ^  V»  ^ 

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LEA   BKOTHEKS   &  CO.  W  CLj 

Nos.  706,  708  &  710  Sansom  St.,  Philadelphia,  October,  1895.  C  tn  -A 
©        -^ 


s. 


OJ  t>^ 


THE  AMERICAN  JOURNAL  OF  THE  MEDICAL     -.      To  one  address,  X  S  _2 

post-paid,        ^   2;  3 
SCIENCES,  Monthly,  $4.00  per  annum.  L       d*  In.s  g 

THE  MEDICAL  NEWS,  Weekly,  $4.00  per  annum.      J         per  annum.       ^  °X  $i 
THE  HEDICAL  NEWS  VISITING  LIST  (4  styles,  see  page  3),  $1.25.    o  ^  .2 
With  either  or  both  above  periodicals,  in  advance,  75c.  *-  C 

THE  YEAR=BOOK  OF  TREATMENT  (see  page  16),  $1.50.  With  either  wj  s  § 
JOURNAL  or  NEWS,  or  both,  75c.  Or  JOURNAL,  NEWS,  VIS=  ^  ^  5 
ITINQ  LIST  AND  YEAR=BOOK,  in  all  $10.75,  *or  $8  50  in  advance.  F  q  ;5 

Subscription  Price  Reduced  to  $4.00  Per  Annum.         > 

THE  MEDICAL  NEWS.  ^ 


|Y  KEEPING  closely  in  touch  with  the  needs  of  the  active  practitioner,  The 
News  has  achieved  a  reputation  for  utility  so  extensive  as  to  render  practicable 
its  reduction  in  price  from  five  to  Four  Dollars  per  annum.  It  is  now  by 
far  the  cheapest  as  well  as  the  best  large  weekly  medical  journal  published 
in  America.  Employing  all  the  recognized  resources  of  modern  journalism,  such  as  the 
cable,  telegraph,  resident  correspondents,  special  reporters,  etc..  The  News  supplies 
in  the  28  quarto  pages  of  each  issue  the  latest  and  best  information  on  subjects  of 
importance  and  value  to  practitioners  in  all  branches  of  medicine.  The  foremost  writers, 
teachers  and  practitioners  of  the  day  furnish  original  articles,  clinical  lectures  and  notes 

(Continued  on  next  page.) 


<1) 


2        Medical  Periodicals,  Visiting  List,  Ledger. 

THE  HEDICAL  NEWS===Continued. 

on  practical  advances;  the  latest  methods  in  leading  hospitals  are  constantly  reported ; 
a  condensed  summary  of  progress  is  gleaned  each  week  from  a  large  exchange  list,  com- 
prising the  best  journals  at  home  and  abroad  ;  a  special  department  is  assigned  to  abstracts 
requiring  full  treatment  for  proper  presentation  ;  editorial  articles  are  secured  from 
writers  able  to  deal  instructively  with  questions  of  the  day ;  books  are  carefully 
reviewed ;  society  proceedings  are  represented  by  the  pith  alone ;  regular  correspondence 
is  furnished  from  important  medical  centres,  and  minor  matters  of  interest  are  grouped 
each  week  under  news  items.  In  a  word  The  Medical  News  is  a  crisp,  fresh,  weekly 
professional  newspaper  and  as  such  occupies  a  well-marked  sphere  of  usefulness,  distinct 
from  and  complementary  to  the  ideal  monthly  magazine,  The  American  Journal 
OF  the  Medical  Sciences. 

The  American  Journal  i  p^Mishec  Monthly 

of  the  t  at  $4.00 

f  Per   Annum. 

The  American  Journal  entered  with  1895  upon  its  seventy-sixth  year,  still  main- 
taining the  foremost  place  among  the  medical  magazines  of  the  world.  A  vigorous 
existence  during  two  and  a  half  generations  of  men  amply  proves  that  it  has  always 
adapted  itself  to  meet  fully  the  requirements  of  the  time. 

Being  the  medium  chosen  by  the  best  minds  of  the  profession  during  this 
period  for  the  presentation  of  their  ablest  papers,  The  American  Journal  has  well 
earned  the  praise  accorded  it  by  an  unquestioned  authority — "From  this  file  alone,  were  all 
other  publications  of  the  press  for  the  list  fifty  years  destroyed,  it  would  be  possible  to  reproduce 
the  great  majority  of  the  real  contributions  of  the  world  to  medical  science  during  that  period." 
Original  Articles,  Reviews  and  Progress  of  the  Medical  Sciences  constitute  the  three  main 
departments  of  this  ideal  medical  monthly. 

COMMUTATION  RATE. 

Taken  together.  The  Journal  and  The  News  afford  to  medical  readers  the  ad- 
vantages of  the  monthly  magazine  and  the  weekly  newspaper.  Thus  all  the  benefits  of 
medical  periodical  literature  can  be  secured  at  the  low  figure  of  $7.50  per  annum. 

Subscribers  can  obtain,  at  the  close  of  each  volume,  cloth  covers  for  The  Journal  (one 
annually),  and  for  The  News  (one  annually),  free  by  mail,  by  remitting  Ten  Cents  for  The 
Journal  cover,  and  Fifteen  Cents  for  The  News  cover. 


The  Medical  News  Visiting  List  for  1896 

Is  published  in  four  styles,  Weekly  (dated  for  30  patients) ;  Monthly  (undated,  for  120 
patients  per  month)  ;  Perpetual  (undated,  for  30  patients  weekly  per  year)  ;  and  Per- 
petual (undated,  for  60  patients  weekly  per  year).  The  60-patient  Perpetual  consists 
of  256  pages  of  assorted  blanks.  The  first  three  styles  contain  32  pages  of  important 
data  and  176  pages  of  assorted  blanks.  Each  style  is  in  one  wallet-shaped  book,  leather- 
bound,  with  pocket,  pencil,  rubber,  and  catheter- scale.  Price,  each,  $1.25.  With  thumb- 
letter  index,  25  cents  extra. 


This  list  is  all  that  could  be  desired.  It  con- 
tains a  vast  amount  of  useful  information,  especi- 
ally for  emergencies,  and  gives  good  tables  of  doses 
and  thei'apeutips. —  Canadian  Practitioner. 

Its  compactness  and  simplicity  are  such  as  to 
Indicate  that  the  highest  point  of  perfection  has 
been  reached  in  works  of  this  class. —  University 
Medical  Magazine. 


The  new  issue  maintains  its  previous  reputation. 
It  adapts  itself  to  every  style  of  book-keeping; 
there  is  space  for  all  kinds  of  professional  records ; 
it  is  furnished  with  a  ready  reference  thumb-letter 
index,  and  has  a  most  valuable  text. — Medical 
Record. 

For  convenience  and  elegance  it  is  not  surpass- 
able. — Obstetric  Gazette. 


SPECIAL  COMBINATIONS  WITH  THE  VISITING  LIST,  see  p.  1. 

J5@°The  safest  mode  of  remittance  is  by  bank  check  or  postal  money  order,  drawn  to 
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the  Publishers  (see  belowj. 

The  Medical  News  Piiysicians'  Ledger. 

Containing  300  pages  of  fine  linen  "  ledger  "  paper  ruled  so  that  all  the  accounts  of  a 
large  practice  may  be  conveniently  kept  in  it,  either  by  single  or  double  entry,  for  a  long 
period.  Strongly  bound  in  leather,  with  cloth  sides,  and  with  a  patent  flexible  back 
which  permits  it  to  lie  perfectly  flat  when  opened  at  any  place.     Price,  $4.00. 

Lea  Brothers  &  Co..  Publishers,  706.  708  &  710  Sansom  Street,  Philadelphia. 


Medical  Dictionary,  Quiz  Manuals. 


THE   STUDENTS' 


AND  THE  ALLIED  SCIENCES, 

COMPRISING  THE   PRONUNCIATION,   DERIVATION  AND  PULL  EXPLANATION   OF  MEDICAL 

TERMS;    TOGETHER   WITH    MUCH   COLLATERAL   DESCRIPTIVE    MATTER, 

NUMEROUS   TABLES,    ETC. 

By   ALEXANDER    DUANE,  M.  D., 

Assistant  Surgeon  to  the  New  York  Ophthalmic  and  Aural  Institute ;  Reviser  of  Medical  Terms  for 
Webste?''s  International  Dictionary. 

iges.     Cloth,  $4.25;  half  leather,  $4.50;  full 
use,  50  cents  extra. 

From  A.  L.  Loomis,  M.  D  ,  Professor  PatholoQy  and 
Practice  of  Medicine,  Medical  Department,  Univer- 
sity City  of  New  York,  New  York. 
It  seems  to  me  entirely  satisfactory  for  the  pur- 
pose for  which  it  is  intended. 

From  J.  C.  Wilson,  M.  D.,  Professor  of  Medicine, 
Jefferson  Medical  College,  Philadelphia. 
It  appears  to  be  well  suited  to  the  purposes  ol 
the  medical  student,  being  simple  as  regards  deri- 
vations and  pronunciation,  explicit  yet  sufficiently 
comprehensive  in  definitions,  and  thoroughly  up 
to  the  times. 

From  James  T.  Whittakee,  M.  D.,  Professor  Theory 
and  Practice  of  Mfdicine,  Medical  College  of  Ohio, 
Cincinnati,  O. 

I  find  it  admirably  adapted  to  the  wants  of  stu- 
I  dents,  and  thoroughly  modern  in  every  particular 
i  in  which  I  have  taken  occasion  to  consult  it.  I 
;  shall  certainly  recommend  it  to  my  class. 


In  one  square  octavo  volume  of  658  p< 
sheep,  15.00.     Thumb-letter  Index  for  quick 

Dr.  Duane  has  spared  no  time,  pains  or  expense 
in  his  endeavor  to  bring  before  the  profession, 
and  especially  the  students  of  medicine,  a  book  em- 
bodying completeness  and  explicitness.  The 
vocabulary  is  abundant  and  its  fulness  is  paral- 
leled by  the  explanation  accorded  each  word.  It 
also  contains  extensive  tables.  Each  word  is  fol- 
lowed by  its  correct  pronunciation,  a  new  feature 
in  works  of  this  kind,  given  by  means  of  a  simple 
and  obvious  phonetic  spelling.  Derivation,  the 
greatest  aid  to  memory,  is  fully  treated  of,  and  for 
the  convenience  of  those  who  do  not  understand 
Greek,  the  English  letters  are  substituted  for 
those  of  the  Greek  in  giving  the  roots  of  the  words 
derived  from  that  language.  The  author's  expe- 
rience as  a  lexicographer  is  fully  attested  by  his 
petition  as  Reviser  of  Medical  Terms  for  Web- 
ster's International  Dictionary.  We  predict  that 
this  will  become  a  standard  and  favorite  work  of 
its  class. — Medical  Fortnightly. 


THE   STUDENTS'  QUIZ  SERIES. 

ANEVf  Series  of  Manuals,  comprising  all  departments  of  medical  science  and  practice, 
and  prepared  to  meet  the  needs  of  students  and  practitioners.  Written  by  promi- 
nent medical  teachers  and  specialists  in  ISTew  York,  these  volumes  may  be  trusted  as 
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and  clear  answers,  the  text  will  impress  vividly  upon  the  reader's  memory  the  salient 
points  of  his  subject.  To  the  student  these  volumes  will  be  of  the  utmost  service  in  pre- 
paring for  examinations,  and  they  will  also  be  of  great  ute  to  the  practitioner  in  recalling 
forgotten  details,  and  in  gaining  the  latest  knowledge,  whether  in  theory  or  in  the  actual 
treatment  of  disease.  Illustrations  have  been  inserted  wherever  advisable.  Bound  in 
limp  cloth,  and  in  size  suitable  for  the  hand  and  pocket,  these  volumes  are  assured  of 
enormous  popularity,  and  are  accordingly  placed  at  an  exceedingly  low  price  in  com- 
parison with  their  value.  For  details  of  subjects  and  prices  see  below. 
ANATOMY     (Double   Number)  — By  Fn%r>    J.  |  CEN  !TO  -  URINARY      AND      VENEREAL 


Bkockwat,  M.  D.,  Assistant  Demonstrator  of 
Anatomy,  College  of  Physicians  and  Surgeons, 
New  York,  and  A.  O'Maxlet,  M.  D.,  Instructor 
in  Surgery,  New  York  Polyclinic.    $1.75. 

P  H  YSI  OLOC  Y— By  F.  A.  Manning,  M.D., 
Attending  Surgeon,  Manhattan  Hosp.,N.Y.  $1. 

CHEMISTRY  AND  PHYSICS  — By  Joseph 
Struthebs,  Ph.  B.,  Columbia  College  School  of 
Mines,  N.Y.,  and  D.  W.  Ward,  Ph.  B.,  Columbia 
College  School  of  Mines,  N.  Y.,  and  Chas.  H. 
Willmarth,  M.  S.,  N.  Y.    SI. 

HISTOLOGY,  PATHOLOGY  AND  BAC- 
TERIOLOCY— By  Bennett  S.  Beach,  M.  D., 
Lecturer  on  Histology,  Pathology  aad  Bacte- 
riology, New  York  Polyclinic.    SI. 

MATERIA  MEDICA  AND  THERAPEU- 
TICS—By  L.  F.  Warner,  M.  D.,  Attending 
Physician, St.  Bartholomew's  Disp  ,N.Y.    $1. 

PRACTICE  OF  MEDICINE,  INCLUDING 
NERVOUS  DISEASES— By  Edwin  T.DoTJ- 
bleday,  M.  D.,  Member  N.Y.  Pathological  Soci- 
ety, and  J.  D.  Nagel,  M.  D  ,  Member  N.  Y. 
County  Medical  Association.    SI. 

SURGERY  [Double  Number)— By  Bbus  B.  Gal- 
laudet,  M.  D.,  Visiting  Surgeon,  Bellevue 
Hospital,  N.Y.,  and  Charles  Dixon  Jones,  M.  D., 
Assistant  Surgeon  Out-Patient  Department, 
Presbyterian  Hospital,  N.Y.   $1.75. 


DISEASES— By  Charles  H.  Chetwood, M.D., 
Visiting  Surgeon,  Demiit  Dispensary,  Dep.  of 
Surg,  and  Gen.-Urln.  Djs.,  New  York.    $1. 

DISEASES  OF  THE  SKIN— By  Charles  C. 
Ransom,  M.  D.,  Assistant  Dermatologist,  Van- 
derbilt  Clinic,  New  York.    $1. 

DISEASES  OF  THE  EYE,  EAR,  THROAT 

AND  NOSE— By  Frank  E.  BIiller,  .M.D., 
Throat  Surgeon,  Vanderbilt  Clinic,  New  York, 
James  P.  McEvoY,  31. D.,  Throat  Surgeon,  Belle- 
vue Hosp.,  Out-Patient  Dep.,  New  York,  and 
J.  E.  Weeks,  M.  D.,  Lect.  on  Ophthal.  and 
Otol.,  Bellevue  Hosp.,  Med.  Col.,  N.  Y.    $1. 

OBSTETRICS  — By  Charles  W.  Hatt,  M.D., 
House  Physician,  Nursery  and  Child's  Hospi- 
tal, New  York.    $1. 

GYNECOLOGY— By  G.  W.  Bratenahl,  M.  D., 
Assistant  in  Gynecology,  Vanderbilt  Clinic, 
New  York,  and  Sinclair  Touset,  M.  D.,  Assist- 
ant Surgeon,  Out-Patient  Department,  Eoose- 
velt  Hospital,  New  York.    $1. 

DISEASES  OF  CH  I  LDREN-By  C.  A.  Rhodes, 

M.  D..  Instructor  in  Diseases  of  Children,  New 
York  Pcst-Graduale  Medical  College.    $1. 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


Dictionaries. 


TWENTY-FIRST    EDITION.       WITH    APPENDIX. 

Dungflison's  Dictionary 

OF   MEDICAL  SCIENCE. 

With  the  Pronunciation,  Accentuation  and  Derivation  of  the  Terms. 

Containing  a  full  Explanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology, 
Medical  Chemistry,  Pharmacology,  Pharmacy,  Therapeutics,  Medicine,  Hygiene,  Dietet- 
ics, Surgery,  Ophthalmology,  Otology,  Laryngology,  Dermatology,  Gynecology,  Obstetrics, 
Pediatrics,  Medical  Jurisprudence  and  "Dentistry,  etc.,  etc.  By  Kobley  DgNGLisoN, 
M.  D.,  late  Professor  of  Institutes  of  Medicine  in  the  Jefferson  Medical  College  of  Phila- 
delphia. New  (21st)  edition,  thoroughly  revised  and  greatly  enlarged.  With  the  Pro- 
nunciation, Accentuation  and  Derivation  of  the  Terms,  by  Richard  J.  Dunglison, 
A.  M.,  M.  D.  "With  Appendix.  Jiid  ready.  In  one  very  large  and  handsome  royal 
octavo  volume  of  1225  pages.  Cloth,  $7.00;  leather,  raised  bands,  $8.00.  Thumb-letter 
Index  for  quick  use,  75  cents  extra. 

THIS  gieat  medical  dictionary,  wliicli  has  been  for  more  than  two  generations  the 
standard  of  the  English  speaking  race,  is  now  issued  in  a  thoroughly  revised  and 
greatly  enlarged  and  improved  edition.  The  new  words  and  phrases  aggregate 
by  actual  count  over  44,000.  Though  the  new  edition  contains  far  more  matter  than  its 
predecessor,  the  whole  is  accommodated  within  a  volume  convenient  for  the  hand. 

The  revision  has  not  only  covered  every  word,  but  it  has  resulted  in  a  number  of 
important  new  features  designed  to  confer  on  the  work  the  utmost  usefulness,  and  to  make 
it  answer  the  most  advanced  demands  of  the  times. 

Pronunciation  has  been  introduced  throughout  by  means  of  a  simj)le  and  obvious 
system  of  phonetic  spelling.  At  a  glance  the  proper  sound  of  a  word  is  clearly  indicated, 
and  thus  a  most  important  desideratum  is  supplied. 

Derivation  affords  the  utmost  aid  in  recollecting  the  meanings  of  words,  and  gives 
the  power  of  analyzing  and  understanding  those  which  are  unfamiliar.  It  is  indicated  in 
the  simplest  manner.  Greek  words  are  spelled  with  English  letters,  and  thus  placed  at 
the  command  of  those  unfamiliar  with  the  Greek  alphabet. 

Definitions,  the  essence  of  a  dictionary,  are  clear  and  full,  a  characteristic  in 
which  this  work  has  always  been  preeminent.  In  this  edition  much  explanatory  and 
encyclopedic  matter  has  been  added,  especially  upon  subjects  of  practical  importance.  Thus 
under  the  various  diseases  will  be  found  their  symjatoms,  treatment,  etc. ;  under  drugs  their 
doses  and  effects,  etc.,  etc.  A  vast  amount  of  information  has  been  clearly  and  conveniently 
condensed  into  tables  in  the  alphabet. 

In  a  word,  Dunglison's  Medical  Dictionary,  in  its  remodelled  and  enlarged  shape,  is 
equal  to  all  that  the  student  and  practitioner  can  expect  from  such  a  work. 

the  existing  condition  of  medical  science.  Thus, 
under  the  heading  Hernia,  besides  the  definition 
of  the  condition,  a  condensed  table  is  given  of 
the  various  forms,  and  a  brief  resume  is  given  of 
the  therapeutical  indications.  Under  the  heading 
Murmurs,  besides  a  description  of  the  various 
forms,  a  table  is  given  of  the  significance  of  the 
murmurs  of  valvular  origin.  Under  Bacteria  the 
leading  classifications  are  recorded,  and  a  para- 
graph is  devoted  to  the  question  of  the  determina- 
tion of  the  pathogenic  properties,  and  another  to 
modes  of  culture  of  the  bacteria — TTie  Montreal 
Medical  Journal. 

So  fully  have  derivations  and  definitions  been 
considered,  and  so  great  is  the  amount  of  prac- 
tical matter,  such  as  symptoms,  treatment  and 
prognosis  of  many  of  the  diseases  described,  that 
the  volume  is  entitled  to  be  called  an  encyclo- 
pedia rather  than  a  dictionary. — The  Brooklyn 
Medical  Journal. 

A  thorough  system  of  phonetic  spelling  gives 
the  pronunciation  of  all  wo^-ds  that  are  not  so  sim- 
ple as  to  require  no  key. — New  Orleans  Medical  and 
Surgiral  Journal. 


The  new  "Dunglison"  is  new  indeed.  The  vast 
amount  of  new  matter  and  the  thoroughness  with 
which  the  work  lias  been  brought  down  to  date 
cannot  fail  to  strike  even  the  least  observant 
reader.  The  immense  advances  made  in  all 
branches  of  medical  science  here  find  represen- 
tation. A  prominent  and  very  useful  feature  of 
the  old  book  is  retained  and  amplified  in  this — we 
mean  the  tables,  which  recur  with  great  fre- 
(}uency  and  represent  a  vast  amount  of  condensed 
information.  In  respect  to  accuracy  the  book  quite 
equals  and  usually  surpasses  any  of  its  contempo- 
raries that  we  are  acquainted  with.  The  American 
Journal  of  the  Medical  Snences. 

Covering  the  entire  field  of  medicine,  surgery 
and  the  collateral  sciences,  its  range  of  usefulness 
can  scarcely  be  measured.  Perhaps  the  most  valu- 
able feature  in  the  present  work  is  the  addition  of 
a  vast  amount  of  practical  matter.  The  type  is 
eommendably  clear. — Medical  Record. 

The  new  subjecis  and  terms  treated  are  no  less 
than  forty-four  thousand,  sufficient  in  themselves 
to  form  a  large  volume.  There  has  been  a  praise- 
worthy attempt  to  render  the  work  an  epitome  of 


The  National  Medical  Dictionary, 

Including  English,  French,  German,  Italian  and  Latin  Technical  Terms  used  in 
Medicine  and  the  CoUjiteral  Sciences,  and  a  Series  of  Tables  of  Useful  Data.  By  John 
S.  Billings,  M.  D.,  LL.  D.,  Edin.  and  Harv.,  D.  C.  L.,  Oxon.,  member  of  the  National 
Academy  of  Sciences,  Surgeon  U.  S.  A.,  etc.  In  two  very  handsome  royal  octavo  volumes 
containing  1574  pages,  with  two  colored  plates.  Per  vohime — cloth,  $6.00 :  leather,  $7.00; 
half  morocco,  marbled  edges,   $8.50.    Subscription  only.     Address  the  publishers. 

A.part  from  the  boundless  stores  of  information 
which  may  be  gained  by  the  study  of  a  good  diction- 
ary, one  is  enabled  by  the  work  under  notice  to  read 
intelligently  any  technical  treatise  in  any  of  the  four 


chief  modern  languages.  There  cannot  be  two 
opinions  as  to  the  great  value  of  this  dictionary  as 
a  book  of  ready  reference  for  all  sorts  and  condi- 
tions of  medical  men. — London  Lancet. 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


Anatomy,  Dictionary. 


THIRTEENTH  EDITION. 


BY  HENKY  GRAY,  F.  R.  S., 

LECTURER    ON    ANATOMY    AT    ST.    GEORGE'S    HOSPITAL,    LONDON. 

Edited  by  T.  PICKERING  PICK,  F.  E.  C.  S., 

Surgeon  to  and  Lecturer  on  Anatomy  at  St.  George's  Hospital,  London,  Examiner  in  Anatomy, 
Royal  College  of  Surgeons  of  England. 

A  new  American  from  the  thirteenth  enlarged  and  improved  London  edition.    In  one 

imperial  octavo  volume  of  1118  pages,  with  636  large  and  elaborate  engravings 

on   wood.     Price,  with  illustrations  in  colors,   cloth,  $7  ;  leather,  |8. 

Price,   with   illustrations    in    black,   cloth,   ^6 ;    leather,   $7. 

SINCE  1857  Gray's  Anatomy  has  been  the  standard  work  used  by  students  of 
medicine  and  practitioners  in  all  English-speaking  races.  So  preeminent  has  it 
been  among  the  many  works  on  the  subject  that  thirteen  editions  have  been 
required  to  meet  the  demand.  This  opportunity  for  frequent  revisions  has  been 
fully  utilized  and  the  work  lias  thus  been  subjected  to  the  careful  scrutiny  of  many  of  the 
most  distinguished  anatomists  of  a  generation,  whereby  a  degree  of  completeness  and  ac- 
curacy has  been  secured  which  is  not  attainable  in  any  other  way.  In  no  former  revision 
has  so  much  care  been  exercised  as  in  the  present  to  provide  for  the  student  all  the 
assistance  that  a  text-book  can  furnish.  The  engravings  have  always  formed  a  distin- 
guishing feature  of  this  work,  and  in  the  present  edition  the  series  has  been  enriched  and 
rendered  complete  by  the  addition  of  many  new  ones.  The  large  scale  on  which  the 
illustrations  are  drawn  and  the  clearness  of  the  execution  render  them  of  unequalled 
value  in  affording  a  grasp  of  the  complex  details  of  the  subject.  As  heretofore  the  name 
of  each  part  is  printed  upon  it,  thus  conveying  to  the  eye  at  once  the  position,  extent 
and  relations  of  each  organ,  vessel,  muscle,  bone  or  nerve  with  a  clearness  impossible 
when  figures  or  lines  of  reference  are  employed.  Distinctive  colors  have  been  utilized 
to  give  additional  prominence  to  the  attachments  of  muscles,  the  veins,  arteries 
and  nerves.  For  the  sake  of  those  who  prefer  not  to  pay  the  slight  increase  in  cost 
necessitated  hj  the  use  of  colors,  the  volume  is  published  also  in  black  alone. 

The  illustrations  thus  constitute  a  complete  and  splendid  series,  which  will  greatly 
assist  the  student  in  forming  a  clear  idea  of  Anatomy,  and  will  also  serve  to  refresh 
the  memory  of  those  who  may  find  in  the  exigencies  of  practice  the  necessity  of  recalling 
the  details  of  the  dissecting  room.  Combining  as  it  does  a  complete  Atlas  of  Anatomy 
with  a  thorough  treatise  on  systematic,  descriptive  and  applied  Anatomy,  the  work  covers 
a  more  extended  range  of  subjects  than  is  cut^tomary  in  the  ordinary  text-books.  It  not 
only  answers  every  need  of  the  student  in  laj'^ing  the  groundwork  of  a  thorough  medical 
education,  but  owing  to  its  application  of  anatomical  details  to  the  practice  of  medicine 
and  surgery,  it  also  furnishes  an  admirable  work  of  reference  for  the  active  practitioner. 

We  always  had  a  kindly  regard  for  the  illustra- 
tions in  Gray,  where  each  organ,  tissue,  artery,  and 
nerve  bear  their  respective  names,  and  in  this  edi- 
tion color  has  been  worked  to  advantage  in  bring- 
ing out  the  relationship  of  vessel  and  nerve.  Of  late 
years,  many  worKs  on  anatomy  have  been  intro- 
duced to  the  profession,  but  as  a  reference  book  for 
the  practical  everyday  physician,  and  as  a  text-book 
for  the  student,  we  thint'it  will  be  difScult  to  sup- 
plant Gray. — Buffalo  Med.  and  Surg.  Journal. 

It  has  thoroughly  and  completely  established 
itself  as  the  anatomy,  par  excellence. — Brooklyn 
Medical  Journal. 

It  embraces  the  whole  of  human  anatomy,  and 
it  particularly  dwells  on  the  practical  or  applied 
part  of  the  subject,  so  that  it  forms  a  most  useful, 
intelligible  and  practical  treatise  for  the  student 
and  general  practitioner.— X)M6im  Journal  of  Medi- 
cal Science , 

In  modern  times  no  book  on  any  medical  sub- 
ject has  held  the  position  of  a  standard  so  long  as 
Gray's  Anatomy.  For  logical  arrangement,  clear, 
terse,  pointed,  and  yet  full  description,  it  is  the 
peer  of  any  work  on  any  scientific  subject.  A 
pioneer  in  helpful  drawings,  it  is  still  in  the  van 
and  leads  in  every  improvement.  The  physician  or 
student  who  requires  but  one  work  on  anatomy 
will  not  need  to  ask  which,  nor  will  those  who  will 


have  more  than  one  need  to  ask  which  one  to  add. 
The  work  is  admitted  to  be  easily  first  on  anatomy 
in  any  language. —  TneAmer.  Practitioner  and  News. 

Teachers  of  analomy  are  almost  unanimous  in 
recommending  "Gray"  as  the  standard  work  for 
the  student.  The  illuslrations  are  conceded  to  be 
the  best  that  have  yet  been  given  to  the  profes- 
sion. In  short,  Graifa  AiKiiomy  is  the  ideal  text- 
book on  this  subject. — Cleveland.  Med.  Gazette. 

Gray's  has  been  the  unvarying  standard  for 
anatomical  study  by  the  vast  majority  of  English- 
speaking  medical  students  for  so  "long  that  it 
would  seem  an  anomaly  to  see  a  student  acquire 
such  knowledge  from  some  other  source. — Medi- 
cal Fortnightly. 

The  matchless  book  of  tlie  doctor's  or  surgeon's 
library  is  and  has  been  Gray's  Anatomy.  Since 
1857  it  has  held  the  leadirgplace  in  all  colleges  as 
a  text-book  and  has  b»=en  the  one  central  figure  in 
the  many  text-books  in  anatomy  that  have  claimed 
attention.  It  is  still  the  standard  text-book. —  The 
Kansas  City  Medical  Index. 

The  careful  scrutiny  to  which  it  has  been  sub- 
jected in  forty  years,  and  the  successive  issues  of 
thirteen  editions  have  made  it  what  it  is  to-day, 
the  most  perfect  work  of  its  kind  extant. —  Uni- 
versity Medical  Magazine. 


HOBLYN'S  DICTIONARY  OF  MEDICINE.  A  Dictionary  of  the  Terms  Used  in  Medicine  and  the 
Collateral  Sciences.  By  Richard  D.  Hoblyn,  M.  D.  In  one  large  royal  12mo.  volume  of  520  double- 
columned  pages.    Cloth,  ?1.50;  leather,  52.00. 

Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


Anatomy,  Physiology. 


BY    BARTON    C.    HIRST,    M.D. 

Professor  of  Obstetrim  in  the  University 
of  Pennsylvania. 


GEORGE    A.    PIERSOL,    M.D. 

Professor  of  Anatomy  and  Embryology 
in  the  University  of  Pennsylvania. 


Magnificent  folio,  containing  220  pages  of  text,  illustrated  with  engravings,  and 
39  full  page,  photographic  plates  from  nature.  In  four  pans,  price,  each,  $5.  Limited 
edition,  for  sale  by  subscription  only.    Address  the  Publishers. 


We  have  before  us  the  fourth  and  last  part  of 
the  latest  and  best  work  on  human  monstrosi- 
ties. This  completes  one  of  the  masterpieces  of 
American  medical  literature.  Typographically 
and  from  an  artistic  standpoint,  the  work  is  un- 
exceptionable. In  this  last  and  final  volume 
is  presented  the  most  complete  bibliography  of 
teratological  literature  extant.  No  library  will  be 
complete  without  this  magnitirent  work. — Jour- 
nal of  the  American  Mediral  Association, 

Altogether,  Hiimnn  il7o?)sfrosiijes  is  a  satisfactory 
production.  It  will  lake  its  place  as  a  standard 
work  on  teratology  in  medical  libraries,  and  it 


must  always  retain  the  honor  of  being  the  first  of 
its  kind  written  in  the  English  language. — The 
British  Medical  Journal. 

This  work  promises  to  be  one  for  which  a  place 
must  be  found  in  the  library  of  every  anatomist, 
pathologist,  obstetrician  and  leratologi^t.  It  is  the 
joint  production  of  an  obstetrician,  and  an  embry- 
ologist,  «nd  histologist,  and  this  fact  makes  it 
certain  that  both  the  obstetric  and  apatomical 
sides  of  the  subject  will  be  fully  represented  and 
described.  The  book  promises  to  he  one  of  the 
greatest  value  to  the  English-speaking  medicaJ 
Viforld. — Edinburgh  Medical  Journal. 


Allen's  System  o!  Hiaman  Anatomy. 

A  System  of  Human  Anatomy,  Including  Its  Medical  and  Surgical 
Relations.  For  the  use  of  Practitioners  and  Students  of  Medicine.  By  Harkison 
Allen,  M.  D.,  Professor  of  Physiology  in  the  University  of  Pennsylvania.  With  an 
Introductory  Section  on  Histology  by  E.  O.  Shakespeahe,  M.  D.,  Ophthalmologist  to 
the  Philadelphia  Hospital.  Comprising  813  double-columned  quarto  pages,  with  380 
illustrations  on  109  full  page  lithographic  plates,  many  of  which  are  in  colors,  and  241 
engravings  in  the  text.  In  six  Sections,  each  in  a  portfolio.  Price  per  Section,  $3.50 ; 
also  bound  in  one  volume,  cloth,  $23.00 ;  very  handsome  half  Kussia,  raised  bands  and 
open  back,  $25.00.     For  .sr//e  hy  avhi^criptinn  only.     Address  the  Publishers. 

Holden's  Landmarks,  Medical  and  Surgical 

Landmarks,  Medical  and  Surgical.  By  Luther  Holden,  F.  E.  C.  S., 
Surgeon  to  St.  Bartholomew's  Hospital,  London.  Second  American  from  the  third  and 
revised  English  ed.,  with  additions  by  W.  W.  Keen,  M.  D.,  Professor  of  Artistic  Anatomy 
in  the  Penna.  Academy  of  Fine  Arts.     In  one  12mo.  volume  of  148  pages.^    Cloth,  $1.00. 

Clarke  k  Lockwood's  Dissector's  lanial. 

The  Dissector's  Manual.  By  W.  B.  Clarke,  F.  K.  C.  S.,  and  C.  B.  Lock- 
wood,  F.  E..  C.  S.,  Demonstrators  of  Anatomy  at  St.  Bartholomew's  Hospital  Medical 
School,  London.  In  one  pocket-size  12mo.  volume  of  395  pages,  with  49  illustrations. 
Limp  cloth,  red  edges,  $1.50.     See  Students^  Series  of  Manuals,  page  30. 


Messrs. Clarke  and  Lockwood  have  written  abook 
that  can  hardly  be  rivalled  as  a  practical  aid  to  the 
dissector.  Their  purpose, which  is  "how  to  de- 
scribe the  best  way  to  display  the  anatomical 
structure,"  has  been  fully  attained.  They  excel  in 
a  lucidity  of  demonstration  and  graphic  terseness 
of   expression,   which   only  a  long  training  and 


intimate  association  with  students  could  have 
given.  With  such  a  guide  as  this,  accompanied 
by  so  attractive  a  commentary  as  Treves'  Surgical 
Applied  Anatomy  (same  series),  no  student  could 
fail  to  be  deeplyand  absorbingly  interested  in  the 
study  of  anatomy. — New  Orleatis  Medical  and  Sur- 
gical .Tournal. 


Treves'  Surgical  Applied  Anatomy. 

Surgical  Applied  Anatomy.  By  Frederick  Treves,  F.  E.  C.  S.,  Senior 
Demonstrator  of  Anatomy  and  Assistant  Surgeon  at  the  London  Hospital.  In  one  pocket- 
size  12mo.  volume  of  540  pages,  with  61  illustrations.  Limp  cloth,  red  edges,  $2.00.  See 
Students'  Series  of  Manuals,  p.  30. 


The  Student's  Guide  to  Surgical  Anatomy :  Being  a  Description  of  the 
most  Important  Surgical  Eegions  of  the  Human  Body,  and  intended  as  an  Introduction  to 
Operative  Surgery.  By  Edward  Bellamy,  F.  E.  C.  S.,  Senior  Assistant- Surgeon  to  the 
Charing- Cross  Hospital.     In  one  12mo.  vol.  of  300  pages,  with  50  illus.    Cloth,  $2.25. 

Wilson's  Human  Anatomy. 

A  System  of  Human  Anatomy,  General  and  Special.  By  Erasmus 
Wilson,  F.  E.  S.  Edited  by  W.  H.  Gobrecht,  M.  D.,  Professor  of  General  and  Surgical 
Anatomy  in  the  Medical  College  of  Ohio.  In  one  large  and  handsome  octavo  volume 
of  616  pages,  with  397  illustrations.     Cloth,  $4.00 ;  leather,  $5.00. 


hartshorne's  handbook  of  anatomy 

and  physiology.    Second  edition,  revised. 
12mo.,  310  pages,  220  woodcuts.    Cloth,  $1.75. 

HORNER'S  SPECIAL  ANATOMY  AND  HISTOL- 


OGY.   Eighth  edition.    In  two  octavo  volumes 
of  low  paees-.  wit,h  .^20  woodcuts      riloth.  SB.OO 
CLELAND'S   DIRECTORY   FOR  THE  DISSEC- 
TION  OF  THE  HUMAN  BODY.    12rao.,  178  pp. 

CI  tb,$l.'25. 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


Physics,  Physiology,  Anatomy,  Chemistry.        7 

sics. 

Medical  Physics.  A  Text-book  for  Students  and  Practitioners  of  Medicine. 
By  John  C.  Draper,  M.  D,,  LL.  D.,  Prof,  of  Chemistry  in  the  Univ.  of  the  City  of 
New  York.     In  one  octavo  vol.  of  734  pages,  with  376  woodcuts,  mostly  original.   Cloth,  $4. 


No  man  in  America  was  better  fitted  than  Dr. 
Draper  for  the  task  he  undertook  aud  he  has  pro- 
vided the  student  and  practitioner  of  medicine 
with  a  volume  at  once   readable  and  thorough. 


culties  to  be  encountered  in  bringing  his  subject 
within  the  grasp  of  the  average  student,  and  that 
he  has  succeeded  so  well  proves  once  more  that 
the  man  to  write  for  and  examine  students  is  the 


Even  to  the  student  who  has  some  kDOwlede;e  o(  j  one  who  has  taught  and  is  teaching  them.  The 
physics  this  book  is  useful,  as  it  shows  him  its  book  is  well  printed  and  fully  illustrated,  and  in 
applications  to  the  profession  that  he  has  chosen.  I  every  way  deserves  grateful  recognition. —  The 
Dr.  Draper,  as  an  old  teacher,  knew  well  the  ditn-  <  MontrenL  Me<iical  Journal. 


s  Fisysioiogy.- 

A  Text-Book  on  Physiology.  By  Edward  T.  Retchert,  M.  D.,  Professor 
of  Physiology  in  the  University  of  Pennsylvania,  Philadelphia.  In  one  very  handsome 
octavo  volume  of  800  pages,  fully  illustrated. 

Power's  Human  FliyBioIogy.— Second  Edition. 

Human  Physiology.  By  Henry  Power,  M.  E.,  F.  E.  C.  S.,  Examiner  in 
Physiology,  Koyal  College  of  Surgeons  of  England.  Second  edition.  In  one  12mo.  vol. 
of  509  pp.,  with  68  illustrations.    Cloth,  $1.50.     See  Students'  Series  of  Manuals,  p.  30. 


Hansons 

Physiological  Physics.    By  J.    McGre«or    Eobertson,  M.  A.,   M.  B., 
Muirhead  Demonstrator  of  Physiology,  UniveKity  of  Glasgow.     In  one  12mo.  volume  of 


537  pages,  with  219  illus.     Limp  cloth, 

The  title  of  this  work  sufficiently  explains  the 
nature  of  its  contents.  It  is  designed  as  a  man- 
ual for  the  student  of  medicine,  an  auxiliary,  to 
his  text-book  in  physiology,  and  it  would  be  particu- 
larly useful  as  a  guide  to  his  laboratory  experi- 


See  Students'  Series  of  Manuals,  page  30. 
ments.  It  will  be  found  of  great  value  to  the 
practitioner.  It  is  a  carefully  prepared  book  of 
reference,  concise  and  accurate,  and  as  such  we 
heartily  recommend  it. — Journal  of  the  American 
Medical  Association. 


Doctrines  of  the  Circulation  of  the  Blood.  A  History  of  Physio- 
logical Opinion  and  Discovery  in  regard  to  the  Circulation  of  the  Blood.  By  John  C. 
Dalton.  M.  D.,  Professor  Emeritus  of  Physiology  in  the  College  of  Physicians  and  Sur- 
geons, New  York.     In   one  handsome  I2mo.  volume  of  293  pages.     Cloth,  $2. 


Dr.  Dalton's  work  is  the  fruit  of  the  deep  research 
of  a  cultured  mind,  and  to  the  busy  practitioner  it 
cannot  fail  to  be  a  source  of  instruction.  It  will 
inspire  him  with  a  feeling  of  gratitude  and  admir- 


ation for  those  plodding  workers  of  olden  times, 
who  laid  the  foundation  of  the  magnificent  temple 
of  medical  science  as  it  now  stands. — New  Orleans 
Medical  and  Surgical  Journal. 


Bell's  Comparative  Anatomy  aid  Fliysiology. 

Comparative  Anatomy  and  Physiology.  By  F.  Jeffrey  Bell,  M.  A., 
Professor  of  Comparative  Anatomy  at  King's  College,  London.     In  one  12mo.  vol.  of  561 


pages,  with  229  illustrations.  Limp  cloth,  $2, 

The  manual  is  preeminently  a  student's  book — 
clear  and  simple  in  language  and  arrangement. 
It  is  well  and  abundantly  illustrated,  and  is  read- 
able and  interesting.    On  the  whole  we  consider 


See  Students'  Series  of  Manuals,  page  30. 

it  the  best  work  in  existence  in  the  English 
language  to  place  in  the  hands  of  the  medical 
student. — Bristol  Medico- Chirurgical  Journal. 


Ellis'  Demonstrations  o!  Anatomy.— SigMli  Edition. 

Demonstrations  of  Anatomy.  Being  a  Guide  to  the  Knowledge  of  the 
Human  Body  by  Dissection.  By  George  Viner  Ellis,  Emeritus  Professor  of  Anatomy 
in  University  College,  London.  From  the  eighth  and  revised  London  edition.  In  one 
very  handsome  octa,vo  volume  of  716  pages,  with  249  illus.    Cloth,  $4.25 ;  leather,  $5.25. 

Roberts'  Compend  o!  Anatomy. 

The  Compend  of  Anatomy.  For  use  in  the  dissecting-room  and  in  pre- 
paring for  examinations.  By  John  B.  Roberts,  A.  M.,  M.  D.,  Lecturer  in  Anatomy  in 
the  University  of  Pennsylvania.     In  one  16mo.  vol.  of  196  pages.     Limp  cloth,  75  cents. 


WOHLER'S  OUTLINES  OF  ORGANIC  CHEBI- 
ISTRY.  Edited  by  Fittig.  Translated  by  Ira 
Remsen,  M.  D  ,  Ph.  D.  In  one  12mo.  volume  of 
550  pages.     Cloth,  S3. 

LKHMAiVN'S  MANUAL  OP  CHEMICAL  PHYS- 
IOLOGY. In  one  octavo  volume  of  327  pages, 
with  41  illustrations.    Cloth,  82.25. 


CARPENTER'S  HUMAN  PHYSIOLOGY.  Edited 
bv  Henry  Power.    In  one  octavo  volume. 

CARPENTER'S  PRIZE  ESSAY  ON  THE  USE  AND 
Abuse  op  Alcoholic  Liquors  in  Health  and  Dis- 
ease. With  explanations  of  scientific  words.  Small 
12mo.    178  pages.    Cloth,  60  cents. 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


8 


Physiology— (Continued),  Chemistry. 


Foster's  Physiology.— Sixth  American  Edition.    Just  Ready. 

Text-Book  of  Physiology.     By  Michael  Fostek,  M.  D.,  F.  R.  S.,  Prelec- 
tor in  Physiology  and  Fellow  of  Ti'inity  College,  Cambridge,  England.     Sixth  American 
edition,  with  notes  and  additions.     In  one  handsome  octavo  volume  of  922  pages,  with 
257  illustrations.     Cloth,  $4.50 ;  leather,  $5.50. 
Notices  of  previous  edition  are  appended. 


It  is  unquestionably  the  standard  textbook  on 
physiology  for  students  and  practitioners.  Tiie 
moderate  price  of  this  well-issued  book  at  once 
shows  how  popular  the  work  has  become.  The 
style  is  plain  enough  even  for  the  beginner;  the 
details  are  sufficient  for  the  teacher;  and  the 
manner  of  dealing  witli  the  topics  is  well-ar- 
ranged for  the  advantage  of  the  practitioner. — 
Virginia  Merli'al  Mont'dy. 

Foster's  Phvsiolfgy  is  an  accepted  text-book  in 
almost  every  medical  college  in  this  country,  and 
already  eornmended  to  all  medical  students.  For 
the  physician  who  aims  to  keep  abreast  of  all  that 
is  new  that  is  true  in  medielnp,  a  work  like  this 
is  a  necessity.  The  illustrations  are  excellent  and 
are    well    printed — The    Cincinnati.    Lancet-fli'  ic. 

One  cannot  read  a  single  chapter  without  being 
impressed  with  the  care  that  the  author  has  be- 


stowed upon  it.  Apparently  nothing  that  is  known 
up  to  the  present  year  concerning  vital  processes 
has  escaped  his  painstaking  attention.  The  details 
receive  the  fullest  consideration.  The  additions 
which  have  been  made  to  this  last  edition  are 
caused  by  an  effort  to  explain  more  fully  and  at 
greater  length  what  seemed  to  be  the  most  funda- 
mental and  important  topics.  The.  publishers 
have  subjected  it  to  the  searching  revision  of  one 
of  the  foremost  American  professors  of  physio- 
logy. We  have  nothing  but  words  of  the  highest 
praise  for  the  classical  and  thorough  manner  in 
which  the  work  is  written,  as  well  as  for  the  liber- 
ality of  the  publishers  for  selling  such  a  large 
work,  and  one  which  miist  necessarily  be  very 
costly  to  produce,  for  an  extremely  moderate 
price. —  The  Canada  Medical  Record. 


Dalton's  Physiology.— Seventh  Edition. 

A  Treatise  on  Human  Physiology.  Designed  for  the  use  of  Students 
and  Practitioners  of  Medicine.  By  John  C.  Dalton,  M.  D.,  Professor  of  Physiology  in 
the  College  of  Physicians  and  Surgeons,  New  York,  etc.  Seventh  edition,  thoroughly 
revised  and  rewritten.  In  one  very  handsome  octavo  volume  of  722  pages,  with  252  beau- 
tiful engravings  on  wood.    Cloth,  $5.00;  leather,  $6.00. 

have  never  been  In  any  doubt  as  to  its  sterling 
worth. — N.  Y.  Medical.  Journal. 

Professor  Dalton's  well-known  and  deservedly- 
appreciated  work  has  long  passed  the  stage  at 
which  it  could  be  reviewed  in  the  ordinary  sense. 
The  work  is  eminently  one  for  the  medical  prac- 
titioner, since  it  treats  most  fully  of  those  branches 
of  physiology  which  have  a  direct  bearing  on  the 
diagnosis  and  treatment  of  disease.  The  work  is 
one  which  we  can  highly  recommend  to  all  our 
readers. — DuhUn  Journal  of  Medical  Science. 


From  the  first  appearance  of  the  book  it  has 
been  a  favorite,  owing  as  well  to  the  author's 
renown  as  an  oral  teacher  as  to  the  charm  of 
simplicity  with  which,  as  a  writer,  he  always 
succeeds  in  investing  even  intricate  subjects. 
It  must  be  gratifying  to  him  to  observe  the  fre- 
quency with  which  his  work,  written  for  students 
and  practitioners,  is  quoted  by  other  writers  on 
physiology.  This  fact  attests  its  value,  and,  in 
great  measure,  its  originality.  It  now  needs  no 
such  seal  of  approbation,  however,  for  the  thou- 
sands who  have  studied  it  in  its  various  editions 


A  Treatise  on  Human  Physiology.  By  Heney  C.  Chapman,  M.  D., 
Professor  of  Institutes  of  Medicine  in  the  Jefferson  Medical  College  of  Philadelphia. 
In  one  octavo  volume  of  925  pages,  with  605  engravings.     Cloth,  $5.50 ;  leather,  $6.50. 

It  represents  very  fully  the  existing  state  of  " 
physiology.  The  present  work  has  a  special  value 
10  the  student  and  practitioner  as  devoted  more 
to  the  practical  application  of  well-known  truths 
which  the  advance  of  science  has  given  to  the 
profession  in  this  department,  which  may  be  con- 
sidered the  foundation  of  rational  medicine. — Buf- 
falo Medical  'ind  Surgical  Joii-rnal. 

Matters  which  have  a  practical  bearing  on  the 
practice  of  medicine  are  lucidly  expressed;   tech- 


nical matters  are  given  in  minute  detail;  elabo- 
rate directions  are  stated  for  the  guidance  of  stu- 
dents in  the  laboratory.  In  every  respect  the 
work  fulfils  its  promise,  whether  as  a  complete 
treatise  for  the  student  or  for  the  phy.sician  ;  for 
the  former  it  is  so  complete  that  he  need  look  no 
farther,  and  the  latter  vvill  find  entertainment  and 
instruction  in  an  admirable  book  of  reference. — 
North  Carolina  Medical  Journal. 


Schofield's  Elementary  Physiology. 


Elementary  Physiology  for  Students.  By  Alfred  T.  ScHOFiEiiD, 
M.  D.,  Late  House  Physician  London  Hospital.  In  one  12mo.  volume  of  380  pages,  with 
227  engravings  and  2  colored  plates  containing  30  figures.     Cloth,  $2.00. 


Frankland  &  Japp's  Inorganic  Chemistry. 

Inorganic  Chemistry.  By  E.  Frankland,  D.  C.  L.,  F.  K.  S.,  Professor  of 
Chemistry  in  the  Normal  School  of  Science,  London.,  and  F.  R.  Japp,  F.  I.  C,  Assistant 
Professor  of  Chemistry  in  the  Normal  School  of  Science,  London.  In  one  handsome 
octavo  volume  of  677  pages  with  61  woodcuts  and  2  plates.     Cloth,  $3.75  ;  leather,  $4.75. 

Clowes'  Qualitative  Analysis.— Third  Edition. 

An  Elementary  Treatise  on  Practical  Chemistry  and  Qualitative 
Inorganic  Analysis.  Specially  adapted  for  use  in  the  Laboratories  of  Schools  and 
Colleges  and  by  Beginners.  By  Frank  Clowes,  D.  Sc,  London,  Senior  Science-Master 
at  the  High  School,  Newcastle-under  Lyme,  etc.  Third  American  from  the  fourth  and 
revised  English  edition.    In  one  12mo.  vol.  of  387  pages,  with  55  illus.     Cloth,  $2.50. 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


Chemistry — (Continued). 


Simon's  Cliemistry.— New  (5t!i)  Edition.    Just  Ready. 

Manual  of  Chemistry.  A  Guide  to  Lectures  and  Laboratory  work  for  Begin- 
ners in  Chemistry.  A  Text-book  specially  adapted  for  Students  of  Pharmacy  and  Medi- 
cine. By  W.  SiMONj  Ph.  D.,  M.  D.,  Professor  ol  Chemistry  and  Toxicology  in  the  College 
of  Physicians  and  Surgeons,  Baltimore,  and  Professor  of  Chemistry  in  the  Maryland  Col- 
lege of  Pharmacy.  New  (5th)  edition.  In  one  8vo.  vol.  of  501  jap.,  with  44  woodcuts  and 
8  colored  plates  illustrating  64  of  the  most  important  chemical  tests.     Cloth,  $3.25. 

The  exhaustion  of  the  very  large  fourth  edition 
in  less  than  two  years  indicates  the  leading  posi- 
tion achieved  by  Professor  Simon's  Chemistry  as  a 
test-book  in  medical  and  pharmaceutical  colleges. 
It  furnishes  an  admirable  selection  of  material 
bearing  upon  the  laws  and  phenomena  of  chem- 


ref erred  to  this  series  of  colorsand  color  changes. 
The  new  edition  has  been  most  carefully  revised 
in  accordance  with  the  advance  of  science  and  in 
order  to  bring  it  into  complete  harmony  with  the 
new  Pharmacopoeia.  All  chemicals  mentioned  in 
tha  last  issue  of  that  wcrk  are  included.  Special 
istry.  As'an  aid  to  laborato'ry  work  a  number  of  i  care  has  been  taken  to  detail  the  most  modern 
experiments  have  been  added.  Physicians  as  weli  I  methods  for  chemical  examination  in  clinical 
as  students  will  aopreciate  the  value  of  the  colored  \  diagnosis.  The  author's  experience  as  a  physician 
plates  of  reactions,  which  give  a  permanent  and  and  as  a  teacher  of  medical  and  pharmaceutical 
accurate  series  of  standards  for  comparison  of  :  students  is  reflected  in  the  special  adaptation  of 
tests,  a  matter  not  susceptible  of  satisfactory  his  book  to  the  needs  of  all  concerned  with  the 
explanation  in  words.  In  medical  practi:'e  im- i  applications  of  chemistry  to  the' art  of  healing. — 
portant  pathological  and  toxicological  questions  i  Soutliern  Practitioner. 
depending  on  the  test-tube  may  with  certainty  be  I 

Attfield's  CMemistry.— Mew  (14tli)  Edition.    Just  Ready. 

Chemistry,  General,  Medical  and  Pharmaceutical;  Including  the 
Chemistry  of  the  U.  S.  Pharmacopoeia.  A  Manual  of  the  General  Principles  of  the 
Science,  and  their  Application  to  Medicine  and  Pharmacy.  By  John  Attfield,  M.  A., 
Ph.  D.,  F.  I.  C,  F.  E..  S.,  etc.,  Professor  of  Practical  Chemistry  to  the  Pharmaceutical 
Society  of  Great  Britain,  etc.  Fourteenth  edition,  specially  revised  by  the  Author 
for  America,  to  accord  with  the  new  U.  S.  Pharmacopoeia.  In  one  12mo.  volume  of  794 
pages,  with  88  illustrations.   Cloth,  |2.75 ;  leather,  $3.25. 

This  substantial  and  handsome  treatise  on  those 
parts  of  chemical  science,  which  are  of  special  in- 
terest to  the  physician  and  the  pharmacist,  is 
adapted  not  only  to  be  a  manual  of  instruction,  but 
also  a  work  of  reference.     It  is  replete  with  the 


latest  information,  and  considers  with  more  or  less 
completeness  the  chemistry  of  every  substance 
recognized  officially  or  in  general  practice.  The 
analytical  tables  are  most  excellent.  Organic 
Chemistry  receives  attention  in  a  most  compre- 
hensive manner,  as  do  practical  toxicology  and 
physiological  chemistry.     The  concluding  parts 


consist  of  a  laboratory  guide  to  physical  and 
quantitative  chemical  analysis  and  of  a  large 
number  of  useful  tables.  The  etymological  notes, 
scattered  through  the  book,  are  a  very  valuable 
feature,  as  are  also  the  questions  following  each 
section.  The  eighty-eight  illustrations  leave  noth- 
ing to  be  desired.  The  metric  system,  and  the 
modern  scientific  chemical  nomenclature,  have 
been  entirely  adopted,  bringing  the  work  into 
close  touch  with  the  latest  United  States  Pharma- 
copcBta,  of  which  it  is  a  worthy  companion. — The 
Pittsburg  Medical  Review. 


Fownes'  Chemistry.- 

A  Manual  of  Elementary  Chemistry;  Theoretical  and  Practical.  By 
George  Fotvnes,  Ph.  D.  Embodying  Watts'  Physical  and  Inorganic  Chemistry.  New 
American,  from  the  twelfth  English  edition.  In  one  large  royal  12mo.  volume  of  1061 
pages,  with   168  engravings  and  a  colored  plate.     Cloth,  $2.75 ;  leather,  $3.25. 


Fownes'  Chemistry  has  been  a  standard  text^ 
book  upon  chemistry  for  many  years.  Its  merits 
are  very  fully  known  by  chemists  and  physicians 
everywhere  in  this  country  and  in  England.  As 
the  science  has  advanced  by  the  making  of  new 
discoveries,  the  work  has  been  revised  so  as  to 
keep  it  abreast  of  the  times.  It  has  steadily 
maintained  its  position  as  a  text-book  with  medi- 


cal students.  In  this  work  are  treated  fully:  Heat, 
Light  and  Electricity,  includin  g  Magnetism.  The 
inSuence  exerted  by  these  iorces  in  chemical 
action  upon  health  and  disease,  etc.,  is  of  the  most 
important  kind,  and  should  be  familiar  to  every 
medical  practitioner.  We  can  commend  the 
work  as  one  of  the  very  best  text-books  upon 
chemistry  extant. — Cincinnati  Med.  News. 


Bloxam's  Cliemistry.— Fiftli  Edition. 

Chemistry,  Inorganic  and  Organic.  By  Charles  L.  Bloxam,  Professoi 
of  Chemistry  in  King's  College,  London.  JSiew  American  from  the  fifth  London 
edition,  thoroughly  revised  and  much  improved.  In  one  very  handsome  octavo 
volume  of  727  pages,  with  292  illustrations.     Cloth,  $2.00 ;  leather,  $3.00. 


Comment  from  us  on  this  standard  work  is  al- 
most superfluous.  It  differs  widely  in  scope  and 
aim  from  that  of  Attfield,  and  in  its  way  is  equally 
beyond  criticism.  It  adopts  the  most  direct  meth- 
ods in  stating  the  principles,  hypotheses  and  facts 
of  the  science.  Its  language  is  so  terse  and  lucid, 
and  its  arrangement  of  matter  so  logical  in  se- 
quence that  the  student  never    has  occasion  to 


complain  that  chemistry  is  a  hard  study.  Much 
attention  is  paid  to  experimental  illustrations  of 
chemical  principles  and  phenomena,  and  the 
mode  of  conducting  these  experiments.  The  book 
maintains  the  position  it  has  always  held  as  one  of 
the  best  manuals  of  general  chemistry  tn  the  Eng- 
lish language. — Detroit  Lancet. 


Luff's  Manual  of  Chemistry. 

A  Manual  of  Chemistry.  For  theuseof  students  of  medicine.  By  Arthttb 
P.  LuTT,  M.  D.,  B.  Sc,  Lecturer  on  Medical  Jurisprudence  and  Toxicological  Chemistry, 
St.  Mary's  Hospital  Medical  School,  London.  In  one  12mo.  vol.  of  522  pages,  with  36 
engravings.     Cloth,  $2.00.     See  Students^  Series  of  Manuals,  page  30. 

Greene's  Manual  of  Medical  Chemistry.  For  the  use  of  Students.  By 
'Wtuliam  H.  Greene,  M.  D.,  Demonstrator  of  Chemistry  in  the  University  of  Pennsyl- 
vania.    In  one  12mo.  volume  of  310  pages,  with  74  illus.     Cloth,  $1.75. 

Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


10  Chemistry — (Continued),  Pharmacy. 


Caspari's  Pliarmacy.— Just  Ready. 

A  Treatise  on  Pharmacy,  for  Students  and    Pharmacists.     By 

Charles  Caspari,  Jr,  Ph.  G.,  Professor  of  the  Theorv  and  Practice  of  Pharmacy  in  the 
Maryland  College  of  Pharmacy,  Joint  Editor  of  The  National  Dispensatory,  fifth  edition. 
In  one  very  handsome  octavo  volume  of  678  pages,  with  288  engravings.     Cloth,  ii!4.50. 

The  author  is  widely  known  as  joint  editor  of  The  National  Dispensatory  (see  next  page) 
and  as  Professor  of  Pharmacy  in  one  of  the  foremost  pharmaceutical  colleges  in  America. 
He  is  therefore  exceptionally  qualified  to  prepare  a  work  of  the  highest  merit,  hoth  as  a 
text-hook  for  students,  and  as  a  practical  reference  for  pharmacists  m  all  the  multifarious 
details  of  their  operations.  Modern  in  every  particular,  ronvenient  in  size  through  avoid- 
ance of  obsolete  and  unnecessary  matter,  and  richly  illustrated,  Caspari's  Pharmacy  is 
equally  assured  of  immediate  popularity  with  pharmacists  and  of  adoption  as  the  standard 
text-book  for  pharmaceutical  students. 

Vaughan  &  Novy  on  Ptomains  and  Leucomains.— New  Ed. 

Ptomains,  Leucomains,  Toxines  and  Antitoxines.  By  Victor  C. 
Vaughan.  Ph.  D.,  M.  D.,  Professor  of  Physiological  and  Pathological  Chemistry,  and 
Associate  Pi-ofessor  of  Therapeutics  and  Mateiia  Medica  in  the  University  of  Michigan, 
and  Frederick  G.  Novy,  M.  D.,  Instructor  in  Hygiene  and  Physiological  Chemistry 
in  the  University  of  Michigan.  New  (third)  edition.  In  one  12mo.  volume  of  about  500 
pages.     In  press. 

A  notice  of  the  previous  issue  is  appended. 


This  book  is  one  that  is  of  the  greatest  import- 
ance, and  the  modern  physician  who  accepts 
bacterial  pathology  cannot  have  a  complete 
knowledge  of  this  subject  unless  he  has  carefully 
perused  it.  To  the  toxieologist  the  subject  is 
alike  of  great  import,  as  well  as  to  the  hygieni.st 


and  sanitarian.  It  contains  information  which 
is  not  easily  obtained  elsewhere,  and  which  ia 
of  a  kind  that  no  medical  ihinker  should  be 
without. —  The  Ainerican  Journal  of  the  Medical 
Sciences. 


Remsen's  Tlieoretical  Cliemistry.—Foiirtli  Edition. 

Principles  of  Theoretical  Chemistry,  with  special  reference  to  the  Con- 
stitution of  Chemical  Compounds.     By  Ira  Eemsen,  M.  D.,  Ph.  D.,  Professor  of  Chem- 
istry in  the  Johns  Hopkins  University,  Baltimore.     Fourth  and  thoroughly  revised  edi- 
tion.   In  one  handsome  royal  12mo.  volume  of  325  pages.     Cloth,  $2.00. 
The  fourth  edition  of  Professor  Remsen's  well 


known  book  cornea  again,  enlarged  and  revised. 
Each  edition  has  enhanced  its  value.  We  may  say 
without  hesitation  that  it  is  a  standard  work  on 
the  theory  of  chemistry,  not  excelled  and  scarcely 
equalled  by  any  other  in  any  language.    Its  trans- 


lation into  German  and  Italian  speaks  for  its  ex- 
alted position  and  the  esteem  in  which  it  is  held 
by  the  most  prominent  chemists.  We  claim  for 
this  little  work  a  leading  place  in  the  chemical 
literature  of  this  country. — The  American  Journal 
of  the  Medical  Sciences. 


Charles'  Physiological  and  Pathological  Chemistry. 

The  Elements  of  Physiological  and  Pathological  Chemistry.  A 
Handbook  for  Medical  Students  and  Practitioners.  Containing  a  general  account  of 
Nutrition,  Foods  and  Digestion,  and  the  Chemistry  of  the  Tissues,  Organs,  Secretions  and 
Excretions  of  the  Body  in  Health  and  in  Disease.  Together  with  the  methods  for  pre- 
paring or  separating  their  chief  constituents,  as  also  for  their  examination  in  detail,  and 
an  outline  syllabus  of  a  practical  course  of  instruction  for  students.  By  T.  Cranstoun 
Charles,  M.  D.,  F.  R.  S.,  M.  S.,  formerly  Assistant  Professor  and  Demonstrator  of  Chem- 
istry and  Chemical  Physics,  Queen's  College,  Belfast.  In  one  handsome  octavo  volume 
of  463  pages,  with  38  woodcuts  and  1  colored  plate.     Cloth,  $3.50. 


Dr.  Charles  is  fully  impressed  with  the  impor- 
tance and  practical  reach  of  his  subject,  and  he 
has  treated  it  in  a  competent  and  instructive  man- 
ner. We  cannot  recommend  a  better  book  than 
the  present.  In  fact,  it  fills  a  gap  in  medical  text- 
books, and  that  is  a  thing  which  can  rarely  be  said 


nowadays.  Dr.  Charles  has  devoted  much  space 
to  the  elucidation  ot  urinary  mysteries.  He  does 
this  with  much  detail,  and  yet  in  a  practical  and 
intelligible  manner.  In  fact,  the  author  has  filled 
his  book  witii  many  practical  hints. — Medical  Rec- 
ord. 


A  Manual  of  Chemical  Analysis,  as  applied  to  the  Examination  of  Medi- 
cinal Chemicals  and  their  Preparations.  Being  a  Guide  for  the  Determination  of  their 
Identity  and  Quality,  and  for  the  Detection  of  Impurities  and  Adulterations.  For  the 
use  of  Pharmacists,  Physicians,  Druggists  and  Manufacturing  Chemists,  and  Pharmaceu- 
tical and  Medical  Students.  By  Frederick  PIoffmann,  A.  M.,  Ph.  D.,  Public  Analyst  to 
the  State  of  New  York,  and  Frederick  B.  Power,  Ph.  D.,  Professor  of  Analytical  Chem- 
istry in  the  Philadelphia  College  of  Pharmacy.  Third  edition,  entirely  rewritten  and 
much  enlarged.     In  one  octavo  volume  of  621  pages,  with  179  illustrations.    Cloth,  $4.25. 

Ralfe's  Clinical  Chemistry. 

Clinical  Chemistry.  By  Charles  H.  Ealfe,  M.  D.,  F.  R.  C.  P.,  Assistant 
Physician  at  the  London  Hospital.  In  one  pocket-size  12mo.  volume  of  314  pages, 
with  16  ilius.     Limp  cloth,  red  edges,  $1.50.     See  Students'  Series  of  Manuals,  page  30. 

Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street.  Philadelphia. 


Pharmacy,  flateria  fledica,  Therapeutics.       11 


NEW  AND  THOROUGHLY  REVISED  EDITION. 


Containing  the  Natural  History,  Chemistry,  Pharmacy,  Actions  and  Uses  of  Medi- 
cines,_  including  those  recognized  in  the  Pharmaco[)oeias  of  the  United  States,  Great 
Britain  and  Germany,  with  numerous  references  to  the  French  Codex.  By  Alfred 
Stille,  M.  D.,  LL.  D  ,  Profess  >r  Emeritus  of  the  Theory  and  Practice  of  Medicine  and  of 
Clinical  Medicine  in  the  University  of  Pennsylvania,  John  M.  Maisch,  Phar.  D.,  late 
Professor  of  Materia  Medica  and  Botany  in  Philadelphia  College  of  Pharmacy,  Secretary 
to  the  American  Pharmaceutical  Association,  Charles  Caspari,  Jr.,  Ph.  G.,  Professor 
of  Pharmacy  in  the  Maryland  College  of  Pharmacy,  Baltimore,  and  Henry  C.  C.  Maisch, 
Ph.  G.,  Ph.  D.  ISfew  (fifth)  edition,  thoroughly  revised  in  accordance  with  the  new  U.  S. 
Pharmacopoeia  (Seventh  Decennial  Kevision).  In  one  magnificent  imperial  octavo 
volume  of  1910  pages,  with  320  engravings.  Cloth,  $7.25,  leather,  $8.00.  With  Eeady 
Eeference  Thumb-letter  Index,  cloth,  $7.75  ;  leather,  $8.50. 

ON  the  first  appearance  of  The  National  Dispensatory  fifteen  years  ago  it  was  at  once 
recognized  by  the  pharmaceutical  and  medical  professions  as  satisfying  the  need 
for  a  work  affording  all  necessary  information  upon  its  subject,  with  authoritative 
accuracy,  and  Avith  a  completeness  and  convenience  attainable  only  by  the  exclusion  of 
obsolete  matter.  Its  success  in  filling  this  want  is  fully  attested  by  the  rapid  demand  for 
five  editions,  and  the  opportunity  thus  afforded  has  been  well  used  in  successive  revisions, 
each  placing  it  abreast  of  the  day  and  maintaining  the  characteristics  which  had  won  for 
it  a  leading  position. 

Of  all  its  issues  the  present  embodies  the  results  of  the  most  exhaustive  revision. 
The  sweeping  changes  in  the  new  United  States  Piiarmacoposia  are  thoroughly  incorpor- 
ated, with  oificial  authorization  of  the  Committee  of  Eevision,  and  full  use  has  been  made 
of  all  valuable  material  in  the  latest  issues  of  foreign  Pharmacopoeias.  The  volume  is 
accordingly  rich  in  pharmaceutical  and  chemical  information,  with  data,  formulas,  tables, 
etc.,  gathered  from  all  official  sources,  but  this  constitutes  only  a  single  department  of  its 
usefulness.  As  an  encyclopaedia  of  the  latest  and  best  therapeutical  knowledge  it  deals 
not  only  with  all  official  drugs,  but  also  with  all  the  new  synthetic  remedies  of  value 
and  with  the  unofficial  prep  irations  now  so  largely  in  use.  Pharmacists  will  appreciate 
its  systematic  descriptions  of  the  materia  medica,  its  clear  explanations  of  chemical  and 
pharmaceutical  processes  and  tests,  and  its  illustrations  of  important  drugs  and  of  the 
most  improv^ed  apparatus.  Physicians  will  readily  perceive  the  indispensable  assistance 
offered  by  its  authoritative  statements  as  to  the  efficacy  of  drugs  in  the  light  of  the  most 
recent  medical  advances.  Arranged  alphabetically  in  the  text,  this  information  is 
placed  most  suggestively  at  command  by  the  recommendations  grouped  under  the  various 
Diseases  in  the  Therapeutical  Index.  Together  with  the  General  Index  this  covers  more 
than  one  hundred  treble-columned  pages  containing  25,000  references.  The  immensity 
of  detail  comprised  in  this  single  volume  of  1900  pages  is  thus  most  forcibly  indicated. 
Though  the  present  edition  contains  far  more  matter  than  its  predecessor  it  is  maintained 
at  the  same  price  in  view  of  the  ever- increasing  demand.  Weights  and  Measures  are 
given  in  both  Ordinary  and  Metric  Systems. 

In  brief  the  new  edition  of  The  National  Dispensatory  is  presented  to  the  medical 
and  pharmaceutical  professions  as  the  equivalentof  a  whole  library  of  pharmaceutical  and 
therapeutic  information;  it  is  the  standard  of  accuracy,  the  embodiment  of  completeness 
without  inconvenient  bulk,  and  a  marvel  of  cheapness  owing  to  the  widespread  demand 
for  it  as  the  authority. 


The  careful  examination  of  this  large  volume 
will  strike  the  reader  with  surprise  at  the  great 
number  of  new  articles  added,  and  the  amount  of 
useful  and  accurate  information  regarding  their 
properties,  methods  of  preparation  and  therapeu- 
tical effects.  The  large  number  of  new  articles 
containing  all  the  latest  synthetic  remedies  and 
unofficial  remedies,  compass  the  entire  range  of 
available  information  in  the  line  of  the  work.  A 
number  of  very  complete  tables  together  with  all 
the  official  re-agents  and  solutions  for  qualitative 
and  quantitative  tests,  appear  in  the  appendix. 
Altogether  this  work  maintains  its  previous  high 
reputation  for  accuracy,  practical  uselulness  and 
encyclopeedic  scope,  and  is  indispensable  alike  to 
the  pharmacist  and  physician.  Every  druggist 
knows  of  it  and  uses  it,  and  almost  every  physi- 
cian properly  consults  it  when  desirous  of  settling 
all  doubtful  questions  regarding  the  properties, 
preparation  and  uses  of  drugs. — Medical  B'.cord. 
The  descriptions  of  materia  medica  are  clear, 
thorough  and  systematic,  as  are  also  the  explana- 
tions of  chemical  and  pharmaceutical  processes 
and  tests.    The  therapeutical  portion  has  been  re- 


vised with  equal  care  and  the  statements  of  the 
action  and  uses  have  been  arranged  not  only 
alphabetically  under  the  various  drugs,  but  for 
practical  medical  usefalness  have  also  been  placed 
at  the  instant  command  of  those  seeking  infor- 
mation in  the  treatment  of  special  diseases  by 
being  arranged  under  the  various  diseases  in  a 
therapeutical  index.  The  readiness  with  which 
any  of  the  vast  amount  of  information  contained 
in  tills  work  is  made  available  is  indicated  by  the 
twenty-five  thousand  references  in  the  two  in- 
dexes at  the  end  of  the  volume. — Boston  Medical 
and  Surqical  Journal. 

It  is  the  official  guide  for  the  medical  and  phar- 
maceutical professions. — Buffalo  Medical  and  Sur- 
gical Journal. 

The  book  is  recommended  most  highly  as  a 
book  of  reference  for  the  physician  and  is  invalu- 
able to  the  druggist  in  his  e very-day  work. — The 
Therapeutic  Gazette. 

This  edition  of  the  Dispensatory  shouldTbe recog- 
nized as  a  national  standard. — The  North  American 
Practitioner. 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


12       Therapeutics,  flateria  fledica — Continued). 


Hare's  Text-Book  of  Practical  Therapeutics.— New  (5tli)  Edition. 

A  Text-Book  of  Practical  Therapeutics ;  With  Especial  Reference  to 
the  Application  of  Remedial  Measures  to  Disease  and  their  Employment  upon  a  Rational 
Basis.  By  Hobart  Amory  Hake,  M.  D.,  Professor  of  Therapeutics  and  Materia  ]\Iedica 
in  the  Jefferson  Medical  College  of  Philadelphia ;  Sec.  of  Convention  for  Revision  of  U.  S. 
Pharmacopoeia.  With  special  chapters  by  Drs.  G.  E.  de  Schweinitz,  Edward 
Martin  and  Barton  C.  Hirst.  New  (5th)  and  revised  edition,  in  one  octavo  volume 
of  740  pages.  Cloth,  $3.75 ;  leather,  $4.75.  Just  ready. 
A  few  notices  of  the  previous  edition  are  appended. 


We  deem  the  portion  of  the  work  descriptive  of 
remedies  admirable  by  reason  of  the  clearness 
and  conciseness  with  which  it  is  written.  The 
descriptions  of  diseases,  though  exceedingly 
brief,  are  nevertheless  sufficiently  explicit  and  so 
expressed  as  to  render  the  work  a  very  practical 
text-book,  and  also  one  which  will  serve  prac- 
titioaers  for  ready  reference.  The  methods  of 
treatment  are  at  once  sensible  and  practical.  The 
more  experienced  the  practitioner  who  turns  to 
this  book  for  reference,  the  more  sure  will  be  the 
approval  of  the  methods  of  treatment  here  pro- 
posed.—  The  North  American  Practitioner. 

The  fact  that  the  fourth  edition  of  this  work  lias 
appeared  within  four  years  attests  its  value  to  the 


practical  needs  of  every-day  medicine  com- 
mended it  from  the  first  to  the  progressive  and 
working  therapeutist.  It  is  not  only  knowing 
what  to  give,  but  when  and  where  to  give,  and 
how  the  drus  will  act  in  given  conditions,  that 
makes  one  a  scientific  practitioner  rather  than  an 
ignorant  empiric.  The  book  in  such  respects 
supplies  every  need.  The  author  is  well  known 
as  a  progressive  therapeutist,  and  it  goes  without 
saying  that  all  the  new  or  valuable  drugs  receive 
their  lull  share  of  attention,  and  it  is  a  great  deal 
to  say  in  this,  as  with  other  features,  that  the  book 
is  up-to-date  in  everything  pertaining  to  the  prac- 
tical therapeutical  needs  of  the  practitioner.  The 
work  has  also  been  revised  in  such  a  way  as  to 


general  practitioner,  and  its  appreciation  by  the    make  it  uniform  with  the  United  States  Pharma- 
medical  student.      Its  wide    application    to   the    copceia. — Medical  Record. 

Maisch's  Materia  Medica.— New  (6th)  Edition.    Just  Ready. 

A  Manual  of  Organic  Materia  Medica;  Being  a  Guide  to  Materia  Medica 
of  the  Vegetable  and  Animal  Kingdoms.  For  the  Use  of  Students,  Druggists,  Pharmacists 
and  Physicians.  By  John  M.  Maisch,  Phar.  D.,  Prof,  of  Materia  Medica  and  Botany  in 
the  Philadelphia  College  of  Pharmacy.  New  (sixth)  edition,  thoroughly  revised  by 
H.  C.  C.  Maisch,  Ph.G.,  Ph.  D.  In  one  very  handsome  12mo.  volume  of  509  pages,  with 
285  engravings.     Cloth,  §3.00. 

A  notice  of  the  previous  edition  is  appended. 


We  have  nothing  but  praise  for  Professor 
Maisch's  work.  It  presents  no  weak  point,  even 
for  the  most  severe  critic.  The  book  fully  sustains 
the  wide  and  well-earned  reputation  of  its  popular 
author.  After  a  careful  perusal  of  the  book,  we 
do  not  hesitate  to  recommend  Maisch's  Manual 


of  Organic  Materia  Medica  as  one  of  the  best,  if  not 
the  best  work  on  the  subject  thus  far  published. 
Its  usefulness  cannot  well  be  dispensed  with,  and 
students,  druggists,  pharmacists  and  physicians 
should  all  possess  a  copy  of  such  a  valuable 
book. — Medical  News. 


A  System  of  Practical  Therapeutics 

BY  AflERlCAN  AND  FOREIGN  AUTHORS. 
Edited   by   HOBART  AflORY   HARE,   fl.  D. 

Professor  of  Therapeutics  and  Materia  Medica  in  the  Jefferson  Medical  College  of  Philadelphia. 

In  a  series  of  contributions  by  seventy-eight  eminent  authorities.  In  three  large 
octavo  volumes  of  3544  pages,  with  434  illustrations.  Price,  per  volume :  Cloth,  $5.00 ; 
leather,  $6.00 ;  half  Russia,  $7.00.     For  sale  by  svhscription  only.     Address  the  Publishers. 


The  various  divisions  have  been  elaborated  by 
men  selected  in  view  of  their  special  fitness.  In 
every  case  there  is  to  be  found  a  clear  and  concise 
description  of  the  disease  under  consideration, 
corresponding  with  the  most  recent  and  well- 
established  views  of  the  subject.  In  treating  of 
the  employment  of  remedies  and  therapeutical 
measures,  the  writers  have  been  singularly  happy 
in  giving  in  a  definite  way  the  exact  methods  em- 
ployed and  the  results  obtained,  both  by  them- 
selves and  others,  so  that  one  might  venture  with 
confidence  to  use  remedies  with  which  he  was 
previously  entirely  unfamiliar.  The  practitioner 
could  hardly  desire  a  book  on  practical  thera- 


is  the  treatment  of  disease,  and  a  work  which  con- 
tributes to  its  successful  management  is  to  be 
looked  upon  as  of  vast  use  to  humanity.  It  can- 
not be  denied  that  therapeutic  resources,  whether 
the  treatment  be  confined  to  the  mere  administra- 
tion of  drugs,  or  allowed  Its  more  extended  appli- 
cation to  the  management  of  disease,  have  so 
greatly  multiplied  within  the  last  few  years  as  to 
render  previous  treatises  of  little  value.  Herein 
will  be  found  the  great  value  of  iiare's  encyclo- 
pedic work,  which  groups  together  within  a  single 
series  of  volumes  the  most  modern  methods 
known  in  the  management  of  disease.  We  can- 
not commend  Hare's  System  of  Practical   Thera- 


peutics  which  he  could  consult  with  more  interest ;  peutics  too  highly;  it  stands  out  first  and  foremost 
and  profit. —  The  North  American  Practitioner.  as  a  work  to    be  consulted  by  authors,  teachers, 

The  scope  of  this  work  is  beyond  that  of  any  i  and   physicians    throughout  the   world. — Buffalo 
previous  one  on  the  subject.    The  goal,  after  all,  |  Medical  and  SurgicalJournal. 

Edes'  Therapeutics  and  Materia  Medica. 

A  Test-Book  of  Therapeutics  and  Materia  Medica.  Intended  for  the 
Use  of  .Students  and  Practitioners.  By  Eobeet  T.  Edes,  M.  D.,  Jackson  Professor  of 
Qinical  Medicine  in  Harvard  University.     Octavo,  544  pp.    Cloth,  $3.50 ;  leather,  $4.50. 


COHEN'S  HANDBOOK  OF  APPLIED  THER.^- 
PEUTICS.  Being  a  Study  of  Principles  Applic- 
able and  an  Exposition  of  Methods  Employed 
in  the  Management  of  the  Sick.  By  Solomon 
SoLis-CoHEN,  M  D.,  Professor  of  Clinical  Medi- 
cine and  Applied  Therapeutics  in  the  Philadel- 
phia Polyclinic.    In  one  large  12mo.  volume, 


with  ilbistrations.  Preparing. 
STILLE'S  THERAPEUTICS  AND  MATERIA 
MEDICA.  A  Systematic  Treatise  on  the  Action 
and  Uses  of  Medicinal  Agents,  including  their 
Description  and  History.  Fourth  edition,  re- 
vised and  enlarged.  In  two  octavo  volumes,  cone 
taining  1936  pages.    Cloth,  SlO.OO ;  leather,  S12.09. 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


Practice  of  fledicine. 


13 


SEVENTH     EDITION. 

FLINT'S  PRACTICE  OF  MEDICINE 

A  Treatise  on  the  Principles  and  Practice  of  Medicine.  Designed 
for  the  use  of  Students  and  Practitioners  of  Medicine.  By  Attstin  Flint,  M.  D.,  LL.  D., 
Professor  of  the  Principles  and  Practice  of  Medicine  and  of  Clinical  Medicine  in  BeUe- 
vue  Hospital  Medical  College,  N.  Y.  Seventh  edition,  thoroughly  revised  by  Feed- 
EKTCK  P.  Henry,  M.  D.,  Professor  of  Principles  and  Practice  of  Medicine  in  the 
Woman's  Medical  College  of  Pennsylvania,  Philadelphia.  In  one  very  handsome  octavo 
volume  of  1143  pages,  with  illustrations.    Cloth,  $5.00 ;  leather,  $6.00. 

Its  peculiar  excellences  and  its  breadth  of  con-  1      Among  the  large  number  of  new  books  upon  the 
caption  have  made  it  a  recognized  authority  from  I  practice  of  medicine  which  have  been  presented 


the  time  its  first  edition  appeared.  The  author 
was  a  born  teacher,  an  indefatigable  observer,  a 
painstaking  worker  and  a  thorough  medical  phi 
losopher.     His  clinical  pictures  of  diseases  are 


to  the  profession  within  the  last  few  years,  there 
is  none  which  will  stand  better  in  the  present  or 
in  the  future  than  the  seventh  edition  of  this 
book.     It  has  been  a  characteristic  of  Dr.  Flint's 


models  of  graphic  description,  minuteness  of  i  book  that  its  desciiptions  of  clinical  cases  and  of 
detail  and  breadth  of  treatment  This  may  appear  the  practical  side  of  diseases  have  always  been 
to  be  high  praise,  but  the  work  has  so  well  earned  i  wonderfully  true  to  life.  Further  than  this,  we 
its  leading  p'ace  in  medical  literature  that  but  one  ^  think  the  profession  is  to  be  congratulated  that 
view  can  be  expressed  concerning  its  general  i  the  publishers,  in  obtaining  an  editor,  chose  one 
character  as  a  text-book.  The  editor  has  done  his  so  peculiarly  well  qualified  to  revise  and  bring  up 
part  in  bringing  it  up  to  date,  not  only  in  refer-  to  date  those  articles  in  connection  with  which 
ence  to  treatment  and  the  adaptation  of  the  newer  the  greatest  progress  has  been  made  in  medical 
remedies,  but  has  made  numerous  additions  in  |  study,  for  Dr.  Henry  represents  at  once  that  side 
the  shape  of  the  newly  discovered  forms  of  disease,  of  professional  life  which  appreciates  all  that  is 
and  has  elaborated  much/n  the  commoner  forms  I  good  and  at  the  same  time  is  not  so  optimistic  as 
which  the  recent  advances  have  made  necessary.  |  to  swallow  in  addition  much  that  is  bad.  We  be- 
The  element  of  treatment  is  by  no  means  ne-  i  lieve  that  the  profession,  the  teachers,  and  the 
gleeted;  in  fact,  by  the  editor  a  fresh  stimulus  is  '  students  of  the  country  will  appreciate  this  volume 
given  to  this  necessary  department  by  a  compre-  '  as  being  one  of  the  beat  all-around  text-books 
Kensive  study  of  all  the  new  and  leading  thera-  I  which  they  can  obtain. — Therapeutic  Gfazette. 
peutic  agents. — Medical  Record. 

Hartsliorne's  Essentials  o!  Practice.— Fiftli  Edition. 

Essentials  of  the  Principles  and  Practice  of  Medicine.  A  Handbook 
for  Students  and  Practitioners.  By  Heney  Hartshoene,  M.  D.,  LL.  D.,  lately  Professor 
of  Hygiene  in  the  University  of  Pennsylvania.  Fifth  edition,  thoroughly  revised  and 
rewritten.     In  one  12mo.  vol.  of  669  pages,  with  144  illus.     Cloth,  $2.75  ;  half  leather,  $3. 


Farquharson's  Therapeutics  and  Materia  Medica.— 4tli  Ed. 

A  Guide  to  Therapeutics  and  Materia  Medica.  By  Kobeet  Far- 
QUHARSON,  M.  D.,  F.  E.  C.  p.,  LL.  D.,  Lecturer  on  Materia  Medica  at  St.  Mary's  Hospi- 
tal Medical  School,  London.  Fourth  American,  from  the  fourth  English  edition. 
Enlarged  and  adapted  to  the  U.  S.  Pharmacopoeia.  By  Frank  Woodbury,  M.  D.,  Pro- 
fessor  of  Materia  Medica  and  Therapeutics  and  Clinical  Medicine  in  the  Medico-Chi- 
rurgical  College  of  Philadelphia.  In  one  handsome  12mo.  vol.  of  581  pp.  Cloth,  $2.50. 
It  may  correctly  be  regarded  as  the  most  modem  !  copceias,  as  well  as  considering  all  non-official  bat 
work  of  its  kind.  It  is  concise,  yet  complete.  !  important  new  drugs,  it  becomes  in  fact  a  miniature- 
Containing  an  account  of  all  remedies  that  have  j  dispensatory. — Pacific  Medical  Journal. 
a  place  in  the  British  and  United  States  Pharma-  | 

Bruce's  Materia  Medica  and  Therapeutics.— Fiftli  Edition, 

Materia  Medica  and  Therapeutics.  An  Introduction  to  Eational  Treat- 
ment. By  J.  Mitchell  Beitce,  M.  D.,  F.  E.  C.  P.,  Physician  and  Lecturer  on  Materia 
Medica  and  Therapeutics  at  Charing-Cross  Hospital,  London.  Fifth  edition.  In  one 
12mo.  volume  of  591  pages.   Cloth,  $1.50.     See  Students'  Series  of  MoMuals,  page  30. 

Thepharmacology  and  therapeutics  of  each  drug  part  of  the  book  contains  an  outline  of  general 
aregivenwithgreatfulness,  and  the  indications  for  therapeutics,  each  of  the  symptoms  of  the  body 
its  rational  employment  in  the  practical  treatment  being  taken  in  turn,  and  the  methods  of  treat- 
of  disease  are  pointed  out.  The  Materia  Medica  j  ment  illustrated.  A  lengthy  notice  of  a  book  so  well 
proper  contains  ali  that  is  necessary  for  a  medical  i  known  is  unnecessary. — Med.  Chronicle. 
student  to  know  at  the  present  day.     The  third  | 


FLINT'S  PRACTICAL  TREATISE  ON  THE 
DIAGNOSIS,  P.4TH0L0G-Y  AND  TREATMENT 
OF  DISEASES  OF  THE  HEART.  Second  re- 
vised p.nd  enlarged  edition.  In  one  octavo  vol- 
ume of  550  pages,  with  a  plate.    Cloth,  84. 

FLINT  ON  PHTHISIS  In  one  octavo  volume 
of  442  pas:es.    Cloth,  §3.50. 

FLINT'S  ESSAYS  ON  CONSERVATIVE  MEDI- 
CINE AND  KINDRED  TOPICS.  In  one  very 
handsome  royal  12mo.  volume  of  210  pages. 
Cloth.  $1.38. 

LYONS'  TREATISE  ON  FEVER.  In  one  8vo. 
volume  of  354  pages.     Cloth,  82.25. 

HUDSON'S   LECTURES   ON   THE  STUDY  OF 


FEVER.  In  one  octavo  volume  of  808  pages. 
Cloth,  82.50. 

LA  ROCHE  ON  YELLOW  FEVER,  in  its  Histori- 
cal, Pathological,  Etiologica;  and  Therapeutical 
Relations.    Two  octavo  vols.,  1468  pp.    Cloth,  87.00. 

BRUNTON'S  PHARMACOLOGY,  THERAPEU- 
TICS  AND  MATERIA  MEDICA.  Octavo,  1305 
pages,  230  illustrations. 

HERMANN'S  EXPERIMENTAL  PHARMACOL- 
OGY. A  Handbook  of  Methods  for  Determining 
the  Physiological  Action  of  Drugs.  Translated, 
with  the  Author's  permission,  and  with  exten- 
sive additions,  by  R.  M.  Smith,  M.  D.  12mo.j 
199  pages,  with  32  illustrations.     Cloth,  §1.50. 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


14  Prac.  of  fledicine,  Treatment,  Digestive  Syst. 
Lyman's  Practice  of  Medicine. 

The  Principles  and  Practice  of  Medicine.  For  the  Use  of  Medical 
Students  and  Practitioners.  By  Henry  M.  Lyman,  M.  D.,  Professor  of  the  Principles 
and  Practice  of  Medicine,  Push  Medical  College,  Chicago.  In  one  very  handsome  octavo 
volume  of  925  pages,  with  170  iUustrations.     Cloth,  $4.75 ;  leather,  $5.75. 


Professor  Lyman's  valued  and  extensive  expe- 
rience here  reduced  in  text- book  form,  is  indeed 
very  valuable  both  to  college  students  and  physi- 
cians. In  this  work  we  have  aQ  excellent  tieatise 
on  the  practice  of  medicine,  written  by  one  who 


ascertain  in  a  short  time  all  the  necessary  facts 
concerning  the  pathology  or  treatment  of  any  dis- 
ease will  find  here  a  safe  and  convenient  guide. — 
The  Charlotte  Mediial  Journal. 
The  reader  of  the  above  volume  will  be  at  once 


is  not  only  familiar  with  his  subject,  but  who  has    struck  with  its  excellence.    Its  contents  are  corn- 
also  learned  through  practical  experience  in  teach-  '  plete  and  concise,  it  is  fully  abreast  with  the  times, 


Ing  what  are  the  needs  of  the  student  and  how 
to  present  the  facts  to  his  mind  in  the  most  readily 
assimilable  form.  Each  subject  is  taken  up  in 
order,  treated  clearly  but  briefly,  and  dismissed 


and  is  su  ;h  a  book  as  is  needed  by  students  and 
practitioners.  The  average  doctor  has  neither  the 
time  nor  the  patience  to  read  through  the  pages 
of  an  encyclopedia  to  gain  the  points  he  desires. 


when  all  ha?  been  said  that  need  be  said  in  order  '  This  Practice  will  give  him  all  the  necessary  in- 
to give  the  reader  a  clear  cut  picture  of  the  dis-  j  formation  in  a  form  easily  grasped.  The  parts  of 
ease  under  discussion.  The  reader  is  not  con-  |  chapters  relating  to  differential  diagnosis  leave 
fused  by  having  presented  to  him  a  variety  of  nothing  to  be  desired;  they  show  the  author's 
different  methocs  of  treatment,  among  which  he    familiarity  with  his  subjects,  and  his  methods  as 


is  left  to  choose  the  one  most  easy  of  execution, 
but  the  author  describes  the  one  whioh  is,  in  his 
judgment,  the  best.  This  is  as  it  should  be.  The 
student  and  even  the  practitioner,  should  be 
taught  the  most  approved  method  of  treatment. 
The  practical  and  busy  physician,  who  wants  to 


a  teacher.  Evidently  the  points  are  not  culled 
from  other  volumes;  they  bear  the  stamp  of 
originality.  In  a  word,  the  volume  is  up  to  date, 
is  readable  and  instructive,  and  is  far  superior  to 
the  majority  of  books  of  the  kind. —  University 
Mf'i^ral  Magazine. 


The  Year-Book  of  Treatment  for  1895. 

A  Comprehensive  and  Critical  Review  for  Practitioners  of  Medi- 
cine and  Surgery.     In  one  12mo.  vol.  of  495  pages.     Cloth,  $1.50. 

.5^**  For  special  commutations  with  periodicals  see  pages  1  and  2. 


It  would  be  difficult  indeed  to  Imagine  a  book 
more  nearly  suited  to  the  everyday  needs  of  the 
medical  practitioner  or  writer  than  this.  The  con- 
tributors to  this  volume  are  among  the  most  promi- 
nent and  well-known  writers  and  teafhers  of  the 
day,  and  their  articles  and  opinions  will  be  appre- 
ciated by  all  who  are  fortunate  and  wise  enough 
to  secure  them.     It  is  the  very  book  the  busy 


prafititioner  needs.  He  can  find  anything  pertain- 
ing to  any  subject  in  a  moment's  time,  and  he  may 
rest  assured  that  it  is  the  most  modern  and  reliable 
view  now  accepted.  It,  year  by  year,  keeps  him 
apprised  of  important  advances  in  all  branches 
of  medicine,  and  presents  them  in  a  well-con- 
densed and  classified  form. —  The  CharloHe  Med- 
ical Journal,  May,  1895. 


The  Year-Books  of  Treatment  for  1891,  1892,  and  1893. 

12mos.,  485  pages      Cloth,  $1.50  each. 


The  Year-Books  of  Treatment  for  1886  and  1887. 

Similar  to  above.     12mos.,  320-341  pages.    Cloth,  $1.25  each. 

Habershon  on  the  Abdomen. 

On  the  Diseases  of  the  Abdomen ;  Comprising  those  of  the  Stomach,  and 
other  parts  of  the  A  littientary  Canal,  (Esophagus,  Caecum,  Intestines  and  Peritoneum.  By 
S.  O.  Habebshon,  M.  D.,  Senior  Physician  to  and  late  Lecturer  on  Principles  and  Prac- 
tice of  Medicine  at  Guy's  Hospital,  London.  Second  American  from  third  enlarged  and 
revised  English  edition.  In  one  handsome  octavo  vol.  of  554  pages,  with  illus.   Cloth,  $3.50. 


This  valuable  treatise  on  diseases  of  the  stomach 
and  abdomen  will  be  found  a  cyclopaedia  of  infor- 
mation, systematically  arranged,  on  all  diseases  of 
the   alimentary   trae*,    from    the    mouth    to  the 


rectum.  k  fair  proportion  of  each  chapter  is 
devoted  to  symptoms,  pathology,  and  therapeutics. 
— iVeio  York  Medical  Journal. 


TANNER'S  MANUAL  OF  CLINICAL  MEDICINE 
AND  PHTSICAL  DIAGNOSIS.  Third  American 
from  the  second  London  edition.  Revised  an^' 
enlarged  by  Tilbxtrt  Fox,  M.D.  In  one  12mo. 
volume  of  362  pp.  with  illus.    Cloth,  §1.50 

DAVIS'  CLINICAL  LECTURES  ON  VARI0U.6 
IMPORTANT  DISEASES.  By  N.  S.  Divis, 
M.  D.  Edited  by  Frank  H.  Davis,  M.  D  Sacond 
edition.    12mo.  287  pages.    Cloth,  S^. 7- 

'WALSHE  ON  THE  DISEASES  OF  THE  HEART 
AND  GREAT  VESSELS.  Third  American  edi- 
tion.    In  1  vol.  8vo.,  416  pp.     Cloth,  S3.00. 

HOLLAND'S  MEDICAL  NOTES  AND  REFLEC- 
TIONS. 1  vol.  8vo..  pp.  493.     Cloth,  83.50. 

TODD'S  CLINICAL  LECTURES  ON  CERTAIN 
ACUTE  DISEASES.  In  one  octavo  volume  of 
320  paees.     Cloth.  82.50. 

FLINT'S  PRACTICAL  TREATISE  ON  THE 
PHYSICAL  EXPLORATION  OF  THE  CHEST 
AND  THE  DIAGNOSIS  OF  DISEASES  AP- 
FiiCTING  THE  RESPIRATORY  ORGANS. 
Second  and  revised  edition.  In  one  handsome 
octavo  volume  of  591  pages.     Cloth,  S4.oO. 

8TURGES'    INTRODUCTION  TO  THE  STUDY 


OF  CLINICAL  MEDICINE.    Being  a  Guide  to 
the  Investigation  of  Disease.    In  one  handsome 

12mo.  volume  of  127  pages.     Cloth,  81.25. 

REYNOLDS'  SYSTEM  OF  MEDICINE.  With 
notes  and  additions  by  Hesrt  Haetshorse,  A.M., 
M.D.  Three  octavo'volumes,  containing  3056 
double-columned  pages,  with  317  illustrations. 
Price  per  volume,  cloth,  S5.00;  sheep,  $6.00;  half 
Russia,  S6.50.     Subscription  only. 

WATSON'S  LECTURES  ON  THE  PRINCIPLES 
AND  PRACTICE  OF  PHYSIC.  Edited  with 
additions,  and  190  illustrations,  by  Henet  Haets- 
HOEXE,  A.  M.,  M.  D.  In  two  large  octavo  volumes 
of  1840  pages     Cloth,  §9.00;  leather,  §11.00. 

PEPPER'-^  SYSTEM  OF  PRACTICAL  MEDI- 
CINE BY  AMERICAN  AUTHORS  Edited  by 
William  Pepper,  M.  D.,  LL.  D.,  Provost  and 
Professor  of  the  Tneory  and  Practice  of  Jledi- 
cine  and  of  Clinical  Medicine  in  the  Univer- 
sity of  Pennsylvania.  The  complete  work,  in 
five  volumes,  contains  5573  pages,  with  19S  illus- 
trations. Price,  per  volume,  cloth,  §5;  leather, 
§6;    ha'f  Rassia,  S7.     Subscription  only. 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


Practice  of  fledicine,  Diagnosis,  Heart.         15 


Musser's  Medical  Diagnosis. 

A  Practical  Treatise  oq  Medical  Diagnosis.  For  the  Use  of  Students 
and  Practitioners.  By  John  H.  Musser,  M.  D.,  Assistant  Professor  of  Clinical  Medicine, 
University  of  Pennsylvania,  Philadelphia,  in  one  very  handsome  octavo  volume  of  873 
pages,  with  162  illustrations  and  2  colored  plates.     Cloth,  So;  leather,  $6. 

The  aim  of  the  author  has  been  to  make  ;  formation  essential  to  good,  scientific  medical 
thb  worli  eminently  practical.  Dr.  Musser  \  work.  It  is  with  pleasure  that  we  can  state  that 
has  succeeded  in  bringing  together  a  large  and  ;  the  work  has  been  adopted  as  a  text-book  at  the 
valuable  collection  of  clinical  data  drawn  from  his  Johns  Hopkins  iledical  School  and  Harvard  Uni- 
own  extended  experience  and  from  exhaustive  versity,  and  that  it  has  met  with  marked  approval 
literary  leseareh,  and  has  presented  them  in  an  ,'  in  other  teaching  centTea.— International  Medical 
unusuaily_  clear  and   concise  manner.    In   brief,    Magazine. 

the  book  is  thorouschly  modern,  readable  and  in-  j  The  whole  book  impresses  one  as  being  the 
structive,  and,  we  believe,  superior  to  any  work  of  !  concentration  of  a  very  thorough  knowledge  of 
the  kind  before  the  profession. —  University  Medical !  all  the  fact?  resorted  to  in  the  making  of  a  careful 
Magazine.  \  diagnosis  by  means  of   modern  methods.     Dr. 

Modern  methods  of  medical  teaching  and  study  '  Musser's  book  will  at  once  take  a  prominent  and 
have  rendered  treatises  like  the  present  an  abso-  '  permanent  position  among  the  text-books  of  the 


lute  necessity.  The  present  work  is  to  be  com- 
mended alike  for  its  logical  arrangement,  accurate 
observation  and  clearness  of  expression.  The 
chapter  on  bacteriology  is  especially  commenda- 
ble, because  it  contains  everything  practically 
necessary  for  clinical  v/or^^. —Medical  Record. 

The  book  should  receive  a  hearty  reception  from 
students  and  medical  men;  it  contains  much  in- 


medical  schools  of  the  country,  and  we  recom- 
mend it  most  highly  to  those  practitioners  who 
wish  not  only  to  get  the  views  of  the  general  pro- 
fession in  regard  to  important  points  of  diagnosis, 
but  who  also  desire  a  work  in  which  the  author 
expresses  his  own  opinions,  based  upon  careful 
observation  and  wide  experience. —  The  Thera- 
peutic Ga.zette. 


Flint  on  Auscultation  and  Percussion.— Fifth  Edition. 

A.  Manual  of  Auscultation  and  Percussion ;  Of  the  Physical  Diagnosis 
of  Diseases  of  the  Lungs  and  Heart,  and  of  Thoracic  Aneurism.  By  Austen  Flen'T,  M.  D., 
LL.  D.,  Professor  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Hospital  Medi- 
cal College,  New  York.  Fifth  edition.  Edited  by  James  C.  Wilson,  M.  D.,  Lecturer 
on  Physical  Diagnosis  in  the  Jefferson  Medical  College,  Philadelphia.  In  one  hand- 
some royal  12mo.  volume  of  274  pages,  with  12  illustrations. 

Whitla's  Dictionary  of  Treatment. 

A  Dictionary  of  Treatment ;  or  Therapeutic  Index,  including 
Medical  and  Surgical  Therapeutics.  By  WrcLiAii  Whitla,  M.  D.,  Professor 
of  Materia  Medica  and  Therapeutics  in  the  Queen's  CoUege,  Belfast.  Eevised  and  adapted 
to  the  United  States  Pharmacopoeia.  In  one  square,  octavo  vol.  of  917  pp.  Cloth,  $4.00. 
We  have  already  dictionaries  of  medicine  and  the  younger  practitioner  will  find  in  it  exactly  the 
dictionaries  of  surgery;  Dr.  Whitla  now  provides  help  he  so  often  needs  in  the  treatment  both  of 
us  with  a  dictionaryof  treatment.  And  reference  ,  those  who  are  ill,  and  those  who  are  ailing.  At  the 
to  the  volume  shows  that  it  really  is  what  it  same  time  the  most  experienced  members  of  the 
professes  to  be.  The  several  diseased  condi-  ^  profession  may  usefully  consult  its  pages  for  the 
tions  are  arranged  in  alphabetical  order,  and  j  purpose  of  learning  what  is  really  trustworthy  in 
the  methods— medical,  surgical,  dietetic,  and  ;  the  later  therapeutic  developments.  The  Diction^ 
climatic — by  which  they  may  be  met,  considered.  |  ary  is,  in  short,  the  recorded  experience  of  a  prac- 
On  every  page  we  find  clear  and  detailed  direc- 
tions for  treatment  supported  by  the  author's 
personal  authority  and  experience  whilst  the 
recommendations  of  other  competent  observers 
are  also  critically  examined.  The  book  abounds 
with  useful,  practical  hints  and  suggestions,  and 


tieal  scientific  therapeutist,  who  has  carefully 
studied  diseases  and  disorders  at  the  bed-side  and 
in  the  consulting-room,  and  has  earnestly  ad- 
dressed himself  to  the  cure  and  relief  of  his 
patients. — TTie  Glasgow  MediealJournal. 


Taylor's  Index  of  Medicine.— Just  Ready. 

An  Index  of  Medicine.  By  Seymoue  Taylor,  M. D.,  M. K.  C. P.,  Assistant 
Physiciantothe  West  London  Hospital,  hi  one  12mo.  vol.  of  802  pages.  Cloth,  $3.75. 
-  The  author  has  prepared  a  work  of  great  value  systems  of  the  body  are  considered,  and  the 
alike  to  physicians  and  students.  The  volume  is  cause,  symptoms,  pathology,  treatment  and 
a  concise  "Practice  of  Medicine,"  the  diseases  prognosis  of  each  affection  are  succinctly  stated, 
being  grouped  systematieaily  in  order  to  secure  Numerous  illustrations  together  with  tabulations 
for  the  reader  the  many  advantages  resulting  of  differential  diagnosis,  tests,  etc.,  elucidate  the 
from  rational  arrangfment.  Aftervaluable  chap-  text  and  cond-nse  a  great  amount  of  necessary 
ters  on  "Disease,"  "G-eneral  Pathology,"  "Gen  knowledge  in  the  clearest  manner.  The  work  is 
eral  Diseases,"  "Specific  Infectious  Diseases"  one  which  merits  and  will  doubtless  obtain  a 
and  "Specific    Fevers,"  the  various  organs  and    wide  popularity. —  The  St.  Lcuis  C!inique,Ma.y,  1S95. 

Fotliergiirs  Handbook  of  Treatment.— Third  Edition. 

The  Practitioner's  Handbook  of  Treatment;  Or,  The  Principles  of 
Therapeutics.  By  J.  Milxer  Fothergill,  M.  D.,  Edin.,  M.  K.  C.  P.,  Lond.,  Physician 
to  the  City  of  London  Hospital  for  Diseases  of  the  Chest.  Third  edition.  In  one  8vo. 
volume  of  661  pages.    Cloth,  $3.75 ;  leather,  $4.75. 

This  is  a  wonderful  book.  If  there  be  such  a  together  in  a  single  chapter,  and  the  relations 
thing  as  "medicine  made  easy,"  this  is  the  work  to  between  the  two  clearly  stated,  cannot  fail  to  prove 
accomplish  this  result. —  Virqinia  Med.ical Monthly.  ,  a  great  convenience  to  many  thoughtful  but  busy 

To  have  a  description  of  the  normal  physiologi-  physicians.  The  practical  value  of  the  volume  is 
cal  processes  of  an  organ  and  of  the  methods  of  |  greatly  increased  by  the  introduction  of  many- 
treatment    of    its    morbid    conditions    brought    prescriptions.— iVew  York  Medical  Journal. 


BROADBENT  ON  THE  PULSE.     In  one  12mo.  volume  of  312  pages.     Cloth,  SI .75.    See  Series  oj 
Clinical  Manuals,  page  .30. 

Lea  Brothers  &  Co.,  Publishers,  706,  708  &710  Sansom  Street,  Philadelphia. 


16   Practice,  Electricity,  Cholera,  Food,  Hygiene. 
Hayem  &  Hare's  Physical  &  Natural  Therapeutics.— Just  Ready. 

Physical  and  Natural  Therapeutics.  The  Eemedial  Use  of  Heat, 
Electricity,  Modifications  of  Atmosplaeric  Pressure,  Climates,  and  Mineral  Waters.  By 
Geobges  Hayem,  M.D.,  Professor  of  Clinical  Me licine  in  the  Faculty  of  Medicine  of 
Paris.  Edited  Avitli  the  assent  of  the  author,  by  Hobart  Amory  Hake,  M.D.,  Professor 
of  Therapeutics  in  the  Jefferson  Medical  College  of  Philadelphia.  In  one  handsome 
octavo  volume  of  414  pages  with  113  engravings.     Cloth,  $3.00. 

For  many  diseases  the  most  potent  remedies  lie  outside  of  the  Materia  Medica,  a  fact 
yearly  attaining  wider  recogaition.  Within  this  large  range  of  applicability  physical 
agencies  when  comiiared  with  drugs  are  more  dii'ect  and  simple  in  their  results.  Medical 
literature  has  long  been  rich  in  treatises  upon  medicinal  agents,  but  an  authoritative 
work  upon  the  other  great  branch  of  therapeutics  has  until  now  been  a  desideratum.  The 
author  and  editor  of  this  work  enjoy  equal  standing,  and  the  volume  is  certain  to  command 
attention  and  to  render  wide-spread  service.  The  section  on  Climate,  rewritten  by  Professor 
Hare,  will  for  the  first  time,  place  the  abundant  resources  of  our  own  countiy  at  the 
intelligent  command  of  American  practitioners.  The  extended  section  on  Medical  Electricity, 
likewise  rewritten,  conforms  to  the  American  development  of  this  subject,  and  explains  the 
many  excellent  forms  of  apparatus  readily  available  in  this  country. 

Herrick's  Diagnosis.— Just  Ready. 

A  Handbook  of  Diagnosis,  By  James  B.  Herbick,  M.D.,  Adjunct  Pro- 
fessor of  Medicine,  Rush  Medical  College,  Chicago.  In  one  handsome  12mo.  volume  of 
429  pages,  with  80  engravings  and  2  colored  plates.     Cloth,  S2.-'^0. 

This  work  affords  students  a  comjaendious  guide  to  the  art  of  identifying  disease.  Prac- 
titioners likewise  will  find  in  its  carefully  prepared  and  well-illustrated  pages  a  convenient 
means  of  refreshing  and  supplementing  their  knowledge  of  a  depai-tment  of  medicine  which 
underlies  rational  and  successful  treatment. 


Teo's  Medical  Treatment. 

A  Manual  of  Medical  Treatment  or  Clinical  Therapeutics.  By 
1.  Bueney  Yeo,  M.  D.,  F.  E.  (1  P.,  Prof,  of  Clinical  Therapeutics  in  King's  CoU.,  London. 
In  two  12mo.  volumes  containing  1275  pages,  with  illustrations.     Cloth,  §5.50. 

The  discussion  of  the  different  ailments  has  a  j  tion,  which  is  a  feature  that  cannot  be  too  highly 
distinctly  practical  turn  toward  the  main  purpose  commended.  It  cannot  fail  to  be  an  exceedingly 
of  the  book.  Standard  formulae  are  introduced  useful,  suggestive  and  instructive  work  to  the 
from  eminent  practitioners,  and  all  the  drugs  of  physician  who  wishes  to  be  well  up  ia  the  present 
recognized  value  are  grouped  in  the  order  of  their  advanced  and  scientific  therapeutics  of  the  day. — 
importance.    The  dosage  receives  careful  atten-    Medical  Record. 

Teo  on  Food  in  Health  and  Disease. 

Food  in  Health  and  Disease-  By  I.  Bubney  Yeo,  M.D.,  F.E.C.  P., 
Professor  of  Clinical  Therapeutics  in  King's  College,  London  In  one  12mo.  volume  of 
590  pages.    Cloth,  $2  00.     See  Series  of  Clinical  3Ianvxils,  page  30. 

Dr. Yeo  supplies  in  a  compact  form  nearly  all  that  |  compass,  and  he  has  arranged  and  digested  hia 
the  practitioner  requires  to  know  on  the  siibject  of  materials  with  skill  for  the  use  of  the  practitioner, 
diet.  The  work  is 'divided  into  two  parts — food  in  We  have  seldom  seen  a  book  which  more  thor- 
health  and  food  in  disease.  Dr.  Teo  has  gathered  |  oughly  realizes  the  object  for  which  it  was  written 
together  from  all  quarters  an  immense  amount  of  \  than  t.his  little  work  of  Dr.  Yeo. — British  Medical 
useful  information  within  a  comparatively  small  |  Journal. 


Bartholow  on  Cholera. 

Cholera :  Its  Causes,  Symptoms,  Pathology  and  Treatment.  By 
Roberts  Bartholow,  M.  D.,  LL.  D.,  Emeritus  Professor  of  Materia  Medica,  General 
Therapeutics  and  Hygiene  in  the  Jefferson  Medical  College  of  Philadelphia.  In  one  12mo. 
volume  of  127  pages,  with  9  illustrations.     Cloth,  $1.25. 

Richai'dson's  Preventive  Medicine. 

Preventive  Medicine.  By  B.  ^.  Eichardson,  M.  D.,  LL.  D.,  F.  E.  S.,  Fel- 
low of  the  Eoyal  Coll.  of  Phys.,  London.  In  one  8vo.  vol.  of  729  pp.  Cloth,  $4;  leather.  $5. 
There  is  perhaps  no  similar  work  written  for  j  scholarly ;  the  discussion  of  the  question  of  disease 
the  general  public  that  contains  such  a  complete,  ,  is  comprehensive,  masterly  and  fully  abreast  with 
reliable  and  instructive  collection  of  data  upon  '  the  latest  and  best  knowledge  on  the  subject,  and 
the  diseases  common  to  the  race,  their  origins,  •  the  preventive  measures  advised  are  accurate, 
causes,  and  the  measures  for  their  prevention,  explicit  and  reliable. — TheAmerican  Journal  of  the 
The  descriptions  of  diseases  are  clear,  chaste  and    Medical  Sciences 


BARTHOLOWS  PRACTICAL  TREATISE  ON  1  SCHREIBER'S  MANUAL  OF  TREATMENT  BY 
THE  APPLICATIONS  OF  ELECTRICITY  TO  I  MASSAGE  AND  METHODICAL  MUSCLE  EX- 
MEDICINE  AND  SURGERY.  By  Kobeets  ;  ERCISE.  Translated  by  Waiter  Mendelson, 
Baetholow,  A.m.,  M.D.,  LL.D.,  Emeritus  Pro-  '■      M.D.,  of  New  Y'orli.    In  one  8vo.  volume  of  274 


fessor  of  Materia  Medica  and  General  Thera- 
peutics in  the  .lefferson  Med.  Coll.  of  Philadel- 
phia, etc.  Third  edition.  In  one  octavo  volume 
of  308  pages,  with  110  illustrations. 
PAVY'S  TREATISE  ON  THE  FUNCTION  OF  DI- 
GESTION; its  Disorders  and  their  Treatment 


pp.,  with  117  engravings. 

CHAMBERS'  MANUAL  OF  DIET  AND  REGIMEN 
IN  HEALTH  AND  SICKNESS.  In  one  hand- 
some octavo  volume  of  302  pp.    Cloth,  82.75. 

STILLfe  ON  CHOLERA:  Its  Origin,  History, 
Causation,  Symptoms,  Lesions,  Prevention  and 


From  the  second  London  edition.    In  one  octavo  i      Treatment.    In  one  handsome  12mo.  volume  of 
volume  of  238  pages.    Cloth,  S2.00.  |      163  pages,  with  a  chart.    Cloth,  Sl.25. 

Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia.  ■ 


Throat,  Nose,  Lungs,  Hind,  Nerves. 


17 


Seller  on  the  Throat  and  Nose.— Fourth  Edition. 

A  Handbook  of  Diagnosis   and  Treatment  of  Diseases  of  the 
Throat,  Nose    and   Naso-Pharynx.     By  Carl  Seilee,,    M.D.,    Lecturer    on 
Laryngoscopy  in  the  University  of  Pennsylvania.     Fourth  edition.    In  one  handsome 
12mo.  volume  of  414  pages,  with  107  illustrations  and  2  colored  plates.     Cloth,  $2.25. 
mi,,.  i..ii_  1      I-.-,  ._._•        1,  ii_^,        ,     .,.    come  expeit  in  the.  use  of  the  laryngeal  mirror,  a 

method  of  examination  too  often  neglected.  The 
anatomy  of  the  larynx  is  explained  with  especial 
care,  and  the  operative  procedures  for  various 
diseases  of  the  throat,  tonsils,  etc.,  are  carefully- 
explained.  Approved  methods  of  treatment  are 
dealt  veith  in  a  very  satisfactory  way,  and  all  the 
most  useful  remedial  agents  are  described. — 
International  Medical  Magazine. 


This  little  book  is  eminently  practical,  and  will 
prove  of  interest  not  only  to  the  specialist,  but  to 
the  general  practitioner  as  well.  It  deals  with  the 
subject  in  a  clear  and  distinct  manner,  and  the 
text  is  copiously  illustrated  with  diagrams  and 
colored  plates.  "So  little  attention  is  paid  ordi- 
narily to  the  examination  of  the  larynx  that  the 
need  of  such  a  book  has  long  been  felt.  By  eon 
suiting  its  pages  anyone  can  learn  the  necessary 
manipulations,  and,  by  a  littie  practice,  soon  be- 


Browne  on  the  Throat  and  Nose.— Fourth  Edition. 

The  Throat  and  Nose  and  Their  Diseases.  By  Lennox  Browne, 
F.  E.  C.  S.,  E.,  Senior  Physician  to  the  Central  London  Throat  and  Ear  HospitaL 
Fourth  and  enlarged  edition.  In  one  imperial  octavo  volume  of  751  pages,  with  120 
illustrations  in  color,  and  235  engravings  on  wood.     Cloth,  §!6.50. 


The  subject  is  here  exhaustively  treated  on 
lines  of  thorough  acquaintance  with  the  anatomy, 
the  physiology  and  physics  of  the  organs  involved 
and  the  pathology  of  the  disease  to  which  they 
are  subject.  To  the  author  we  have  awarded  the 
credit  of  having  added  to  a  thorough  understand- 
ing of  the  diseases  with  which  he  deals  the  choice 
of  the  best  treatment  afforded  by  the  present  state 


of  knowledge. —  The  Amer.  Practitioner  and  News. 

Although  quite  complete  enough  for  the  use  of 
specialists,  it  is  at  the  same  time  so  clear  as  to  be 
of  daily  value  to  the  general  practitioner,  who  will 
find  at  the  end  of  the  volume  a  number  of  well- 
tried  formulas  most  in  vogue  at  the  London  hos- 
pitals for  diseases  of -the  throat — The  Canada 
Medical  Record. 


Tuke  on  the  Influence  of  the  Mind  on  the  Body. 

Illustrations  of  the  Infiuence  of  the  Mind  upon  the  Body  in 
Health  and  Disease,  Designed  to  elucidate  the  Action  of  the  Imagination.  By 
Dajstiei,  Hack  Tuke,  M.  D.,  Joint  Author  of  the  Manual  of  Psychological  Medicine, 
etc.  New  edition.  Thoroughly  revised  and  rewritten.  In  one  8vo.  volume  of  467  pages, 
with  2  colored  plates.   Cloth,  $3  00. 


It  is  impossible  to  peruse  these  interesting  chap- 
ters without  being  convinced  of  the  author's  per- 
fect sincerity,  impartiality,  and  thorough  mental 
grasp.  Dr.  Tuke  has  exhibited  the  requisite 
amount  of  scientific  address  on  all  occasions,  and 
the  more  intricate  the  phenomenathe  more  firmly 
has  he  adhered  to  a  physiological  and  rational 


method  of  interpretation.  Guided  by  an  enlight- 
ened deduction,  the  author  has  reclaimed  for 
science  a  most  interesting  domain  in  psychology, 
previously  abandoned  to  charlatans  and  empirics. 
This  book,  well  conceived  and  well  written,  must 
commend  itself  to  every  thoughtful  understand- 
ing.— Neio  York  Medical  Journal. 


Ross  on  Diseases  of  the  Nervous  System. 

A  Handbook  on  Diseases  of  the  Nervous  System.  By  James 
Ross,  M.  D.,  F.  R.  C.  P.,  LL.D.,  Senior  Assistant  Physician  to  the  Manchester  Eoyal 
Infirmary.     In  one  octavo  vol.  of  725  pages,  with  184  illus.     Cloth,  $4.50 ;  leather,  $5.50. 

Glouston  on  Mental  Diseases. 

Clinical  Lectures  on  Mental  Diseases.  By  Thomas  S.  Cloifston, 
M.  D.,  Lecturer  on  Mental  Diseases  in  the" University  of  Edinburgh.  With  an  Appen- 
dix, containing  an  Abstract  of  the  Statutes  of  the  United  States  and  of  the  Several 
States  and  Territories  relating  to  the  Custody  of  the  Insane.  By  Charles  F.  Folsom, 
M.  T>.,  Ass't  Professor  of  Mental  Diseases,  Med.  Dep.  of  Harvard  Univ.  In  one  octavo 
volume  of  541  pages,  with  eight  lithographic  plates,  four  of  which  are  colored.     Cloth,  $4. 

°Dr.  Folsom's  Abstract  also  separate,  in  one  8vo.  vol.  of  108  pages.    Cloth,  $1,50. 


Playfair  on  Nerve  Prostration  and  Hysteria. 

The  Systematic  Treatment  of  Werve  Prostration  and  Hysteria. 
By  "VY.  S.  PiAYFAiR,  M.  D.,  F.  E.  C.  P.     In  one  12mo.  volume  of  97  pages.    Cloth,  $1.00. 


SAVAGE  ON  IISSANITY  AND  ALLIED  NEU- 
ROSES. In  one  12mo.  volume  of  551  pages,  with 
18  illustrations.  Cloth,  §2.00.  See  Series  of  Clin- 
ical Manuals,  page  30. 

BLANDFORD  ON  INSANITY  AND  ITS  TREAT- 
MENT. Lectures  on  the  Treatment,  Medical 
and  Legal,  of  Insane  Patients.  In  one  very 
handsome  octavo  volume. 

JONES'  CLINICAL  OBSERVATIONS  ON  FUNC- 
TIONAL NERVOUS  DISORDERS.  Second 
American  Edition.  In  one  handsome  octavo 
volume  of  340  pages.     Cloth,  $3.25. 

BROWNE  ON  KOCH'S  REMEDY  IN  RELATION 
TO  THROAT  CONSUMPTION.  In  one  octavo 
volume  of  121  pages,  vrith  45  illustrations,  4  of 
which  are  colored,  and  11  charts.    Cloth,  S1.50. 

FULLER  ON  DISEASES  OF  THE  LUNGS  AND 


AIR-PASSAGES.  Their  Pathology,  Physical  Di- 
agnosis, Symptoms  and  Treatment.  From  the 
second  and  revised  English  edition.  In  one 
octavo  volume  of  475  pages.    Cloth,  83.50. 

SLADE  ON  DIPHTHERIA;  its  Nature  and  Treat- 
ment, with  an  account  of  the  History  of  its  Pre- 
valence in  various  Countries.  Second  and  revised 
edition.    In  one  12mo.  vol.,  158  pp.     Cloth,  81.25. 

SMITH  ON  CONSUMPTION ;  its  Early  and  Reme- 
diable Stages.    1  vol.  8vo.,  253  pp.    Cloth,  82.25. 

LA  ROCHE  ON  PNEUMONIA.  1  vol.  8vo.  of  490 
pages.    Cloth,  83.00. 

WILLIAMS  ON  PULMONARY  CONSUMPTION; 
its  Nature,  Vaiieties  and  Treatment  With  an 
analysis  of  one  thousand  cases  to  exemplify  Its 
duration.   In  one  8vo.  vol.  of  303  pp.  Cloth,  ^.50. 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


18       Nervous  and  flental  Diseases,  Histology. 
Dercum  on  Nervous  Diseases— Just  Ready. 

A  Text- Book  on  Nervous  Diseases.  JBy  American  Authors.  Edited 
bv  F.  X.  Dercum,  M.D.,  Clinical  Professor  of  Diseases  of  the  Nervous  System  in  the 
Jeflerson  Medical  College,  Philadelphia.  In  one  handsome  octavo  volume  of  1054 
pages,  with  341  engravings  and  7  colored  plates.     Cloth,  $6.00  ;  leather,  $7.00. 

LIST   OF  CONTRIBUTORS. 

N.  E.  Brill,  M.D.  S  Weir  Mitchell,  M.D. 

Charles  W.  Burr,  M.D.  C.  A.  Hertek,  M.D.  Charles  A.  Oliver,  M.D. 

Joseph  Collins,  M.D.  George  W.  Jacoby,  M.D.  William  Osler,  M.D. 

Charles  L.  Iiana,  M.D.  William  W.  Keen,  M.D.  Frederick  Peterson,  M.D. 

F.  X.  Dercum.M.D.  Philip  Coombs  Knapp,  M.D.  Morton  Prince,  M.D. 

Geo.  K  de  Schweinitz,  M.D.         James  Hendrie  Lloyd,  M.D.  Wharton  Sinklek,  M.D. 

E.  I).  Fishek,  M.D.  Charles  K.  Mills,  M.D.  M.  Allen  Starr,  M.D. 

Landon  Carter  Gray,  M.D.  James  C.  Wilson,  M.  D. 

The  prevailing  impression  that  Nervous  Diseases  j^resent  peculiar  difficulties  possibly 
arises  not  so  much  from  the  nature  of  the  subject  as  from  the  manner  in  which  it  has  generally 
been  presented,  a  belief  which  has  led,  after  careful  studj^,  to  the  somewhat  novel  arrange- 
ment of  this  work.  In  brief,  the  general  aifections  are  considered  first,  and  attention  is  then 
progressively  directed  to  those  which  are  more  and  more  special.  The  choice  of  subjects  and 
the  space  devoted  to  each  have  been  arranged  with  special  reference  to  practical  needs,  and  it 
is  believed  that  the  mode  of  handling  details  is  conducive  to  clearness,  utility  and  complete- 
ness. A  glance  at  the  List  of  Contributors  will  show  that  this  volume  represents  the  views  of 
gentlemen  widely  recognized  as  authorities  in  neurological  science,  and  especially  known  in 
connection  with  the  subjects  assigned  to  them.  The  work  is  likewise  representative  of  our 
great  medical  schools,  and  hence  it  embodies  not  only  high  authority  but  is  likewise  illustra- 
tive of  the  best  methods  of  instruction.  Free  use  has  been  made  of  illustrations  in  black 
and  colors.    The  series  t)f  pictures  is  lai-gely  original. 

Gray  on  Nervous  and  Mental  Diseases.— New  (2d)  Ed.  Just  Ready. 

A  Practical  Treatise  on  Nervous  and  Mental  Diseases.  By  Landon 
Carter  Gray,  M.D.,  Professor  of  Diseases  of  the  Mind  and  Nervous  System  in  the  New 
York  Polyclinic.  New  (2d)  edition.  In  one  very  handsome  octavo  volume  of  728  pages, 
with  172  engravings  and  3  colirerl  plates.     Cloth,  $4.75  ;  leather,  $o.75. 

The  period  of  less  than  two  years  which  has  sufficed  to  exhaust  the  first  edition  of  this 
work  has  witnessed  epoch-making  discoveries  in  the  data  of  the  science,  and  the  ojiportunity 
thus  presented  has  been  fully  utilized  in  the  revision  now  at  the  command  of  the  profession. 
Dr.  Gray's  book  is  notable  for  its  clear,  adequate  and  masterly  exposition  of  both  nervous  and 
mental  diseases  within  the  limits  of  a  single  convenient  volume.  These  affections,  owing  to 
their  widespread  i?revalence  and  their  peculiarities  m  this  country,  possess  unrivalled  import- 
ance for  American  physicians.  Their  close  interrelation  gives  especial  value  to  an  authorita- 
tive work  which  handles  them  in  proper  conjunction.  The  series  of  illustrations  abounds  in 
typical  portraits,  admirable  engravings  and  clear  diagrams,  and  m  the  present  edition  it  has 
been  enriched  with  colored  plates. 

on  Nerve  Injuries  and  Tlieir  Treatment.— In  Press. 


Remote  Consequences  of  Injuries  of  H'erves  and  Their  Treat- 
ment. An  examination  of  the  present  condition  of  wounds  received  in  1863-5,  with, 
additional  illustrative  cases.  By  John  K.  Mitchell,  M.  D.,  Assistant  Physician  to  the 
Orthopsedic  Hospital  and  Infirmary  for  Nervous  Diseases,  Philadelphia.  In  one  hand- 
some 12mo.  volume  of  239  pages,  with  12  illustrations.     Cloth,  $1.75.     Just  ready. 

The  author  has  chosen  a  subject  of  great  clinical  importance  to  physicians  as  well  as  to 
surgeons.  Injuries  of  the  nerves  are  common  in  civil  as  well  as  in  militaiy  life  and  lead  to 
various  painful  and  intractable  conditions.  Dr.  Mitchell  has  had  access  to  authentic  records 
covering  thirty  years,  and  his  researches  arrive  at  important  results  based  upon  an  ample 
number  of  cases  under  observation  for  a  prolonged  period. 


Hamilton  on  Nervous  Diseases.— Second  Edition. 

Nervous  Diseases ;  Tlieir  Description  and  Treatment.  By  Allen  McLane 
Hamilton,  M.  D.,  Attending  Physician  at  the  Hospital  for  Epileptics  and  Paralytics, 
Blackwell's  Island,  N.  Y.  Second  edition,  thoroughly  revised  and  rewritten.  In  one 
octavo  volume  of  598  pages,  with  72  illustrations.    Cloth,  |4.00. 


Klein's  Histology.— Fourtli  Edition. 

Elements  of  Histology.  By  E.  Klein,  M.  D.,  F.  K  S.,  Joint  Lecturer  on 
General  Anatomy  and  Physiology  in  the  Medical  School  of  St.  Bartholomew's  Hospital, 
London.  Fourth  edition.  In  one  12mo.  volume  oi  376  pages,  with  194  illus.  Limp 
cloth,  $1.75.    See  Student^  Series  of  Manuals,  page  30. 

PEPPER'S   SURGICAL   PATHOLOGY.     In  one  I     illustrations.    Limp  cloth,  red  edges,  S2.00    See 
pocket-size  12mo.  volume  of  511  pages,  with  81  |      Students'  Series  of  Manuals,  page  30. 

Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


I 


Pathology,  Histology,  Bacteriology.  19 

Green's  Pathology  and  Morbid  Anatomy.— New  (8th)  Edition 

Pathology  and  Morbid  Anatomy.  By  T.  Henry  Gkeen,  M.  D,  Lecturer 
on  Pathology  and  Morbid  Anatomy  at  Charicg-Cross  Hospital  Medical  School,  London 
Seyenth  American  from  the  eighth  and  revised  English  edition.  In  one  handsome  oc'avo 
volume  of  59o  pages,  with  224  engravings,  and  a  colored  plate  Cloth,  $2.75  Just  rmdv 
Green's  Pathology  and  3Iorhid  Anatomy  h&s  long  been  unquestionably  the  leadin"  text- 
book on  Its  subjects  m  English-speaking  schools  of  medicine,  a  fact  attested  by  the  demand 
for  seven  American  and  eight  English  editions.  The  present  issue  has  been  throuffhlv  revised 
to  represent  the  latest  knowledge,  new  chapters  bemg  added,  and  every  pao-e  bearino- evidence 
of  change.  The  notable  list  of  illustrations  has  been  enriched  by  the  addition  of  «xtv  new 
engravings  and  a  colored  plate.  ^ 

Gibbes'  Practical  Pathology  aadTMorbidrHistology. 

Practical  Pathology  and  Morbid  Histology.  By  Heneage  Gibbes, 
M.  D..  Professor  of  Pathology  in  the  University  of  Michigan,  Medical  Department.  In 
one  very  handsome  8vo.  vol.  of  314  pp.,  with  60  illus.,  mostly  photographic.      Cloth   %2  75 

In  fulness  of  directions  as  to  the  modes  of  the  tissues  for  examination,  cut,  stain  and  mount 
investigating  morbid  tissues  the  book  leaves  sections,  etc.  Tne  second  part  deals  with  bacteri- 
httle  to  be  desired.  The  work  is  throughout  ology,  with  the  different  forms  of  cultivation 
profusely  illustrated  with  reproductions  of  micro-  microscopic  examinations  of  the  bacteria  etc' 
photographs.  We  may  say  that  tne  practical  The  third  part,  which  comprises  more  than  half 
histologist  will  gain  much  useful  information  the  book,  treats  of  morbid  histology.  Tnis  partis 
from  the  boo);..— The  London  Lo.ncet.  illustrated  with  a  great  number  of  beautiful  photo- 

The  student  of  morbid  histology  and  bacteri-  |  micrographs  in  which  the  microscopic  field  is 
ology  has  at  his  hand,  in  tnis  neat  volumo  of  some  I  reproduced  with  a  distinctness  that  is  really 
three  hundred  pa2;es,  a  most  excellent  guide  and  |  remarkable.  Tne  fourth  part  contains  some  very 
one  which,  unless  he  be  a  very  advanced  student,  |  practical  instruction  on  photography  with  the 
he  cannot  afford  to  be  without.  The  work  is  microscope.  Workslikethisof  Dr.  Gibbes  will  soon 
divided  into  four  parts,  the  first,  that  of  practical  popularize  histology  among  the  profession  at  large 
patnology,  containing  clear  and  precise  directions  whereas  it  is  now  to  a  large  number  of  physicians 
in  histological  technique,  showing  how  to  prepare  I  almost  a  sealed  book. — Medical  Record. 

Senn's  Surgical  Bacteriology.— Second  Edition. 

Surgical  Bacteriology.  By  jS'ichoeas  Senn,  M.  D.,  Ph.  D.,  Professor  of 
Surgery  in  Rush  Medical  College,  Chicago.  New  (second)  edition.  In  one  handsome 
octavo   of  268  pp.,  with  13  plates,  of  which  10  are  colored,  and  9  engravings.  Cloth,  $2.00 


The  book  is  really  a  systematic  collection  in  the 
most  concise  form  of  such  results  as  are  published 
in  current  medical  literature  by  the  ablest  workers 
in  this  field  of  surgical  progress ;  and  to  these  are 
added  the  author's  own  views  and  the  results  of 
his  clinical  experience  and  original  investigations. 
The  book  is  valuable  to  the  student,  but  its  chief 
value  lies  in  the  fact  that  such  a  compilation 


makes  it  possible  for  the  busy  practitioner,  whose 
time  for  reading  is  limited  and  whose  sources  of 
information  are  often  few,  to  become  conversant 
with  the  most  modern  and  advanced  ideas  in  sur- 
gical pathology,  which  have  "laid  the  foundation 
for  the  wonderful  achievements  of  modern  sur- 
gery."— AnnaU  of  Surgery. 


Abbott's  Bacteriology.— New  (M)  Edition. 

The  Principles  of  Bacteriology :  a  Practical  Manual  for  Students  and 
Physicians.  By  A.  C.  Abbott,  M.  D.,  First  Assistant,  Laboratory  of  Hygiene,  University 
of  Pennsylvania,  Philadelphia.  New  (2d)  edition,  thoroughly  revised  and  greatly 
enlarged.  In  one  very  handsome  12mo.  volume  of  472  pages,  with  94  illustrations,  of 
which  17  are  colored.     Cloth,  $2.75. 

Its  scope  has  been  much  extended,  so  that  it  [  the  addition  ©f  much  new  matter.  Its  illustra- 
now  contains  all  that  is  necessary  for  a  beginner!  tions,  partly  colored,  are  helpful  in  the  elucidation 
to  learn  in  order  to  gain  a  practical  working  |  of  the  text.  Ample  instruction  is  given  as  to 
knowledge  of  the  subject.  It  is  particularly  j  needed  apparatus,  cultures,  stainitigs,  microscop- 
adapted  to  the  wants  of  students  and  practitioners  i  ic  examinations,  ete.    The  pathogenic  bacilli  are 


who  wish  to  pursue  their  study  without  the  aid  of 
an  instructof. — Medicine. 

The  instructions  for  methods  of  work  are  all 
lucid  and  concise.  It  is  the  most  satisfactory  and 
comprehensive  book  on  practical  bacteriology  in 
our  language. — Chicago  Clinical  Review,  Nov.,  1894. 

The  second  edition  has  been  much  enlarged  by 


fully  described  both  by  the  text  and  illustrations, 
and  the  methods  of  conducting  examinations  are 
fully  set  forth.  It  will  win  its  way  and  become  a 
favorite. —  Virginia    Medical  Monthly. 

On  the  whole  the  book  is  one  of  the  best  of  its 
kind  and  the  most  practical  in  the  English  lan- 
guage.— Maryland  Medical  Journal. 


Coats'  Treatise  on  Pathology. 

A  Treatise  on  Pathology.  By  Joseph  Coats,  M.  D.,  F.  F.  P.  S.,  Patholo- 
gist to  the  Glasgow  Western  Infirmary.  In  one  very  handsome  octavo  volume  of  829 
pages,  with  339  beautiful  illustrations.     Cloth,  $5.50 ;  leather,  $6.50. 

Medical  students  as  well  as  physicians,  who  |  manner,  the  changes  from  a  normal  condition 
desire  a  work  for  study  or  reference,  that  treats  I  effected  in  structures  by  disease,  and  points  out 
the  subjects  in  the  various  departments  in  a  very  the  characteristics  of  various  morbid  agencies, 
thorough  manner,  but  without  prolixity,  will  cer-  ;  so  that  they  can  be  easily  recognized.  But,  not 
tainly  give  this  one  the  preference  to  any  with  !  limited  to  morbid  anatomy,  it  explains  fully  how 
which  we  are  acquainted.  It  sets  forth  the  most  j  the  functions  of  organs  are  disturbed  by  abnormal 
recent    discoveries,  exhibits,    in   an    interesting  |  conditions. —  Cincinnati  Medical  News. 

Schafer's  Histology.— Fourth  Edition. 

The  Essentials  of  Histology.  By  Edwakd  A.  Schafer,  F.  R  S.,  Jodrell 
Professor  of  Physiology  in  University  College,  London.  New  (fourth)  edition.  In  one 
octavo  volume  of  311  pages,  with  325  illustrations.     Cloth,  $3.00. 


PAYNE'S  MANUAL  OF  GENERAL  PATHOL- 
OGY. Designed  as  an  Introduction  to  the  Prac- 
tice of  Medicine.    By  Joseph  F.  Patxe,  M.  D., 


F.  R.  C.  P.,  Lecturer  on  Pathological  Anatomy, 
St.  Thomas'  Hospital,  London. 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


20 


Surgery. 


We  hare  yet  to  see  the  same  amount  of  scholarly 
and  extensive  information  on  the  subject  of  surgery 
in  any  other  single  volume — seldom  in  a  number  of 
volumes.  As  a  masterly  epitome  of  what  has  been 
said  and  done  in  surgery,  as  a  succinct  and  logical 
statemeut  of  the  principles  of   this  subject,  as  a 


AshJiurst's  Surgery.— Sixth  Edition. 

The  Principles  and  Practice  of  Surgery.  By  John  Ashhuest,  Je. 
M.  D.,  Professor  of  Surgery  and  Clinical  Surgery  in  the  Univ.  of  Penna.,  Surgeon  to  the 
Penna.  Hospital,  Philadelphia.  Sixth  edition,  enlarged  and  thoroughly  revised. 
Octavo,  1161  pages,  656  engravingsand  a  colored  plate.     Cloth,  §6.00 ;  leather,'$7.00. 

sion.  In  this  edition  he  has  incorporated  an  ac- 
count of  the  more  important  recent  observations  in 
surgical  science,  as  well  as  such  novelties  in  sur- 
gical practice  as  meritthe  classification  of  improve- 
ments. Dr.  Charles  B.  Xancrede,  of  Ann  Arbor, 
has  contributed  a  new  chapter  OD  surgical  bacteri- 
model  text-book,  vre  do  not  know  its  equal.  It  is  :  ology;  Lir.  Barton  C.  Hirst  has  revised  the  sections 
the  best  single  text-book  of  surgery  that  we  have  i  on  gynecological  subjects;  and  Drs.  George  E. 
yet  seen  in  this  country.— Seiv  York  Post  Graduate.  \  de  Schweinitz  and  B.  Alexander  Randall  have  re- 
The  author  has  been  before  the  surgical  world  !  vised  tHe  chapters  on  diseases  of  the  eye  and  ear. 
so  long  and  is  so  versatile  and  resourceful  that  '  Those  surgeons  who  possess  earlier  editions  of 
his  several  editions  are  rapidly  taken  up.  i  Ashhurst's  treatise  will  make  haste  to  obtain  this 
Ashhurst  has  taken  great  pains  to  render  this  j  new  one.  and  those  who  are  not  familiar  with  the 
sixth  edition  fully  equal  to  the  demands  of  the  work  will  necessarily  add  it  to  their  libraries, 
present,  and  has  constructed  it  on  lines  chichi —Buffalo  Medical  and  Surgical  Journal. 
merit  a  continuance  of  the  confidence  of  the  profes-  ) 

Young's  Orthopedic  Surgery. 

A  Manual  of  Orthopedic  Surgery,  for  Students  and  Practi- 
tioners. By  James  K.  Youxg,  M.  D.,  Instructor  in  Orthopedic  Surgex-y,  University  of 
Pennsylvania,  Philadelphia.  In  one  octavo  volume  of  446  pages,  with  285  illustrations. 
Cloth,  84  ;  leather,  S5. 

The  present  work  will  be  found  to  meet  a  want '  approved  modern  views,  and  the  treatment  is 
among  students  in  acquiring  a  knowledge  of  the  very  thoroughly  and  comprehensively  considered, 
subject,  and  among  practitioners  who  constantly  i  Especial  attention  has  been  given  to  the  mechani- 
see  a  greater  or  less  number  of  deformities  and  cal  part  of  the  subject.  A  verv  valuable  feature 
who  desire  information  regarding  the  most  of  the  work  is  the  large  number  of  excellently- 
recent  views  on  the  pathology  and  treatment  of  executed  drawings  which  illustrate  the  text  In 
this  subject.  Dr.  Ycung's  large  experience  has  '  those  cases  in  which  doubt  is  apt  to  occur,  or  in 
particularly  fitted  him  for  the  preparation  of  this  which  the  symptoms  may  be  obscure,  the  dififer- 
work,  which  is  based  upon  his  personal  observa-    ential  diagnosis  has  been  very  fully  g'iven.    This 

tions,  although  the  literature  of  the  subject  has    '    '        '  "  '  ■     "    ' 

been  carefully  sifted,  and  whatever  of  import- 
ance he  has  thus  obtained  has  been  made  full 
use  of,  due  credit  being  given.  The  pathology 
will   be    found     to   correspond    with   the    most 


ground  has  been  well  covered,  and  the  work 
may  be  relied  upon  as  reflecting  the  present 
position  of  the  subject  of  which  it  treats.— CT^i- 
■versity  Medical  Magazine. 


Roberts'  Modern  Surgery. 

The  Principles  and  Practice  of  Modern  Surgery.  For  the  use  of  Stu- 
dents and  Practitioners  of  Medicine  and  Surgery.     By  John  B.  Roberts,  M.  D.,  Prof,  of 
Anatomy  and  Surgery  in  the  Philadelphia  Polyclinic.     Prof,  of  Surgery  in  the  Woman's 
Medical  College  of  Pennsylvania.     Lecturer  in  Anatomy  in  the  Univ.  of  Penna.     Octavo 
780  pages,  501  illustrations.     Cloth,  $4.50;  leather.  $5.50.  ' 

Erichsen's  Science  and  Art  of  Surgeryi^Eighth  Edition. 

The  Science  and  Art  of  Surgery ;  Being  a  Treatise  on  Surgical  Injuries, 
Diseases  and  Operations.  By  John  E.  Erichsex,  F.  E.  S.,  F.  E.  C.  S.,  Professor  of  Sur- 
gery in  University  College,  London,  etc.  From  the  eighth  and  enlarged  English  edition. 
In  two  large  Svo.  vols,  of  2316  pp.,  with  984  engraving-s  on  wood.     Cloth,  $9;  leather,  $11. 

Bryant's  Practice  of  Surgery.— Fourth  Edition. 

The  Practice  of  Surgery.  By  TnoiiAS  Bryant,  F.  E.  C.  S.,  Surgeon  and 
Lecturer  on  Surgery  at  Guy's  Hospital,  London.  Fourth  American  from  the  fourth  and 
revised  English  edition.  In  one  large  and  very  handsome  imperial  octavo  volume  of  1040 
pages,  with  727  illustrations.     Cloth,  $6.50;  leather,  $7.50. 

of  589  pages.  Cloth,  S2.00.  See  Students'  Series 
of  Manuals,  page  30. 

MILLER'S  PRACTICE  OF  SURGEE,Y.  Fourth 
and  revised  American  edition.  In  one  large  Svo. 
vol.  of  fi82  pp..  with  864  Illustrations.    Cloth, S3.75. 

MILLER'S  PRINCIPLES  OF  SURGERY.  Fourth 
American  from  the  third  Edinburgh  ed.  In  one 
Svo.  vol.  of  638  nages,  with  340  illus.     Cloth,  83.75. 

PIRRIE'S  PRINCIPLES  AND  PRACTICE  OF 
SURGERY.  Edited  by  John  Neill,  M.  D.  In 
onp  8vo.  vol.  of  784  pp.  with  316  illus.    Cloth,  $3.75. 

GANT'S  STUDENT'S  SURGERY.  By  Feedebick 
James  Gant,  F.  R.  C.  S.  Square  octavo,  848  pages, 
1.59  engravings.     Cloth.  ffi}.75. 

HOLMES'  SYSTEM  OF  SURGERY.  THEORET- 
ICAL AND  PRACTICAL.  By  Various  Authors. 
Edited  by  Timothy  Holmes,  M.  A.  .American  edi- 
tion, revised  and  re-edited  by  John  H.  Pack.a.ed, 
M.  D.  Three  large  octavo  volumes,  3137  pages, 
979  illustrations  on  wood  and  13  lithographic 
plates.  Per  set.  cloth,  SIS.OO;  leather,  §21.00. 
Subset  iptio7i  only. 


DRUITT'S  MANUAL  OF  MODERN  SURGERY,  j 
Twelfth  edition,  thoroughly  revised  by  Staxlet  ' 
BoTD,  M.  B  Svo.  965  pages,  with  373  illustrations.  ■ 
Cloth,  84.00:   leather,  §-=5  00.  i 

HOLMES' TREATISE  ON  SURGERY;  ITS  PRIN- 
CIPLES   AND    PRACTICE.      From    the    fifth! 
English  edition,  edited  by  T.  Piceieeixg  Pick,  I 
F.  R.  C.S.    In  one  octavo  volume  of  997  pages,  I 
with  428  illustrations.   Cloth,  S6.<  0;  leather,  S7.00. 

MARSH  ON  THE  JOINTS.  In  one  12mo.  volume  j 
of  468  pages,  with   64  woodcuts  and  a  colored! 
plate.  Cloth,  32.00.  See  Stries  of  Clin  cal  Manuals, 
page  30.  i 

BUTLIN  ON  DISE.ASES  OF  THE  TONGUE.  By  ' 
Hexey  T.  BuTLix,  F.  R.  C.S.,  Assistant  Surgeon  ! 
to  St.  Bartholomew's  Hospital,  London.  In  one  i 
12mo.  volume  of  456  pages,  with  8  colored  plates  I 
and  3  woodcuts.  Cloth,  S3.50.  See  -Series  of  Clin-  \ 
icnl  Manvnls  page  30.  I 

GOULD'S    ELEMENTS    OF    SURGICAL   DIAG-  ' 
NOSIS.    By   A.    Peakce   Gould,    M    S.,    M.  B.,  ' 
F.R.C.  S.,  Assistant  Surgeon  to  Middlesex  Hos- 
pital, London.    In  one  pocket-size  12mo.  volume 


Lea  Brothers  &  Co.,  Publishers.  706,  708  &  710  Sansom  Street,  Philadelphia. 


Surgery — (Continued).  21 

Wharton's  Minor  Surgery  and  Bandaging.— Second  Edition. 

Minor  Surgery  and  Bandaging.  By  Henry  E.  Whabton,  M.  D., 
Demonstrator  of  Surgery  in  the  University  of  Pennsylvania.  In  one  12mo.  volume  of 
529  pages,  witli  416  engravings,  many  being  photographic.     Cloth,  $3.00. 

The  book  is  one  of  the  very  best  treatises  on  [  localities  of  the  body.  The  author  has  thoroughly 
minor  =<ureery  and  it  ought  to  be  adopted  as  a  ;  revised  that  portion  of  the  work  relating  to  the 
text- book  on  the  subjects  of  which  it  treats.  It  I  aseptic  and  antiseptic  methods  of  wound  treat- 
contain*  more  practical  surgery  within  its  limits  •  ment,  than  which  there  is  no  more  important 
and  boundaries  than  any  book  of  its  kind  we  have  \  subject  in  the  whole  domain  of  surgery.  Much 
ever  seen  Its  illustrations  are  to  be  specially  i  new  matter  has  been  added,  which  brings  it 
commended  particularly  those  that  relate  to  '  abi east  of  the  very  latest  knowledge  on  the  sub- 
bandaging  most  of  which  have  been  taken  from  |  jects  of  which  it  tresits.— Buffalo  Medico  land  Sur- 
photographs  of  applied  bandages  in  the  several  |  gical  Jowrnal. 

Treves'  System  o!  Surgery.— Vol.  I.  Jnst  Ready. 

A  System  of  Surgery.  In  Contributions  by  twenty- five  English  Authors. 
Edited  by  Frederick  Treves,  F.E  C.S  ,  Surgeon  to  and  Lecturer  on  Surgery  at  the  Lon- 
don Hospital,  Examiner  in  Surgery  at  the  University  of  Cambridge.  In  two  large  octavo 
volumes.  Vol.  I.,  1378  pages,  with  463  engravings,  and  2  colon d  plates.  Clo.h,  $8.00, 
Just  Beady.     Vol.  II.,  Preparing. 

Treves'  Operative  Surgery.— Two  Volumes. 

A  Manual  of  Operative  Surgery.    By  Frederick  Treves,  F.E  C.S., 
Surgeon  atd  Lecturer  on  Anatomy  at  the  London  Hosp.tal.     I^^^,  «f ^XrluTo' 
containing  1550  pages,  with  422  engravings.    Complete  work,  cloth,  $9.00 ;  leather,  ^1.00. 
-•■•■'    excellentjudgment  displayed  in  the  arduous  task 
of  selecting  from  among  the  thousands  of  vary- 
ineprocedures  those  most  worthy  of  description ; 
for  the  way  in  which  the  still  more  diificult  task 


We  have  no  hesitation  in  declaring  it  the  best 
work  on  the  subject  in  the  English  language,  and 
indeed,  in  many  respects,  the  best  m  any  lan- 
guage. It  cannot  fail  to  be  of  the  greatest  use 
both  to  practical  surgeons  and  to  those  general 
practitioners  who,  owing  to  their  isolation  or  to 
other  circumstances,  are  forced  to  do  much  ot 
their  own  operative  work.  We  feel  called  upon 
to   recommend  the    book    so    strongly   for   the 


lor  iii«   wj'   i"   .n.iv^ii  "».--  ■ •- — - 

of  choosing  among  the  best  of  those  has  been 
accomplished;  and  for  the  simple,  clear, 
straigbtforward  manner  in  which  the  information 
thus  gathered  from  all  surgical  literature  has 
been  conveyed  to  the  reader.— 4nnais  of  Surgery. 


Treves'  Student's'Handbook'of  Surgical  Operations.  In  one 
square  12mo.  volume  of  508  pa^es^th  94  illustrations.     Cloth,  |2.o0. 

A  Manual  of  Surgery.  I^T^^^ti^by  Various  Authors  edited  by  Feei> 
ERICK  TMS  F  E  C  S.  In  three  12mo.  volumes,  containing  1866  pages,  with  213 
Sgrfvings      Price  per  set,  doth^f6^00^JeeSi^^der^^     of  Manuals,  page  30. 

Treves  on  Intesto^TobSr^I^ti^^ri^e  12mo.  volume 
with  60  ilS     Limp  cloth,  ■blue^dges^$2^00^^ee^er^^    Ckmcal  Manuals,  page  30. 

Smith's  Operative  Surgery.— Revised  Edition. 

ThP  PrineiT3les  and  Practice  of  Operative  Surgery.    By  Stephen 

pages,  with  1005  illustration     Cloth  ?«0i  it'o^Id  1.  „  a  bo„..„.f„»ee  t»  th. 

surgery  yet  published.  The  book  is  a  compendium    of  ^^urgery    t  ^^^^^^  ^.^^ .  .^  ^.g^^grs,  no 

for  the  modern  surgeon     The  Present  edition  is  }  "^^^^If^"^^- l^^^is^l  the  subject,  consult  its  pages 
much  enlarged,  and  the  text  has  been  thoroughly    matter  now  excellent  prjnt,  num- 

Ball  on  the  Rectum  anffis.-New  E£tion^  ^^ 

^5%Sf  ??  C^S  utgSty  E^xaminSiS  sJrgery,  Dublin.  Second  edi- 
^rS  ^^^^^e-[7^^is,  with  60  engravings  and  4  colored  plates. 
Crth,  $2.25.    Just  ready.     ^^^SeHesofClMca^^ 

Cheyne  on  Wounds,  Ulcers"andlhscesses.-Just  Ready. 

The  Treatment  of  Wounds,  Ulcers  and  Abscesses  ByW.WATSOx 
Cheyke,  M.  B.,  F  E  S,  F.  R.  C.  S  ,  Professor^of  Surgery  in  King's  College,  London.  In 
one  12mo.  volume  of  207  pages.     Cloth,  $1.25. 

PICK  ON  FRACTURES  AND  5I^i:55I^nO^^^:^I^^^^  See  Series  of  Clinical  31anuals, 

In  one  12mo.  vol.  of  530  pp.,  with  93  illustrations.  |  page  30. 

Lea  Brothers  &  Co.,  Publish^,^^Jo6^^oi&7WSansom  Street,  Philadelphia. 


22 


Surgery— (Continued),  Fractures,  Dislocations. 


Vols  I.  and  11.  Just  Ready.    Vol.  III.  Shortly.    Vol.  IV.  Preparing 

A   SYSTEM    OF   SURGERY. 

BY    AMERICAN    AUTHORS. 

Edited  by  Feederic  S  Dennis,  M.D.,  Professor  of  the  Principles  and  Practice 
of  Surgery,  Belleyae  Hospital  Medical  College,  New  York;  President  of  the  American 
Surgical  Association,  etc.  Assisted  by  John  S.  Billings,  M.D,  LL.D,  D  CL  Deputy 
Surgeon-General  US.  A  In  four  imperial  octavo  volumes  of  about  900  pages  each^ 
prolusely  J  ustra  ed  in  black  and  colors.  Price  per  volume,  cloth,  ^6  ;  leathS?  half 
Morocco,  gilt  back  and  top,  $8.50.  For  srde  by  subscription  only.  Address  thTjPublish^l 
LIST    OF    CONTRIBUTORS. 


RoBEUT  Abbe,  M.D,, 
GoRHAM  Bacon,  M.I). 
Herman  M.  Biggs,  M.D., 
John  S.  Billings,  M.D., 
William  T.  Bull,  M.D., 
William  H.  Caemalt,  M.D., 
Henry  C.  Coe,  M.D., 
P.  S.  Conner,  BI.D., 
William  T.  Councilman,  M.D 
D.  Beyson  Delavan,  M.D., 
Frederic  S   Dennis,  M  D., 
Edward  K.  Dunham,  M  D  , 
William  H.  Forwood,  M.D., 
George  R.  Fowler,  M.D., 
Frederick  H.  Gerrish,  M.D., 
Arpad  G.  Geesteh,  M.L'., 

There  really  is  now  no  complete  work  in  English 
which  can  be  considered  as  the  rival  of  this.  That 
the  editor  has  selected  his  collaborators  judiciously 
will  be  conceded  when  the  names  are  read  over. 
Each  one  of  them  is  a  teacher  of  surgery  or  a 
director  of  some  large  clinic,  and  each  is,  there- 
fore, prepared  to  speak  from  an  extended  expe- 
rience as  well  as  from  extensive  study.    The  three 


Virgil  P.  Gibney,  M.D., 
William  A.  Hardaway.  M.D., 
Frank  T.  Hartley,  M.D., 
Joseph  Taber  Johnson,  M.D,, 
William  W.  Keen,  M.D., 
William  T.  Lusk,  M.D., 
Charles  McBurney,  M.D., 
Rudolph  Matas,  M.D., 
Henry  H.  Mudd,  M  D., 
Charles  B.  Nancrede,  M.D., 
Henry  D.  Noyes,  M.  D., 
RoswELL  Park,  M.D  , 
WiLLARD  Parker,  M.D., 
Lewis  3.  Pilcher,  M.I)., 
William  H.  Polk,  M.D., 


Charles  H.  Porter,  M.D., 
Maurice  H.  Richardson,  M.D 
John  B.  Roberts,  M.D., 
George  E.  de  Schweinitz,  M  D 
Nicholas  Senn,  M.D., 
Stephen  Smith,  M.D., 
Lewis  A.  Stimson,  M.D., 
Robert  W.  Taylor,  M.D., 
Louis  McL.  Tiffany,  M.D., 
J.  Collins  Warren,  M.D., 
Henry  R,  Wharton,  M.D., 
Robert  F.  Weir,  M.D., 
William  H.  Welch,  M.D., 
J.  William  White,  M.D., 
Horatio  C.  Wood,  M.D., 


volumes  which  are  to  succeed  this  are  to  be  as 
replete  with  information  and  as  abreast  of  the 
times  as  this  one  already  furnished.  The  editors, 
the  publishers  and  the  profession  at  large  may  be 
warmlv  congratulated,  and  we  may  feel  that  a 
long.felt  want  for  some  such  general  treatise  has 
at  last  been  mpphed.— American  Journal  of  the 
Medical  Sciences,  June,  1895. 


Stimson's  Operative  Surgery.— New  (3d)  Edition,  Just  Ready. 

^    .        A  Manual  of  Operative  Surgery.     By  Lewis  A.  Stimson,  B  A    M  D 
Proiessor  of  Clinical   Surgery  m  the  University   of  the  City   of  New  York      N^w  rSrD 
edition.     In  one  royal  12mo.  volume  of  614  pages,  with  306  illustrations.     Ckth  $3  75  ^ 

The  demand  for  a  third  edition  of  Professor  Stimson's  excellpnt  nrn-r.^n?  ^f'n 
^«r,er,/ attests  the  service  it  has.rendered  to  thousands TphySusST^mlo^s'S 
author  has  utilized  this  opportumty  to  place  the  work  fully\abreast  of  the  Sadvanced 
surgery.  The  profuse  series  of  illustrations  has  been  largely  re-enc^raved  ami  ^rVll.v^I  ^ 
been  made  to  it  wherever  clearnessand  fulness  of  instructiol  couM^b  \SomoteffiX  As 
surgeiy  is  chiefly  oj^erative,  an  authoritative  volume  on  its  procedures  i^s  an  Sdispensabi;  part 
of  the  equipment  of  every  surgeon  and  likewise  of  every  physician  in  general  practice      ^ 

Hamilton  on  Fractiir^s^and^isScations^^Eiglitli  Edition. 

T^  ^  A  Practical  Treatise  ou  Fractures  and  DislocatioTi^  B^  v^k-kt-v 
H.  Hamilton,  M.  D.,  LL.D  Surgeon  to  Bellevue  HospLS  York  New fstM^S 
P^'  ^vised  and  edited  by  Stephen  Smith,  M.  D.,  Prof,  of  Clinical  Surgerrin  Univ  of 
City  of  N.  Y.    In  one  octavo  volume  of  832  pp.,  with  507  illus.    Cloth,  $5  50    leather  $650 


Its  numerous  editions  are  convincing  proof  if  any 
is  needed,  of  its  value  and  popularity.  It  is  pre- 
eminently the  authority  on  fractures  and  disloca- 
tions, and  universally  quoted  as  such.  In  the  new 
edition  it  has  lost  none  of  its  former  worth.  The 
additions  it  has  received  by  its  recent  re  vision  make 
it  a  work  thoroughly  in  accordance  with  modern 
practice,  theoretically,  mechanica'ly,  aseptically 
The  task  of  writing  a  complete  treatise  on  a  sub- 


ject of  such  magnitude  is  no  easy  one.  Dr.  Smith 
has  aimed  to  make  the  present  volume  a  correct 
of^snrilVv^  our  knowledge  of  this  department 
of  surgery.  The  more  one  reads  the  more 
one  IS  impressed  with  its  completeness.  The  work 
has  been  accomplished,  and  has  been  done  clearlv 
%Tn]^^l^9  excellently  well.-^o.to..  3Iedicaland 
burgical  Journal. 


Stimson  on  Fractures  and  Dislocations, 

A  Treatise  on  Fractures  and  Dislocations.    By  Lewis  A.  Stimson 
M.  D.     In  two  handsome  octavo  volumes.     Vol.  I.,  FRACTUitES,  582  pages,  360  illustrS 

S' J.^'n    1  •%.   '''^«°7''.TT-Vu  *^   P,^^'^'    ^^*^    163   illustradons.^   CoClete   w^^^^^^^ 
cloth,  15.50 ;  leather,  $7.50.    Either  volume  separately,  cloth,  $3.00  •  leather  $4  00 


The  appearance  of  the  second  volume  marks  the 
completion  of  the  author's  original  plan  of  prepar- 
ing a  work  which  should  present  in  the  fullest 
manner  all  that  is  known  on  the  cognate  subjects 
of  Fractures  and  Dislocations.  The  volume  on 
Fractures  assumed  at  once  the  position  of  authority 
on  the  subject,  and  its  companion  on  Dislocations 
will  no  doubt  be  similarly  received.    This  volume 


exhibits  the  surgery  of  Dislocations  as  it  is  taught 
and  prac Used  by  the  most  eminent  surgeons  of  fhe 
present  time.  Containing  the  results  If  such  ex! 
tended  researches  it  must  for  a  long  time  be  re- 
garded as  an  authority  on  all  subjects  pertaining 
to  dislocations.  Every  practitioner  of  surgery  wil! 
feel  It  incumbent  on  him  to  have  it  for  ^onstarit 
referencc-Cmcmnalli  Medical  News  *'''°^^«^t 


Lea  Brothers  &  Co..  Publishers,  706.  708  &  710  Sanson,  Street.  Philadelphia. 


ophthalmology. 


23 


Norris  &  Oliver's  Ophthalmology. 

A  Text-Book  of  Ophthalmology.  By  Wim.iam  F.  Nobris,  M.  D., 
Professor  of  Ophthalmology  in  the  Liniversity  of  Pennsylvania,  and  Charges  A.  ULrvER, 
M.  D,  Surgeon  to  Wills'  Eye  Hospital,  Philadelphia.  In  one  very  handsome  octavo 
vol  of  632  pages,  with  357  engravings  and  5  colored  plates.     Cloth,  ^Jio  ;  leather,  ?)0. 

Tie"  whilst  the  high  grade  and  unbiased  opinions    mology  and  Otology. 
of  the  teachings  serve  to  give  it  a  rank  superior  I        

Berry  on  the  Eye.— Mew  (2d)  Edition. 

Diseases  of  the  Eye.  A  Practical  Treatise  for  Students  of  Ophthalmology. 
T^^  rn^r^^pS  A  tTfrry  \1  B  F  E.  C.  S.,  Ed.,  Ophthalmic  Surgeon,  Edinburgh  Eoyal 
?n^fi?maTy  New  (seSd)  Jtion.  in  on^  octavo  Volume  of  750  pages,  with  197  illustra- 
tions,  mostly  lithographic.     Cloth,  $8.00. 


This  is  by  far  the  best  work  upon  its  theme  m 
the  English  language  that  we  have  seen,  for  the 
diction  is  pure  and  clear  and  b?sides  the  beauti- 
ful illustrations  of  normal  and  diseased  conditions 
make  it  a  valuable  addition  to  the  .libra,iT  of  all 
practitioners,  general  as  well  as  special.  We  have 
never  seen  more  real  delineation  of  disease,  the 
coloring  is  perfect,  and  each  illustration  is  an 


"obiect-lesson."  We  cannot  but  reiterate  what  we 
said  at  the  beginning,  that  we  have  had  great  pleas- 
ure in  the  perusal  of  this  work,  and  great  profit,  and 
that  we  consider  it  the  best  on  the  subject  m  the 
English  language  to-day,  not  only  for  its  diction 
but  for  its  initructive  illustrations.— 7/^6  A-merican 
Journal  of  the  Medical  Sciences. 


Juler's  OBMMmic  Science  and  Fractice.-Mew  (2d)  Edition. 

dUlCi  ^   y^  Ophthalmic  Science  and  Practice     By  Henry  E 

T.^^^  -fT-RrSS^nifr  Assistant  Surgeon,  Eoyal  Westminster  Ophthalmic  Hospital; 

this  work  testifies  to^^^  succ^^L^^^.L^on^           '  concise,  and  couched  in  language  that  cannot  fail 
tS^^  ill^lt^ftfoljrol  a°ir?hTfm$o?rtXcti^ns  |  to  be  understood.- T.e  Medical  Age. 
olf  the  eye.    The  volume  is  particularly  rich  m  | 


sjiii£5  on  the  Eye.— Fit...  »»..-.--        ^  „  ^  ^  .  ophthalmic 

T^-     „^^c,  «*•  flTA  Wvp     By  Edward  Nettleship,  F.  E.  C.  b.,  Upntnaimic 

S5»rfl  S^O^t^^rr  tSl  JSSsSlK 
PMradllpSa'^In^ne  P2l^^^^^^^  of  loO  pages,  lith  164  iUustrations,  selections  from 

MWstStypes  and  formul^.  anda    o,-^^^^^^^^^^^^  ^,,eh  seems  to  be  as- 

and  supplies  their  needs  admirably,  but  it  is  ^^    f^^^^,^,^^  parts  of  clinical  ophthalmology.-^ «* 

Carter  &  Frost's  Ophthalmic  Surgery. 

ophthalmic  surgery.    By  ^.-^-l^^^^^l^l^ril^^^^^^^ 
Ophthalmic  Surgery  at  St  George's  Hospital,  Londo^,  ^.V^'altClon.     In  one  12mo: 
it  L-^--  -  ?Pj?S^^^^^^^  t'^st-types  and  dots  and  appen- 

11^7^lZr&:Ci22rSee  SeHes  of  Clvr^icalMa^al.,  page  30. 


TTTOMPSON  ON  THE  URINARY  ORGANS. 
Lectured  on  Diseases  of  the  Urinary  Organs 
Bv  Sm  Henrt  Thompson,  Professor  of  Ohmcal 
Surgery  in  University  College  H^A^Pi  .'*'•  l^o'J.^o^- 
lecf  nd'^^merican  from  the  third  English  editiop. 

??om  the  third  English  edition.    In  one  octavo 
^olumeof  359  pagers,  with  47  engravmgs  and  3 

bIIham''on'''SaL    DISEASES:   A  Clinical 

^^iWe  to  their  Diagnosis  and  TreatrneBt^   12mo. 

304  pages,  with  21  Illustrations.    Cloth,  82.00. 


OT-T7T  T.ci  ON  THE  EYE.    In  one  octavo  volume. 

rfuRENCB  AND  MOON'S  HANDY  BOOK  OF 
OPHTHALMIC  SURGERY,  for  the  use  of  Prac- 
titioners. Second  edition  In  o'l*  "«*•%«  '"l" 
vTrno  r>f  997  naffes    with  65  i  lus.     Cloth,  82.75. 

L^wsoN  ON  Injuries  to  the  eye,  orbit 

4ND  EYELIDS:  Their  Immediate  and  Remote 
Effects.  In  one  octav-o  volume  of  -104  pages,  with 
o9  illimtrations      Oloth,S3.50  „„„ 

MORR  S  ON   k  DISEASES   OF   THE 

KIDNEY     By  Henky  Moruis,  F.  R.  C.  S.,  Surgeon 
,      to  Middlese/Hospital,  London     12mo    554  pp^ 
with  40  woodcuts,  and  6  colored  plates.    Limp 
cloth,  $2.25.    See  Series  of  aimcal  Manuals,  p.  30. 


iges,  wii-u  ii  1""°"^" -- ^ III- 

Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


24      Otology,  Urinary  &  Renal  Dis.,  Dentistry. 


Politzer  on  Diseases  of  the  Ear.— TMrd  Edition. 

A   Text-Book  of  Diseases  of  the  Ear  and  Adjacent  Organs. 

By  Dr.  Ajdam  Politzer,  Imperial-Eoyal  Professor  of  Aural  Theraneiitics  in  the  Univer- 
sity of  Vienna,  Chief  of  the  Imjierial  Royal  University  Clinic  for  Diseases  of  the  Ear  in 
the  General  Hospital,  Vienna.  Translated  into  English  from  the  third  ai  d  revised 
German  edition,  by  Oscar  Dodd,  M.  D.,  Clinical  Instructor  in  Diseases  of  the  Eye  and 
Ear,  College  of  PJiysicians  and  Surgeons,  Chicasro.  Edited  by  Sir  William  Dalby, 
F.  E..  C.  S.,  M.  B.,  Consulting  Aural  Surgeon  to  St.  George's  Hospital,  London.  In  one 
large  octavo  volume  of  748  pages,  Avith  330  illustrations.     Cloth,  $5.50. 


This  edition  of  the  eminent  Vienna  professor's 
well-known  work  will  be  welcoKied  by  those  who 
wish  to  obtain  a  complete  account  of  all  that  is 
known  in  connection  with  aural  diseases.  Who- 
ever peruses  it  carefully  cannot  fail  to  be  struck 
with  the  details,  the  extensive  references,  and 
especially  the  valuable  pathological  data,  which 


underlie  the  clinical  remarks  and  details  of  meth- 
ods of  treatment.  The  indications  for  treatment 
are  clear  and  relisble.  We  can  confidently  rec- 
ommend it,  for  it  contains,  as  stated  by  the  editor 
in  his  preface,  all  that  is  known  upon  the  subject. 
— London  Lancet. 


Field's  Manual  of  Diseases  of  the  Ear.    Fourth  Edition. 

A  Manual  of  Diseases  of  the  Ear.  By  George  P.  Field,  M.  R  C.  S., 
Aural  Surgeon  and  Lecturer  on  Aural  Surgery  in  St  Mary's  Hospital  Medical  School, 
London.  In  onp  octavo  o^"  391  pp.,  with  73  engravings  and  21  colored  plates.  Cloth,  $3.75. 
To  those  who  desire  a  concise  work  on  diseases  }  large  class  of  cases  of  ear  disease  that  comes 
of  the  ear,  clear  and  practical,  this  manual  com-  properly  within  his  province.  The  illustrations 
mends  itself  in  the  highest  degree.  It  is  just  such  are  apt  and  well  executed  while  the  make-up  of 
a  work  as  is  needed  by  every  general  practi-  the  work  is  beyond  criticism. — The  American 
tioner  to  enable   him  to    treat  intelligently    the  '  Practitioner  and  News. 

Burnett  on  the  Ear.— Second  Edition. 

The  Ear,  Its  Anatomy,  Physiology  and  Diseases.  A  Practical 
Treatise  for  the  use  of  Medical  Students  and  Practitioners.  By  Charles  H.  Burnett, 
A.  M.,  M.  D.,  Professor  of  Otology  in  the  Philadelphia  Polyclinic ;  President  of  the 
American  Otological  Society.  Second  edition.  In  one  handsome  octavo  volume  of  580 
pages,  with  107  illustrations.   Cloth,  $4.00 ;  leather,  $5.00. 

Black  on  the  Urine.— Just  Ready. 

The  Urine  in  Health  and  Disease,  and  Urinary  Analysis,  Physi- 
ologically and  Pathologically  Considered.  By  D.  Campbell  Black,  M.  D., 
L.  E.  C.  S.,  Professor  of  Physiology,  Anderson  College  Medical  School.  In  one  12mo. 
volume  of  256  pages,  with  73  engravings.     Cloth,  $2.75. 

Roberts  on  Urinary  and  Renal  Diseases.— Fourth  Edition. 

A  Practical  Treatise  on  Urinary  and  Renal  Diseases,  including 
Urinary  Deposits.  By  Sir  William  Egberts,  M.  D.,  Lecturer  on  Medicine  in  the 
Manchester  School  of  Medicine,  etc.  Fourth  American  from  the  fourth  London  edi- 
tion.    In  one  handsome  octavo  volume  of  609  pages,  with  81  illustrations.     Cloth,  $3.50. 

Purdy  on  Bright's  Disease  and  Allied  Affections. 

Bright's  Disease  and  Allied  Affections  of  the  Kidneys.  By 
Charles  W.  Purdy,  M.  D.,  Professor  of  Genito-Urinary  and  Kenal  Diseases  in  the  Chi- 
cago Polyclinic.     In  one  octavo  vol.  of  288  pages,  with  illustrations.     Cloth,  $2.00. 

The  American  Text-Books  of  Dentistry.— Preparing. 

In  Contributions  by  Various  Authors.  In  two  octavo  volumes  of  about 
600  pages  each,  fully  illustrated.  Volume  I.,  Operative  Dentistry.  Edited  by 
Edward  C.  Kirk,  D.  D.  S.,  Lecturer  on  Operative  Dentistry,  Dept.  of  Dentistry,  Univ.  of 
Penna.  Volume  IL,  Mechanical  Dentistry.  Edited  by  Charles  J.  Essig,  M.  D., 
D.  D.  S  ,  Prof,  of  Mechanical  Dentistry  and  Metallurgy,  Dept.  of  Dentistry,  Univ.  of  Penna. 

The  American  System  of  Dentistry.    Volume  IV.  Preparing. 

In  Treatises  by  Various  Authors.  Edited  by  Wilbur  F,  Litch,  M.  D., 
D.  D.  S.,  Professor  of  Prosthetic  Dentistry,  Materia  Medica  and  Therapeutics  in  the 
Pennsylvania  College  of  Dental  Surgery.  In  four  very  handsome  octavo  volumes  con- 
taining over  4000  pages,  with  about  2400  illustrations  and  many  full-page  plates.  Per 
volume,  cloth,  $6  ;  leather,  $7  ;  half  Morocco,  gilt  top,  $8.     For  sale  by  subscription  only. 


As  an  encyelopsedia  of  Dentistry  it  has  no  su- 
perior. It  should  form  a  part  of  every  dentist's 
library,  as  tlie  information  it  contains  is  of  the 

Greatest  value  to  all  engaged  in  the  practice  of 
entistry. — American  Journal  of  Dental  Science. 
A  grand  system,  big  enough  and  good  enough 
and  handsome  enough  for  a  monument  (which 


doubtless  It  is),  to  mark  an  epoch  in  the  history  of 
dentistry.  Dentists  will  be  satisfied  with  it  and 
proud  of  it — they  must.  It  is  sure  to  be  precisely 
what  the  student  needs  to  put  him  and  keep  him 
in  the  right  track,  while  the  profession  at  large 
will  receive  incalculable  benefit  from  it. — Odonto- 
graphic  Journal. 


COLEMAN'S  MANUAL  OF  DENTAL  SUEGEEY 
AND  PATHOLOGY.  By  Alfbed  Coleman,  L:D.S. 
Thoroughly  revised  and  adapted  to  the  use  of 


American  Students,  by  Thomas  C.  Steuwagen, 
D.  D.  S.  Octavo,  412  pages,  with  331  illustrations. 
Cloth,  $3.25. 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


Impotence,  Sterility,  Venereal,  Skin.  25 


Taylor  on  Venerea!  Diseases.— Sixth  Edition.    Just  Ready. 

The  Pathology  and  Treatment  of  Venereal  Diseases.  By  Eobeet 
W.  Taylok,  A.m.,  M.D.,  Clinical  Professor  of  Genito-Urinary  Diseases  in  the  College 
of  Physicians  and  Surgeons,  New  York.  Sixth  edition.  In  one  very  handsome  octavo 
volume  of  10(2  pages,  with  230  engravings  and  7  colored  plates.  Cloth,  $5.50:  leather, 
16.50.  '  -^        >  > 

The  perennial  prevalence  of  the  Venereal  Diseases,  and  their  power  to  invade  all  tissues 
of  the  body  and  consequently  to  modify  all  other  human  maladies,  unite  to  render  a  working 
knowledge  of  this  subject  essential  to  every  physician,  surgeon  and  specialist.  The  writer  of 
this  book  has  long  enjoyed  a  position  of  preeminent  authority.  Since  the  exhaustion  of  the 
fifth  edition  of  Bumstead  &  Taylor  on  Venereal  Diseases,  Dr.  Taylor  has  been  assiduously 
engaged  in  sifting  the  results  of  the  immense  activity  directed  towards  this  subject  in  recent 
years,  and  m  the  present  volume  he  places  at  the  command  of  the  profession  a  body  of 
knowledge,  complete,  clear,  modern  and  authoritative,  a  work  new  both  in  text  and  illustra- 
tions.    It  is  assured  of  the  foremost  position  as  a  text-book  and  work  of  reference. 

Fuller  on  Male  Sexual  Disorders.— Just  Ready. 

Discrdersof  the  Sexual  Organs  in  the  Male.  By  Etjgene  Fuller, 
M.D.,  Instructor  in  Venereal  and  Genito-Urinary  Diseases,  New  York  Post-Graduate 
Medical  School.  In  one  verv  handsome  octavo  volume  of  238  pages,  with  25  engravings 
and  8  full-paged  plates.     Cloth,  $2.00. 

Extensive  experience  in  private  practice  and  in  one  of  the  leading  New  York  medical 
schools  has  convinced  the  author  tliat  male  sexual  disorders  arise  more  frequently  from 
pathological  states  of  the  organs  themselves  than  from  neurological  or  mental  causes.  He  has 
endeavored  in  this  work  to  place  the  literature  of  sexual  pathology  abreast  of  that  on  sexual 
neurology  and  to  furnish  the  profession  with  a  guide  to  diagnosis  and  treatment  in  which 
all  the  etiological  factors  are  considered  according  to  their  relative  importance.  The  rich 
rewards  obtained  by  charlatans  practising  in  this  branch  of  medicine  may  be  considered  in  a 
certain  sense  as  an  expression  of  public  opinion  upon  the  comparative  success  of  the  regular 
practitioner.  Rational  methods  must  rescue  this  most  important  class  of  disease  from  the 
empirics,  and  a  work  pointing  the  way  to  successful  treatment  founded  upon  sound  pathology 
and  diagnosis  will  benefit  the  f>rofession  almost  as  much  as  their  patients. 

Gross  on  Impotence,  Sterility,  etc.— Fourth  Edition. 

A  Practical  Treatise  on  Impotence,  Sterility,  and  Allied  Dis- 
orders of  the  Male  Sexual  Organs.  By  Samuel  W.  Gross,  A.M.,  M.  D., 
LL.  D.,  Prof,  of  Surgery  in  the  Jefferson  Med.  Coll.  of  Phila.  Fourth  edition,  thoroughly 
revised  by  F.  E.  Stuegis,  M.D,,  Prof,  of  Dis.  of  the  Genito-Urinary  Organs  and  of  Venereal 
Dis.,  N.  Y.  Post  Grad.  Med.  School.    In  one  8vo.  vol.  of  165  pp.,  with  18  illus.     CI.,  $1.50. 

Culver  &  Hayden's  Manual  of  Venereal  Diseases. 

A  Manual  of  Venereal  Diseases.  By  Evekett  M.  Culver,  M.  D.^ 
Pathologist  and  Assistant  Attending  Surgeon,  Manhattan  Hospital,  New  Y^ork,  and  James 
E.  Hayden,  M.  D.,  Chief  of  Clinic  Venereal  Department,  College  of  Physicians  and  Sur- 
geons, New  York.  In  one  12mo.  volume  of  289  pages,  with  33  illus.  Cloth,  |1.75. 
This  book  is  a  practical  treatise,  presenting  in  a    '  ■" *■ —  '-^ '  — «tu,-. 


condensed  form  the  essential  features  of  our  pres- 
ent knowledge  of  the  three  venereal  diseases, 
syphilis,  chancroid  and  gonorrhea.  We  have  ex- 
amined this  work  carefully  and  have  come  to  the 
conclusion  that  it  is  the  most  concise,  direct  and 
able  treatise  that  has  appeared  on  the  subject  of 


venereal  diseases  for  the  general  practitioner  to 
adopt  as  a  guide.  The  general  practitioner  needs 
a  few  simple,  concise  and  clearly  presented  laws, 
in  the  execution  of  which  he  cannot  fail  either  to 
cure  or  prevent  the  ravages  of  the  maladies  in 
question  and  their  direful  results. — Buffalo  iledical 
and  Surgical  Journal. 


Cornii  on  Syphilis. 

Syphilis,  its  Morbid  Anatomy,  Diagnosis  and  Treatment.  By  V. 
CoKNiL,  M.D.  Specially  revised  by  the  Author,  and  translated  with  notes  and  additions 
by  J.  Henry  C.  Simes,  M.  D.,  and  J.  William  White,  M.D.  Octavo  461  pages,  with 
84  illustrations.     Cloth,  $3.75. 

Hardaway's  Manual  o!  Skin  Diseases. 

Manual  of  Skin  Diseases.  With  Special  Keferenceto  Diagnosis  and  Treat- 
ment. For  the  u'e  of  Students  and  General  Practitioners.  By  W.  A.  Hardaway,  M.  D., 
Professor  of  Skin  Diseases  in  the  Missouri  Medical  College.   12mo.,  440  pp.   Cloth,  $3.00; 


GROSS'  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES, INJURthS  AND  MALFORMATIONS 
OF  THE  URINjiRY  BLADDER,  THE  PROS- 
TATE GLAND  AND  THE  URETHRA.  Bv 
Samuel  D.  Gross,  M.D.,  LL.D.,  D.C.L.,  etc.  Third 
edition,  thoroughly  revised  by  Samuel  W.  Geoss, 
M.D.  In  one  octavo  volume  of  574  pages,  with 
170  illustrations.    Cloth,  S4.50. 

HUTCHINSON    ON  SYPHILIS.      In  one  12mo. 


volume  of  542  pages,  with  9  ehromo-lithographs. 

Cloth,  $2.25.     See    Seiies    of   Clinical    Manuals, 

page  30. 
HILL  ON  SYPHILIS  AND  LOCAL  CONTAGIOUS 

1 )  I SORDERS.  In  one  8vo  vol.  of  479  p.  Cloth,  $3.25. 
LEE'S   LECTURES  ON  SYPHILIS  AND  SOME 

FORMS    OF    LOCAL    DISEASE    AFFECTING 

THE    ORGANS    OF    GENERATION.     In  one 

8vo.  volume  of  246  pages.    Cloth,  $2.25. 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


26 


Venerea!  and  Skin  Diseases. 


Hyde  on  the  Skin.— Third  Edition. 


A  Practical  Treatise  on  Diseases  of  the  Skin.  For  the  use  of  Stxidents 
and  Practitioners.  By  J.  Kevins  Hyde,  A.  M.,  M.  D.,  Professor  of  Dermatology  and  Ven- 
ereal Diseases  in  Rush  Medical  College,  Chicago.  Third  edition.  In  one  octavo  volume 
of  802  pages,  with  9  colored  plates  and  108  engravings.     Cloth,  $5.00 ;  leather,  $6.00. 

The  third  edition,  just  issued,  fulfils  all  the  ex-    for  information  as  to  how  to  manage  his  patients 

pectations  warranted  by  the  great  accumulation       

of  dermatological  material  since  the  earlier 
editions  were  Drought  out,  and  puts  this  work  at 
the  head  of  the  modern  American  treatises  on 
skin  diseases.  The  author  has  introduced  thirty- 
five  new  diseases  in  this  edition.  He  is  especially 
to  be  congratulated  on  his  chapter  on  tuberculosis. 
Five  plates  and  tweLty  two  woodcuts,  all  of  great 
excellence,  have  been  added  to  the  illustrations. 
The  excellence  of  the  chapters  on  treatment,  to- 
gether with  the  care  that  has  been  bestowed  on 
subjects  that  have  acquired  new  interest,  make 
the  book  one  to  be  warmly  recommended. — Bus- 
ton  Medif-al  and  Surgval  Jouriial. 

The  qualities  that  have  contributed  so  much  to 
its  previous  popularity  still  remain.  The  chief  of 
these  unquestionably  are  the  standpoint  of  prac- 
tical medicine  from  which  it  speaks  and  its  wealth 
of  therapeutical  information.  The  writer  knows 
no  book  in  which  one  can  seek  more  satisfactorily 


with  skin  diseases.  The  present  edition'may  be 
commended  as  being  an  exposition  of  the  subject 
fully  up  to  the  present  state  of  our  knowledge. 
—  The  Chicaao  Clhiical  Revew. 

Dr.  Hyde's  book  may  be  heartily  commended 
to  the  student  and  practitioner  alike  as  one  of  the 
best  exponents  of  the  subject  now  before  the  pro- 
fession.—  The  American  Joutnnl  of  the  Medical 
Sciencef:. 

Dr.  Hyde  is  an  experienced  scholar  as  well  as  a 
competent  author,  and  his  former  editions  were 
received  with  approval  by  dermatologists  as  well 
as  by  those  general  practitioners  who  are  inter- 
ested in  the  study  and  treatment  of  diseases  of 
the  skin.  The  treatise  is  one  that  affords  much 
satisfaction  in  that  it  is  a  sale  guide  for  both  stu- 
dents and  praciitioners,  either  general  or  special, 
and  particularly  does  it  adapt  itself  to  the  use  of 
dermatologists. — Buffalo  Medical  and  Surgical  Jour- 

vnl. 


Taylor's  Clinical  Atlas  of  Venereal  and  Skin  Diseases. 

A  Clinical  Atlas  of  Venereal  and  Skin  Diseases:  Including  Diag- 
nosis, Prognosis  and  Treatment.  By  Egbert  W.  Taylor,  A.  M.,  M.  D.,  Clinical  Pro- 
fessor of  Genito-Urinary  Diseases  in  the  College  of  Physicians  and  Surgeons,  New  York; 
In  eight  large  folio  parts,  and  comprising  58  beautifully  colored  plates  with  213  figures, 
and  431  pages  of  text  with  85  engravings.  Price  per  part,  $2.50.  Bound  in  one  volume, 
half  Pussia,  $27  ;  half  Turkey  Morocco,  $28.  For  sale  by  subseription  only.  Specimen 
plates  sent  on  receipt  of  10  cents.     A  full  prospectus  sent  to  any  address  on  application. 

Jackson's  Ready-Reference  Handbook  of  Skin  Diseases. 

The    Ready-Reference    Handbook  of  Diseases  of  the  Skin.    By 

George  Thomas  Jackson,  M.  D.,  Professor  of  Dermatology,  Woman's  Medical  CoUege 
of  the  New  York  Infirmary,  in  one  12mo.  volume  of  544  pages,  with  60  illustrations 
and  a  colored  plate.     Cloth,  $2.75. 

Morris  on  tlie  Skin. 

Diseases  of  the  Skin.  An  Outline  of  the  Principles  and  Practice  of  Der- 
matologv.  By  Malcolm  Morris,  F.  E.  C.  S  ,  Surgeon  to  the  Skin  Department,  St.  Mary's 
Hospital,  London.  In  one  square  octavo  volume  of  565  pages,  with  19  chromo-lithographic 
figures  and  17  engravings.     Cloth,  $3.50. 

The  present  work  is  entirely  new  and  is  |  pla''e  within  the  intelligent  command  of  the 
designed  to  be  es.-entially  clinical  and  practical  ■  reader  the  very  full  recommendations  as  to 
in  scope.  Diagnosis,  symptoms,  causation  and  I  ireatment.  Every  part  of  the  book  represents  the 
prognosis  receive  sufficient  space  to  convey  a  mo.st  modern  knowledge  and  methods — Pacific 
clear  idea  of  the  nature  of  each  disease,  and  to    Medical  JournaK 


Pye-Smith  on  Diseases  of  tlie  Skin. 

A  Handbook  of  Diseases  of  the  Skin.  By  P.  H.  Pye-Smith,  M.  D., 
F.E.  S  ,  Physician  to  Guy's  Hospital,  London.  In  one  octavo  volume  of  407  pages, 
with  26  illustrations,  23  of  which  are  colored.     Cloth,  $2.00. 

The  book  is  an  excellent  one,  and  we  commend  ;  known  as  one  of  the  eminent  physicians  to  Guy's 
it  to  all  interested  in  the  subject.  It  is  written  by  |  Hospital,  and  we  have  no  hesitation  in  saying 
one  entirely  familiar  with  skin  diseases,  botli  \  thao  tie  has  written  an  original  and  valuable 
from  the  standpoint  of  the  specialist  and  the  \  handbook  on  skin  diseases,  sound  and  practical 
general  practitioner.    Dr.  Pye-Smith  is  favorably  !  in  all  its  bearings. — Internalional  Med.  Magazine. 


Jamieson  on  Diseases  of  tlie  Skin. 

Diseases  of  the  Skin.  A  Manual  for  Students  and  Practitioners.  By 
W.  Allan  Jamieson,  M.  D.,  Lecturer  on  Diseases  of  the  Skin,  School  of  Medicine,  Edin- 
burgh. Third  edition,  revised  and  enlarged.  In  one  octavo  volume  of  656  pages,  with 
woodcut  and  9  double-page  chromo  lithographic  illustrations.    Cloth,  $6.00. 


The  scope  of  the  work  is  essentially  clinical,  lit- 
tle reference  being  made  to  pathology  or  disputed 
theories.  Almost  every  subject  is  followed  by 
illustrative  cases.  The  pages  are  filled  with  inter- 
est to  all  thosp  occupied  with  skin  diseases.    The 


general  practitioner  will  find  the  book  of  great 
value  in  matters  of  diagnosis  and  treatment.  The 
latter  is  quite  up  to  date,  and  the  formulse  have 
been  selected  with  care. — Medical  Record. 


HILLIER'S  HANDBOOK  OF  SKIN  DISEASES; 
for  Students  and  Practitioners.  Second  Ameri- 
can edition.  In  one  I2mo.  volume  of  353  pages, 
with  plates.    Cloth,  S^.25. 


WILSON'S  S  rUDENT'S  BOOK  OF  CUTANEOUS 
MEDICINE  AND  DISEASES  OF  THE  SKIN. 
In  one  handsome  small  octavo  volume  of  535 
Cloth,  53.50. 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


Diseases  of  Women. 


27 


The  American  Systems  of  Gynecology  and  Obstetrics. 

Systems  of  Gynecology  and  Obstetrics,  in  Treatises  by  American 
Authors.  Gynecology  edited  by  IVIatthetv  D.  Makn,  A.  M.,  M.  D.,  Professor  of  Obstetrics 
and  Gynecology  in  the  Medical  Department  of  the  Universitv  of  BuflFalo;  and  Obstet- 
rics edited  by  Barton  Cooke  Hiest,  M.  D.,  Associate  Professor  of  Obstetrics  in  the 
University  of  Pennsylvania,  Philadelphia.  In  four  very  handsome  octavo  volumes,  con- 
taining 3612  pages,  1092  engravings  and  8  plates.  Complete  work  now  ready.  Per  vol- 
ume: Cloth,  85.00;  leather,  $6.00;  half  Eussia,  $7.00.  For  sale  by  subscriptim  only. 
Address  the  PvMishers.  Full  descriptive  circular  free  on  application. 
In  our  notice  of  the  "System  of  Practical  Medi-    It,  like  the  other,  has  been  written  exclusively 


cine  by  American  Authors,"  we  made  the  follow- 
ing statement:— "It  is  a  work  of  which  the  oro- 
fession  in  this  country  can  feel  proud.  Written 
exclusively  by  American  physicians  who  are  ac- 
quainted with  all  the  varieties  of  climate  in  the 
United  States,  the  character  of  the  soil,  the  man- 
ners and  customs  of  tlie  people,  etc.,  it  is  pecul- 
iarly adapted  to  the  wants  of  American  practition- 
ers of  medicine,  and  it  seems  to  us  that  every  one 
of  them  would  desire  to  have  it."  Every  word 
thus  expressed  in  regard  to  the  "American  Sys- 
tem of  Practical  Medicine"  is  applicable  to  the 
"System  of    Gynecology  by  American  Authors." 


by  American  physicians  who  are  acquainted  with 
al  I  the  characteristics  of  American  ^jeople,  who  are 
well  informed  in  regard  to  the  peculiarities  of 
American  women,  their  manners,  customs,  modes 
of  living,  etc.  As  every  practising  physician  is 
called  upon  to  treat  diseases  of  female's,  and  as 
they  constitute  a  class  to  which  the  family  phy- 
sician must  give  attention,  and  cannot  pass  over 
to  a  specialist,  we  do  not  know  of  a  work  in  any 
department  of  medicine  that  we  should  so  strongly 
recommend  medical  m.en  generally  purchasing. — 
Oinclnnuti  Med.  News. 


Emmet's  Gynsecology.— TMrd  Edition. 

The  Principles  and  Practice  of  Gyneecology ;  For  the  use  of  Students 
and  Practitioners  of  Medicine.  By  Thoiias  Addis  Emmet,  M.  D.,  LL.  D.,  Surgeon  to 
the  Woman's  Hospital,  New  York,  etc.  Third  edition,  thoroughly  revised.  In  one 
large  and  very  handsome  8vo.  vol.  of  880  pp.,  with  150  illus.  Cloth,  $5 ;  leather,  $6. 
We  are  in  doubt  whether  to  congratulate  the  ,  the  privilege  thus  offered  them  of  perusing  the 
author  more  than  the  profession  upon  the  appear-  ;  views  and  practice  of  the  author.  His  earnestness 
ance  of  the  third  edition  of  this  well-known  work.  :  of  purpose  and  conscientiousness  are  manifest. 
Embodying,  as  it  does,  the  life-long  experience  of  j  He  gives  not  only  his  individual  experience  but 
one  who  has  conspicuously  distinguished  himself  i  endeavors  to  represent  the  actual  state  of  gj'nse- 
as  a  bold  and  successful  operator,  and  who  has  cological  science  and  art. — British  Medical  Jour- 
devoted  so  much  attention  to  the  specialty,  we  I  nah 
feel  sure  the  profession  will  not  fail  to  appreciate  ; 


Tail's  Diseases  o!  Women  and  Abdominal  Surgery. 

Diseases  of  "Women  and  Abdominal  Surgery.  By  Lawson  Tait, 
F.K.  C.  S.,  Professor  of  Gynecology  in  Queen's  College,  Birmingham,  late  President  of 
the  British  Gynecological  Society,  Fellow  American  Gynsecological  Society.  In  two 
octavo  vols.  Vol.  I.,  5o4  pp.,  62  engravings  and  3  plates.  Cloth,  §3.  Vol.  II.,  -preparing, 
Mr.  Tait  never  writes  anything  that  does  not  on  the  technique  of  surgical  operations,  ingenious 
command  attention  by  reaso"n  of  the  originality  of    theories  on  pathology,  daring  innovations  en  long^ 


his  iaeas  and  ttie  clear  and  forcible  manner  in 
which  they  are  expressed.  This  is  eminently 
true  of  the  present  work.  Germs  of  truth  are 
thickly  scattered  throughout;  single  happily 
worded  sentences  express  what  another  author 
would  have  expanded  into  pages.    U>eful  hints 


tablished  lines — tiiese  succeed  one  another 
with  a  bewildering  rapidity.  His  position  has 
long  been  assured.  We  cannot  repress  our  admi- 
ration for  the  restless  genius  of  the  great  sur- 
geoa. — American  .Journal  of  the  Medical  Sciences. 


Edis  on  Diseases  o!  Women. 

The  Diseases  of  Women.  Including  their  Pathology,  Causation,  Symptoms, 
Diagno.=.is  and  Treatment.  A  Manual  for  Students  and  Practitioners.  By  ARTHm  W. 
Edis,  M.  D.,  Lond.,  F.  K.  C.  P.,  M.  E.  C.  S.,  Ai^sistant  Obstetric  Physician  to  Middlesex 
Hospital,  late  Physician  to  British  Lying-in-Hospital.  In  one  handsome  octavo  volume 
of  576  pages,  with  148  illustrations.     Cloth,  $3.00 ;  leather,  |)4.00. 

The  special  qualities  which  are  conspicuous  j  among  the  more  common  methods  of  treat- 
are  thoroughness  in  covering  the  whole  ground,  ment,  and  yet  very  little  is  said  about  them  m 
clearness  of  description  and  conciseness  of  state-  I  many  of  the  text-books.  The  book  is  one  to  be 
ment.  Another  marked  feature  of  the  book  is  j  warmly  recommended  especially  to  students  and 
the  attention  paid  to  the  details  of  many  minor  !  general  practitioners,  who  need  a  concise  but  corn- 
surgical  operations  and  procedures,  as,  for  j  plete  re.si^mg  of  the  whole  subject.  Specialists,  too, 
instance,  the  use  of  tents,  application  of  leeche.s,  will  find  many  useful  hints  in  its  p&ges.— Boston 
and    use    of    hot   water    injections.      These    are  |  Meoical  arid  Surgical  Journal. 

Duncan  on  Diseases  o!  Women. 

Clinical  Lectures  on  the  Diseases  of  Women ;  Delivered  in  Saint 
Bartholomew's  Hospital.     By  .J.   Matthews  Dids-can,  M.  D.,    LL.  D.,    F.  E.  S.  E.,   etc 

In  one  octavo  volume  of  175  pages.     Cloth,  §1.50. 


HODGE  ON  DISEASES  PECULIAR  TO  WOMEN. 
Including  Displacements  of  the  Uterus.  Second 
edition,  revised  and  enlarged.  In  one  beatiti- 
fully  printed  octavo  volume  of  519  pages,  with 
original  illustrations.    Cloth,  $i.lO. 


WEST'S  LECTURES  ON  THE  DISEASES  OF 
WOMEN  Third  American  from  the  third  Lon- 
don edition.  In  one  octavo  volume  of  543  pages. 
Cloth,  S3.75;  leather,  Si.75. 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


28 


Diseases  of  Women — (Continued). 


Thomas  &  Mimde  on  Diseases  of  Women.— Sixth  Edition. 

A  Practical  Treatise  on  the  Diseases  of  Women,  By  T.  Gatllard 
Thomas,  M.  D..  LL.  D,  Emeritus  Professor  of  Diseases  of  "Women  in  tlie  College  of 
Physicians  and  Surg^eons,  ISTew  York,  and  Paul  F.  MiisdE;  M.D.,  Professor  of  Gynecol- 
ogy in  the  ZSJ^ew  Itork  Polyclinic.  Sixth  edition,  thoroughly  revised  and  rewritten 
by  Dr.  Muxde.  In  one  large  and  handsome  octavo  volume  of  824  pages,  with  347 
illastrations,  of  which  201  are  new.     Cloth,  $5.00 ;  leather,  I'l.OO, 

The  profe,«sion  has  sadly  felt  the  want  of  a  text-  |  book  we  know,  and  will  be  of  especial  value  to  the 
book  on  diseases  of  women,  which  should  be  com-  |  general  pra3tiiioner  as  well  as  to  the  specialist, 
prehensive  and  at  the  same  time  not  diffuse,  ;  The  illustrations  are  very  satisfactory. — Boston 
fiystematically  arranged  so  as  to  be  easily  grasped  •  Mediral  and  Surgical  Journal. 

by  the  student  of  limited  experience,  and  which  I  This  worJi,  which  has  already  gone  through  five 
should  embrace  the  wonderful  advances  which  ■  large  editions,  and  has  been  translated  into 
have  been^  made  within  the  last  two  decades.  |  French,  German,  Spanish  arid  Italian,  is  too  well 
Dr.  Munde  brings  to  his  work  a  most  practical  1  known  io  require  commendation.  It  continues  to 
knowledge  of  the  subjects  of  which  he  treats  and  :  be  the  most  practical  and  at  the  same  time  the 


an  exceptional  acquaintance  vrith  the  world's  liter- 
ature of  this  important  branch  of  medicine.  The 
result  is  what  is,  perhaps,  on  the  whole,  the  best 
practical  treatise  on  the  subject  in  the  English 
language.    It  is,  as  we  have  said,  the  best  text- 


most  complete  treatise  upon  the  subject  in  print, 
the  changes  that  have  been  made  only  increasing 
its  value. — The  Archives  of  Gyne'-ology,  Obstetrics 
and  Pediatrics. 


Sutton  on  Tumors,  Innocent  and  Malignant. 

Tumors.  Innocent  and  Malignant.  Their  Clinical  Features  and  Ap- 
propriate Treatment.  By  .J.  Bla:std  Sutton^.  F.  E.  C.  S.,  Assistant  Surgeon  to  the  Mid- 
dieses  Hospital,  London.  In  one  very  handsome  octavo  volume  of  526  pages,  with  250 
engravings  and  9  full  page  plates.     Cloth,  $4.50. 

Sutton  has  without  doubt  written  the  best  I  many  years  of  research  upon  a  subject  embracing 
general  work  on  tumors  which  has  yet  appeared  |  someof  the  commonest,  most  painful  and  hitherto 
in  the  English  language.  We  urge  all  of  our  |  hopeless  of  human  affections.  As  this  work  deals 
readers  to  get  this  splendid  book. — The  St.  Louis  \  exhaustively  with  tumors  it  will  furnish  the 
Medi-tal  and  Surgical  Journal.  I  surgeon,  gynecologist  and    general   practitioner 

The  author  is  widely  known  as  one  of  the  fore-  j  with  indispensable  aid  in  the  early  recognition 
most  surgeons  and  pathologists  of  London.    His  j  and  successful  treatment  of  this  class  of  disease, 
ability  has  already  been  reeognizpd  in  his  earlier  '•  — Th,e  Omah/i  Clinic. 
works.    In  the  present  instance   he   has   spent 

Sutton  on  tlie  Ovaiies  and  Fallopian  Tubes. 

Surgical  Diseases  of  tlie  Ovaries  and  Fallopian  Tubes,  including 
Tubal  Pregnancy.  By  J.  Blasd  Sttttost,  F.  E.  C.  S.,  Assistant  Surgeon  to  the 
Middlesex  Hospital,  London.  In  one  square  octavo  volume  of  544  pages,  with  119 
engravings  and  5  colored  plates.     Cloth,  $3.00. 


This  is  not  a  book  to  be  rf  ad  and  then  shelved ; 
it  is  one  to  b*  studied.  It  is  not  based  upon 
hypotheses  but  upon  facts.  It  makes  pathology 
practical,  and  mctileates  a  practice  based  upoii 
pathology.  It  is  succinct,  yet  thorough;  practi- 
cal, yet  seientiSc:  conservative,  yet  bold      It  is 


is  not  for  them  alone;  the  general  practitioner 
needs  just  such  a  book.  It  will  be  of  immense 
service  to  him  in  the  study  of  pelvic  diseases,  and 
will  assuredly  open  his  eyes  to  the  progress  made 
by  conscientious,  painstaking  workers  like  Dr. 
Sutton  in  the  fieid  of  pathology  and  differential 


probably  on  the  table  of  all  gynecologists;  but  it  i  diagnosis. — International   Medical  Magazine. 

Davenport's  Non-Sm^gical  Gynscology.— Second  Edition. 

Diseases  of  Women,  a  Manual  of  Non-Surgical  Gynsscology. 
Designed  especially  for  the  Use  of  Students  and  General  Practitioners.  By  Feancis 
H.  Davestoet,  M.  D.,  Assistant  in  GynaE-eology  in  the  iledical  Department  of  Harvard 
University.  Second  edition.  In  one  12mo.  vol.  of  314  pages,  with  107  illus.  Cloth,  $1.75. 
Many  vaJuable  volumes  already  exist  on  the  ]  the  actual  test  of  experience,  and  being  concisely 
surgical  aspects  of  gynecology,  but  scant  attention  j  and  clearly  written,  conveys  a  great  amount  of  in- 
has  been  paid  in  recent  years  to  the  non-surgical  1  formation  in  a  convenient  space. — Annals  of  GyncB- 
treatment  of  women's  diseases.  The  present  '  cology  aiid  Pcediatry. 
volume,  dealing  with  nothing  which  has  not  stood 

May's  Manual  of  Diseases  of  Women.— Second  Edition. 

A  Manual  of  tlieDiseases  of  "Women.  Being  a  concise  and  systematic 
expcsition  of  the  theory  and  practice  of  gynecology.  By  Chaeles  H.  Mav,  M.  D., 
late  House  Surgeon  to  Mount  Sinai  Hospital,  Xew  York.  Second  edition,  edited  by 
L.  S.  Bau,  M.  D.,  Attending  Gynecologist  at  the  Harlem  Hospital,  Iv .  Y.  In  one  12mo. 
volume  of  360  pages,  with  31  illustrations.     Cloth,  $1.75. 


This  i«  a  manual  of  gynecology  in  a  very  con- 
densed form,  and  the  fact  that  a  second  edition 
has  been  called  for  indicates  that  it  has  met  with 
a  favorable  reception.  It  is  intended,  the  author 
tells  us,  to  aid  the  student  who  after  having  care- 
fully perused  larger  works  desires  to  review  the 
subject,  and  he  adds  that  it  may  be  useful  to  the 
practitioner  who  wishes  to  refresh  his  memorv 


rapidly  but  has  not  the  time  to  consult  larger 
works.  We  are  much  struck  with  the  readiness 
and  convenience  with  which  one  can  refer  to  any 
subject  contained  in  this  voiume.  Carefully  com- 
piled indexes  and  ample  illustrations  also  "enrich 
the  work.  This  manual  will  be  found  to  fulfil  its 
purposes  very  satisfactorily. — The  Physiciai  and 
Surgeon. 


iSHWELL'S  PRAGTICAIi  TBEATISE  ON  THE 
DISEASES  PECULIAB   TO   WOMEJS'.     Third 


American  from  the  third  and  revised  London 
edition.    In  one  Sro.  voL,  pp.  520.    Cloth,  $3.50. 


Lea  Brothers  &  Co.,  Publishers.  706,  708  &  710  Sansom  Street.  Philadelphia. 


Obstetrics.  29 

Parvin's  Science  &  Art  of  Obstetrics.— New  fSdj  Ed.  Just  Ready. 

The  Science  and  Art  of  Obstetrics.    By  TnEOPHixrs  Parvix,  M.D., 

L.L  D.,  Professor  ot  Obstetrics  and  the  Diseases  of  Women  and  Children  in  Jeflerson 
Medical  College,  Philadelphia.  Is'ew  (3d)  edition  In  one  verv  handsrme  octavo  volume 
of  677  pages,  with  267  engravings,  and  2  colored  plates.     Cloth.' $4.25 ;  leather,  iic.2o 

Xo_  branch  of  medicine  has  enjoyed  greater  advancement  during  recent  vears  than 
Obstetrics,  and  none  is  more  important  for  the  vast  majoritv  of  practitioners.  The"  universal 
distribution  of  the  cases,  and  the  dependence  of  two  lives  in  each,  render  it  incumbent  upon 
every  physician  accepting  obstetric  engagements  to  possess  the  most  recent  and  authoritative 
works.  The  vast  experience  of  the  author  and  his  eminent  position  as  a  teacher  have  led  to 
the  demand  for  successive  editions  of  his  great  work,  each  ot  which  has  been  revised  to  reflect 
its  subject  to  date  of  issue.  In  the  present  edition  nearly  one-third  has  been  rewritten,  and 
additional  illustrations  and  two  colored  plates  enrich  its  abundant  pictorial  teachings. 

Playfair's  Midwifery.— New  (8th)  Edition. 

A  Treatise  on  the  Science  and  Practice  of  Midwifery.    By  ^Y.  S. 

Playtazr,  M.  p.,  F.  Pl.  C.  p..  Professor  of  Obstetric  Medicine  in  King's  College,  Lon- 
don, Examiner  in  Midwifery  in  the  Universities  of  Cambridge  and  London,  and  to  the 
Eoyal  College  of  Physicians.  Sixth  American,  from  the  eighth  English  edition.  Edited, 
with  additions,  by  Egbert  P.  Harris,  M.  D.  In  one  handsome  octavo  volume  of  697 
pages,  with  217  engi-avings  and  -5  plates.     Cloth,  $-4,00 :  leather,  $5.00. 

This  well-known  treatise  has  been  either  a  tezt-  ities  on  the  obstetric  art. — Buffalo  Medical  and 
book  or  work  of  reference  in  most  medical  schools  ,  Svrg'cal  JoarnoJ. 

for  the  past  seventeen  years,  and  in  the  numerous  The  author's  object  has  been  to  place  in  the 
editions  which  have  appeared  it  has  betn  kept  hands  of  r^is  readers  an  epitome  ot  the  science 
constantly  in  the  foremost  rank  of  the  books  which  and  practice  of  midwifery,  which  embodies  all 
have  been  written  on  this  subject,  and  is  a  work  recent  ad^-ances,  and  especially  to  dwell  on  the 
which  can  be  conscientiously  recommended  to  the  Practical  part  of  the  subject^  so  as  to  make  his 
r,-^^faa^\^^      Th^  An^.„  \f^J  d„  „i  books  8  re  lab  e  Kiude  toihe  doetorin  tne  Tjraetice 

fTOfe9^ion.-TheAaany  Mea.  Anvals.  ^^  ^^.^  ^^^^^^  important  and  responsible  bfanch  of 

This  work  of  Piayfau-  must  occupy  a  fore-  ,  medicine.  The  demand  for  this  eighth  edition  of 
most  place  la  obstetric  medicme  as  a  safe  t^e  work  testifies  to  the  success  with  whi^h  the 
guide  to  both  student  and  obstetrician.  It  holds  ':  autnor  has  executed  his  purpose.— T/ie  Medical 
a  place  among  the  ablest  English  speaking  author-    Fortviahfbi. 


King's  Manual  of  Obstetrics.— New  (6tli)  Edition.  Jnst  Ready. 

A  Manual  of  Obstetrics.  By  A.  F.  A.  Ki^-g.  M.D.,  Professor  of  Obsterics 
and  Diseases  of  Women  in  the  Medical  Department  of  the  Columbian  Lniversity,  Wash- 
ington, D.C.,  and  in  the  University  of  Vermont,  etc.  Xew  (6th)  edition.  In  one  12[no. 
volume  of  532  pages,  with  221  illustrations.     Cloth, $2.50. 

The  presentation  of  a  subject  in  ej^itome  renders  a  double  service.  It  enables  students 
to  grasp  the  essentials  in  a  manner  best  suited  to  an  intelligent  conception  of  the  whole,  and 
it  furnishes  practitioners  with  the  most  convenient  means  of  refreshing  their  knowledge  as 
well  as  with  a  quick  reference  in  emergencies.  Six  editions  of  this  JIanual  indicate  that  both 
classes  of  readers  have  learned  to  appreciate  its  advantages.  The  author  possesses  in 
eminent  degree  the  art  of  selecting  the  essentials  of  his  subject,  and  presenting  thein  in  clear 
language  with  adequate  illustrations.     The  jjresent  edition  has  been  thoroughly  revised. 


Barnes'  System  of  Obstetric  Medicine  and  Surgery. 

A  System  of  Obstetric  Medicine  and  Surgery,  Theoretical  and 

ClinicaL  For  the  Student  and  the  Practitioner.  By  Egbert  Bar>-e5,  M.  D.,  Phys- 
ician to  the  General  Lying-in  Hospital,  London,  and  FA>-corRT  Bar>-e?,  M.  D.,  Obstetric 
Physician  to  St.  Thomas'  Hospital,  London.  The  Section  on  Embryology  by  Prof.  Milnes 
Marshall.     In  one  Svo.  volume  of  872  pp.,  with  231  illustrations.    Cloth,  $5 ;  leather,  $6. 

Davis'  Obstetrics.— Preparing. 

A  Treatise  on  Obstetrics.  For  Students  and  Practitioners.  By  Edvtard 
P.  Da VI-,  A.  M.,  M.  D.,  Professor  of  Obstetrics  and  Diseases  of  Infancy  in  the  Phil  idel- 
phia  Polyclinic,  Clinical  Professor  of  Obstetrics  in  the  .Jeflerson  Medical  College  of 
Philadelphia.     In  one  very  handsome  octavo  volume  of  500  pages?,  richly  illustrated. 

Landis  on  Labor  and  tbe  Lying-in  Period. 

The     Management    of    Labor,    and    of  the   Lying-in    Period. 

By  Hkxrv  G.  La>-dis,  A.  M.,  M.  D.,  Professor  of  Obstetrics  aad  the  Diseases  of  Women 
in  Starling  Medical  College,  Columbus,  Oliio.  In  one  handsome  12mo.  volume  of  334 
pages,  with  28  illustrations.     Cloth,  $1.75. 

EAMSBOTHA^rS     PRINCIPLES     AXD     PEAC-  GHT'RCHILL   ON"    THE    PUERPERAL   EEVER 

TICE  '  OF     OBSTETRIC     :\IEDICINE     AN'D  AND  OTHER  DISEASES  PECULIAR  TO  WO- 

SURGERY.     In  one  octavo  volume  of  640  pages,  MEX.     In  oneSvo.  vol.  of  4154  page*.    Cloth.  82..'=>r|. 

with  64  fullpase  plates  and  43  woodcuts  in  the  LEISHM^XS  SYSTEM    OF   MIDWIFERY.  I>- 

text     Leather "S7  CLUDING  THE  DISEASES  OF  PREGNANCY 

TANNER  ON  PREGNANCY.     Octavo,  490  pages,  AND  THE  PUERPERAL  STATE.    Octavo, 
colored  plates,  16  cuts.    Cloth,  S4.25 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


30      Dis.  of  Children,  Obstetrics — (Cont'd),  Manuals. 
Smith  on  Children.— Seventh  Edition. 

A  Treatise    on   the    Diseases    of  Infancy    and    Childhood.    B7 

J.  Lewis  Sjoth,  M.  D.,  Clinical  Professor  of  Diseases  of  Children  in  the  Bellevue  Hospital 
Medical  College,  ZSTew  York.  jMew  (seventh)  edition,  tlioroiighly  revised  and  rewritten. 
In  one  handsome  octavo  volume  of  881  pages,  with  51  illus.  Cloth,  $4.50 ;  leather,  $5.50. 
We  have  always  considered  Dr.  Smith's  book  as  '■  is  always  conservative  and  thorough,  and  the 
one  of  the  very  best  on  the  subject.  It  has  always  1  evidence  of  research  has  long  since  placed  its 
been  practical— a  field   book,  theoretichl  where  ,'  author  in  the  front  rank  of  medical  teachers. — 


theory  has  been  deduced  from  practical  experi- 
ence. He  takes  his  theory  from  the  bedside  and 
the  pathological  laboratory.  The  very  practical 
character  of  this  book  has  always  appealed  to  us 


The  American  Journal  oj  the  Medical  Sciences. 

In  the  present  edition  we  notice  that  many  ol 
the  chapters  have  been  entirely  rewritten.  Full 
notice  is  taken  of  all  the  recent  advances  that 


It  i.s  characteristic  of  Dr.  Smith  in  all  his  writings  j  have  been  made.    Many  diseases  not  previously 


to  collect  whatever  recommendations  are  tound  in 
medical  literature,  and  his  search  has  been  wide. 
One  seldom  fails  to  find  here  a  practical  suggestion 
after  search  in  other  works  has  been  in  vain.  In 
the  seventh  edition  we  note  a  variety  of  changes 
in  accordance  with  the  progress  of  the  times.  It 
still  stands  foremost  as  ihe  American  text-book. 
The  literary  style  could  not  be  excelled,  iis  advice 


trested  of  have  received  special  chapters.  The 
work  is  a  very  practical  one.  Especial  care  has 
been  taken  that  the  directions  for  treatment  shall 
be  particular  and  full.  In  no  other  work  are  such 
careful  in.structions  given  in  the  details  of  infant 
hygiene  and  the  artificial  feeding  of  infants. — 
Montreal  Medical  Journal. 


Herman's  First  Lines  in  Midwifery. 

First  Lines  in  Midwifery:  a  Guide  to  Attendance  on  Natural 
Labor  for  Medical  Students  and  Midwives.  By  G.  Ernest  Herman,  M.  B., 
F. E.G. P.,  Obstetric  Physician  to  the  London  Hospital.  In  one  12mo.  volume  of  198 
pages,  with  80  illustrations.     Cloth,  $1.25.     See  Student's  Series  of  Manuals,  below. 

This  is  a  little  book,  intended  for  the  medical  I  will  prove  valuable  to  the  beginner  in  midwifery 
student  and  the  educated  midwife.  The  work  '  and  could  be  read  with  advantage  by  the  majority 
is  written  in  a  plain,  simple  style,  and  is  as  of  practitioners,  old  and  young. —  The  Medical 
much  as  possible  devoid  of  technical  terms.    It    Fortnightly. 


Owen  on  Surgical  Diseases  of  Children. 

Surgical  Diseases  of  Children.  By  Edmund  Owen,  M.  B.,  F.  E.  C.  S., 
Surgeon  to  the  Children's  Hospital,  Great  Ormond  Street,  London.  In  one  12mo.  vol- 
ume of  525  pages,  with  4  chromo-lithographic  plates  and  85  woodcuts.  Cloth,  $2.00, 
See  Series  of  Clinical  Manuals,  below. 


Student's  Series  of  Manuals. 


A  Series  of  Fifteen  Manuals,  for  the  use  of  Students  and  Practitioners  of  Medicine  and  Surgery, 
written  by  eminent  Teachers  or  Examiners,  and  issued  in  pocket-size  12mo.  volumes  of  300-540  pages, 
richly  illustrated  and  at  a  low  price.  The  following  volumes  are  now  ready:  Luff's  Manual  of  Chem- 
istry, 82;  Heemak's  First  Lines  in  Midwifery,  Si. 25;  Treves'  Manual  of  Surgery,  by  various  writers,  in 
three  volumes,  per  set,  g6;  Bell's  Comparative  Anatomy  and  Physiology,  82;  Gouid's  Surgical 
Diagnosu,  82;  'Ro^'e<\t:so^''s  Physiological  Physics, %2;  BnvcES  Materia  Medica  and  Therapeutics  (5th  edi- 
tion). 81.50;  Power's  Human  Physiology  {2d  edixion),  81.50;  Claeke  and  Lockwood's  Difsertors'  Man- 
ual, $1.50;  Ralfe's  Clinical  Chemistry,  $1.50;  Treves'  Surgical  Applied  Anatomy,  82;  Pepper's  Surpieai 
Pathology,  82;  and  Klein's  Elements  of  Histology  (4th  edition),  81.75.  The  following  is  in  press 
Pepper's  Forensic  Medicine.    For  separate  notices  see  index  on  last  page. 

Series  of  Olinical  Manuals. 

In  arranging  for  this  Series  it  has  been  the  design  of  the  publishers  to  provide  the  profession  with 
a  collection  of  autlioritative  monographs  on  important  clinical  subjects  in  a  cheap  and  portable  form. 
The  volumes  contain  about  550  pages  and  are  freely  illustrated  by  chromo-lithographs  and  wood- 
cuts. The  following  volumes  are  now  ready:  B.u-l  on  the  Rectum  and  Anuf,  second  edition,  82.25; 
Yeo  on  Food  in  Health  and  Disease,  ^2;  Beoadbent  on  the  Puise,  81-75;  Carter  &  Frost's  Ophthalmic 
Surgery,  $2.25 ;  Hutchinson  on  Syphilis,  $2.25;  Marsh  on  the  Joints,  82;  Owen  on  Surgical  Diseases 
of  Children,  $2;  Moeeis  on  Surgical  Dis  ases  of  the  Kidney,  82.25;  Pick  on  Fractures  and  Disloca- 
tions, 82;  BuTLiN  on  the  Tongue,  $^.50;  Tbeves  on  Intestinal  Obstruction,  $2;  and  Savage  on  Insa.nity 
and  Allied  Neuroses,  $2.  The  following  is  in  preparation:  Lucas  on  Diseases  of  the  Urethra.  For  sepa- 
rate notices  see  index  on  last  page. 

Hartshorne's  Conspectus  of  the  Medical  Sciences. 

A  Conspectus  of  the  Medical  Sciences ;  Containing  Handbooks  on  Anat- 
omy, Physiology,  C'hemistry,  Materia  Medica,  Practice  of  Medicine,  Surgery  and  Obstetrirs. 
By  Henry  Hartshorne,'A.  M.,  M.  D.,  LL.  D.,  lately  Professor  of  Hygiene  in  the  Uni- 
versity of  Pennsylvania.  Second  edition,  thoroughly  revised  and  greatly  improved.  In 
one  large  royal  12mo.  vol.  of  1028  pages,  with  477  illus.     Cloth,  $4.25;  leather,  $5.00. 


PARBY  ON  EXTRA-UTERINE  PREGNANCY: 
Its  Clinical  History,  Diagnosis,  Prognosis  and 
Treatment.    Octavo,  272  pages.    Cloth,  82.50. 

CONDIE'8  PRACTICAL  TREATISE  ON  THE 
DISEASES  OF  CHILDREN.  Sizth  edition,  re- 
vised and  augmented.  In  one  octavo  voiurce  of 
77S  r.i:i?p=      Cloth,  s^.25  ;  leather,  S6.25. 

LUDLOW'S  MANUAL  OF  EXAMINATIONS.  A 
Manual  of  Examinations  upon  Anatomy,  Physi- 


Physician  to  the  Philadelphia  Hospital,  etc. 
Third  edition,  thoroughly  revised,  and  greatly 
enlarged.  In  one  12mo.  volume  of  816  pages, 
with  370  illustrations.    Cloth,  §3.S5;  leather,  $3  75. 

WEST  ON  SOME  DISORDERS  OF  THE  NERV- 
OUS SYSTEM  IN  CHILDHOOD.  In  one  small 
12mo.  volume  of  127  paees.    Cioth,  81.00. 

WINCKEL'S  COMPLETE  TREATISE  ON  THE 
PATHOLOGY  AND  TREATMENT  OF  CHILD- 


ology.  Surgery,  Practice  of  Medicine,  Obstetrics,  BEh'.     ForStudents  and  Practitioners.     Trans- 

Materia    Medica,    Chemistr}',    Pliarmacy    and,  lated  from  the  second  German  ediiion,  by  . I.  R. 

Therapeutics.     To  which   is"  added  a   Medical  i  Chadwick.  M.  D.    Octavo  484  pages.    Cloth,  $4.00. 
Formulary.    By  J.  L.  Ludlow,  M.  D.,  Consulting 

Lea  Brothers  &  Co.,  Publishers,  706.  708  &  710  Sansom  Street,  Philadelphia. 


riedicai  Jurisprudence,  Historical. 


31 


Taylor's  Medical  Jurisprudence.— Twelfth  Edition. 

T  .  A  Manual  Of  MediealJurisprudence.  By  Alfred  S.  Tayloe,  M.  D., 
Lecturer  on  Med.  Jurisprudence  and  Chemistry  in  Guy's  Hosp.,  London.  Kew  America^ 
from  the  12th  English  edition.  Thoroughly  revised  bv  Clark  Bell,  Esq.,  of  tlie  New 
York  But.  in  one  octavo  volume  of  787  pages,  with  56  iUus.  Cloth,  $4.50;  leather  $5  50 
This  IS  a  complete  revision  of  all  former  Ameri-  I  into  the  criminal  courts.  The  editor  has  given  to 
Th°is^eH,-M.''n^.'^^t^-'^"'°°,'  °^  '^''  Standard  book.  !  two  profe.ssion.  a  reference  Vok  to  be  Sdupon^ 
n«w  ^.tVl    r^  '^.'^''^^  ^."lS"°t°^,  entirely    -r/,e   Amencnn  Journal  of  the   Medical   Science.. 

h^l^ewruVe^  h,^/r''°i^?  °^  t^  ^""^  havmg  i  No  library  is  complete  without  Taylor's  Medical 
^f.fhJtZ  u  \^^^  ^^.'*5'"-  ^i^'^'X.  ^'^'^^  *°^  '  JurUprudence,  as  its  authority  is  accepted  and  un- 
authorities  have  been  cited  and  the  citations  |  questioned  by  the  coarls.-Buffalo  Medical  and 
brought  down  to  the  latest  date.    The  book  has  ]  Surqical  Journnl  ^^t:    c  .,   «,«* 

long  been  a  standard  treatise  on  the  subject  of  |  There  is  no  other  work  upon  the  subject  which 
medical  jurisprudence  and  ha-,  gone  through  I  has  been  so  uniformly  recognized  or  so  widely 
many  editions— twelve  English  and  eleven  Ameri-  \  quoted  and  'oUowed  by'courts  in  England  and  this 
can.    Mr.  Olark  Bell  has  enlareed   and  imnroved     cnunt.rv     Thiu  oit.T7or,th  Arn^-joo,,  ^.i.-fi —  ,.,  <-„ii„ 


can.  Mr.  Clark  Bell  has  enlarged  and  improved 
what  already  seemed  complete,  by  bringing  his 
many  citations  of  cases  down  to  date  to  meet  the 

g resent  law;  and  by  adding  much  new  matter  he 
as  furnished  the  medical  profession  and  the  bar 
with  a  valuable  book  of  reference,  one  to  be  relied 
upon  in  daily  practice,  and  quite  up  to  the  present 
needs,  owing  to  its  exhaustive  character.  It 
would  seem  that  the  book  is  indispensable  to  the 
library  of  both  physician  and  lawyer,  and  particu- 
larly the  legal  practitioner  whose  duties  take  him 


country.  This  eleventh  American  edition  is  fully 
abreast  with  the  most  recent  thought  aad  knowl- 
edge. On  the  basis  of  his  own  researches,  of  the 
investigations  of  scientists  throughout  the  wrld, 
and  of  the  decisions  of  our  own  courts,  Mr.  Bell 
has  incorporated  in  it  a  wealth  of  praciical  sug- 
gestion and  instructive  illustration  which  cannot 
fail  to  strengthen  the  hold  it  has  so  long  had 
upon  the  profession. —  The  Criminal  Law  Magazine 
and  Reporter. 


By  the  Same  Author. 
Poisons  in  Relation  to  Medical  Jurisprudence  and  Medicine.    Third 
American,  from  the  thu'd  and  revised  English  edition.     In  one  large  octavo  volume  of  7S8 
pages.     Cloth,  $5.50 ;  leather,  $6.50. 

Lea's  Superstition  and  Force.— Mew  Edition.    Just  Ready. 

Superstition  and  Force:    Essays  on  The  Wager  oi"  Law,  The 
Waser  ^  ot     Battle,  The    Ordeal  and   Torture.    By  Hesry    Charles    Lea, 
LL.  D.,  Xew  (4th)  edition,  revised  and  enlarged.     Koyal  12mo.,  629  pages.     Cloth,  $2.75. 
Both  abroad  and  a"  home  the  work  has  been  I  consulted  but  exhausted.    The  subject  matter  is 
accepted  as  a  standard  authority,  and  the  author    '       ■■    -    •  ■  ■  -  .      .  .. 

has  endeavored  by  a  complete  revision  and  con- 
siderable additions  to  render  it  more  worthy  of 
the  universal  favor  which  has  carried  it  to  a 
fourth  edition.  Tne  known  erudition  and  fidelity 
of  the  author  are  guarantees  that  all  possible  origi- 
nal sources  of  information  have  been  not  onlv 


handled  in  such  an  able  and  philosophic  man- 
ner that  to  read  and  study  it  is  a  step  toward 
liberal  education.  It  is  a  comfort  to  read  a  book 
that  is  so  thorough,  well  conceived  and  well  done. 
We  should  like  to  see  it  made  a  text-book  in  our 
law  schools  and  prescribed  course  for  admission 
to  the  bar. — Leqai  Intelligencer. 


By  the  same  Author. 
Chapters  from  the  Seligious  History  of  Spain.— In  one  12mo.  volume 
of  522  pages.     Cloth  $2.50. 


The  width,  depth  and  thoroughness  of  research 
which  have  earned  Dr.  Lea  a  high  European  place 
as  the  ablest  historian  the  Inquisition  has  yet 
found  are  here  applied  to  some  side-issues  of  that 
great  subject.    We  have  only  to  say  of  this  volume 


that  it  worthily  complements  the  author's  earlier 
studies  in  ecclesiastical  history.  His  extensive 
and  minute  learning,  much  of  it  from  inedited 
manuscripts  in  Mexico,  appears  on  every  page. — 

London  Antiqua-'-j/. 


In  one  8vo.  volume  of  219 


By  the  same  Author. 
The  Formulary  of  the  Papal  Penitentiary. 

pages,  with  a  frontispiece.     Cloth,  $2.50. 

By  the  Same  Author, 
Studies  in  Church  History.    The  Rise  of  the  Temporal  Power— Ben- 
efit of  Clergy — Sxcommunication — The  Early  Church  and  Slavery.    Sec- 
ond and  revised  edition.      In  one  royal  octavo  volume  of  605  pages.     Cloth,  $2.50. 

The  author  is  preeminently  a  scholar;  he  takes 
ap  every  topic  allied  with  the  leading  theme  and 
traces  it  out  to  the  minutest  detail  with  a  wealth 
of  knowledge  and  impartiality  of  treatment  that 
compel  admiration.  The  amount  of  information 
compressed  into  the  book  is  extraordinary,  and 
the  profuse  citation  of  authorities  and  references 


makes  the  work  particularly  valuable  to  the  student 
who  desires  an  exhaustive  review  from  original 
sources.  In  no  other  single  volume  is  the  develop- 
ment of  the  primicive  church  traced  with  so  much 
clearness  and  with  so  definite  a  perception  of 
complex  or  conflicting  forces. — Boston   Traveller. 


By  the  Same  Author. 
An  Historical  Sketch  of  Sacerdotal  Celibacy  in  the  Christian 
Church.  Second  edition,  enlarged.  In  one  octavo  volume  of  685  pages.  Cloth,  $4.50. 
This  subjeethasrecently  been  treated  with  very  |  more  light  on  the  moral  condition  of  the  Middle 
great  learning  and  with  admirable  impartiality  by  Ages,  and  none  which  is  more  fitted  to  dispel  the 
aa  Anaerican  author,  Mr.  Her.ry  0.  Lea,;  in  his  Bts-  gross  illusions  concerning  that  period  which  posi- 
tory  of  Sacernotni  Celibacy,  which  is  certainly  one  tlve  writers  and  writers  of  a  certain  ecclesiastical 
of  the  most  valuable  works  that  America  has  pro-  ]  school  have  conspired  to  sustain.— iecAt/'s  History 
duced.  Since  the  great  history  of  Dean  Milman,  ■  of  European  Morah,  Chap.  V. 
I  know  no  work  in  English  which  has  thrown 

By  the  Same  Author. 
A  History  of  AuricTilar  Confession  and  Indulgences  in  the  Latin 
Church.     In  three  octavo  volumes  of  500  pages.     In  press. 

Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


Index  to  Catalogue  of    Medical   Publications 

OF 

Lea  Brothers  &  Co., 

706,  708  &  710  SANSON!  Street,  PHILADELPHIA. 


Abbott's  Bacteriology    ....    19 

Allen's   v^natomy B 

American  Journal  of  the  Med- 
ical Sciences 2 

American  Systems  of  Gynecol- 
ogy and  Obstetrics .         ...    27 
American  System  of  Practical 

Medicine 14 

American  System  of  Dentistry    24 
American  Text-Books  of  Dent- 
istry   24 

Ashhurst's  Surgery 20 

Ash  well  on  Diseases  of  Women    28 

Atttield's  Chemistry 9 

Ball  on  the  Rectum  and  Anus  21,  30 
Barnes'  System  of  Obstetric 

Medicine  and  Surgery      ...    29  ! 
Bartholow  on  Cholera    ....    IS 
Bartholow  on  Eleclriciiy      .    .    16 
Basham  on  Renal  Diseases    .    .    23 
Bell's    Comparative   Anatomy 

and  Physiology 7,  30 

Bellamy's  Surgical  Anatomy    .      6 

Berry  on  the  Eye 23 

Billings'  National  Medical  Dic- 
tionary   4 

Black  on  the  Urine 24 

Blandford  on  Insanity   ....    17 

Bloxam's  Chemistry 9 

Broadbent  on  the  Pulse  .  .  15,  30 
Browne  on  Koch's  Remedy  .  .  17 
Browne  on  the   Throat,   Nose 

and  Ear 17 

Bruce's    Materia   Medica    and 

Therapeutics 13,  30 

Bmnton's  Materia  Medica  and 

Therapeutics 13 

Bryant's  Practice  of  Surgery     .    20 
Bumstead  and  Taylor  on  Vene- 
real Diseases     See  Taylor  .    .    25 

Burnett  on  the  Ear 24 

Butlin  on  the  Tongue  ,  .  .  20, 30 
Carpenter  on  the  Use  and  Abuse 

of  Alcohol 7 

Carpenter's  Human  Physiology  7 
Carter   <fe  Frost's   Ophthalmic 

Surgery 23,30 

Caspari's  Pharmacy  .  .  .  .  10 
Chambers  on  Diet  and  Regimen  16 
Chapman's  Pluman  Physiology  8 
C  h  a  r  1  e  s'  Physiological  and 
Pathological  ('hertiistry  .  .  . 
C  h  e  y  I)  e  on  Wounds,   Ulcers 

and  Abcessess 

Churchill  on  Puerperal  Fever 
Clarke  and  Lockwood's  Dissec- 
tors' Manual 

Cleland's  Dissector  .... 
Clouston  on  Insanity  .  .  . 
Clowes'  Practical  Chemistry 

Coats'  Pathology 

Cohen's  Applied  Therapeutics 
Coleman's  Dental  Surgery 
Condie  on  Diseases  of  Children 
Cornil  on  Syphilis        ... 
Culver  &  Hayden  on  Venereal 

Diseases 

Dalton  on  the  Circulation 
Dalton's  Human  Physiology 
Davenport  on  Dis  of  Women 
Davis'  Clinical  Lectures     .    . 

Davis'  Obstetrics 

Dennis'  System  of  Surgery  . 
Dercum  on  Nervous  Diseases 
Dispensatory.  The  National . 
Draper's  Medical  Physics  .    . 


10 

21 

29 

6,30 
6 

17 
8 
19 
12 
24 
30 
25 

25 
7 
8 
28 
14 
29 


Druitt's  Modern  Surgery 
Duane's  Medical  Dictionary 

Duncan  on  Diseases  of  Women  27 

Dungllson's  Medical  Dictionary  4 
Edes'  Materia  Medica  and 

Therapeutics 12 

Edis  on  Diseases  of  Women  .     .  27 

Ellis'  Anatomy        7 

•  Emmet's  Gynaecology    ....  27 

Erichsen's  Surgery 20 

Farquharson's  Therapeutics 

and  Maieria  Menica        ...  13 
Field's   Manual  of  Diseases  of 

the  Ear 24 

Flint  on  Auscultation  and  Per- 
cussion    15 

Flint  on  Phthisis 13 

Flint  on  Respiratory  Organs     .  14 

Flint  on  the  Heart 13 

Flint's  Essays I3 

Flint's  Practice  of  Medicine  .    .  I3 
Folsom's  Laws  of  XJ.  S.  on  Cus- 
tody of  Insane 17 

Foster's  Physiology 8 

Fothergill's   Handbook   of 

Treatment 15 

Fownes'  Elementary  Chemistry  9 
Frankland    and    Japp's   Inor- 
ganic Chemistry 8 


Fuller  on  the  Lungs  and  Air        | 

Passages 17  i 

Fuller  on  Male  Sexual  Disorders  25 
Gant's  Student's  Surgery  .  .  20 
Gibbes"  Practical  Pathology  .  19 
Gould's  Surgical  Diagnosis  .  20,  30 
Gray   on  Nervous  and  Mental 

Diseases 18 

Gray's  Anatomy 5 

Greene's  Medical  Chemistry  .  9 
Green's  Pathologj'  and  Morbid 

Anatomy       19 

Gross  on  Impotence  and  Sterility  25 
Gross  on  Urinary  Organs   ...    25 
Habershon  on  the  Abdomen     .    14 
Hamilton  onFractures  and  Dis- 
locations    22 

Hamilton  on  Nervous  Diseases  IS 
Hardaway  on  the  Skin  ...  25 
Hare's  Practical  Therapeutics  .  12 
Hare's  System  of  Practical 

Therapeutics 12 

Hartshorne's  Anatomy   and 

Physiology    .    .         .    ,    .    .    .      6 
Hartshorne's  Conspectus  of  the 

Medical  Sciences      .    ,    .    .    .    30 
Hartshorne's  Essentials  of 

Medicine  .  13 

Hayem's  Physical  and  Natural 

Therapeutics 16 

Herman's  Midwifery     ....    30 
Hermann's  Experimental  Phar- 
macology   13 

Herrick's  Diagnosis 16 

Hill  on  Syphilis ,  .    25 

Hillier's  Handbook  of  Skin 

Diseases 26 

Hirst   &    Piersol    on    Human 

Monstrosities 6 

Hoblyn's  Medical  Dictionary    .     5 

Hodge  on  Women 27 

Hoffmann  and  Power's  Chem- 
ical Analysis 10 

Holden's  Landmarks  ....  6 
Holland's    Medical  Notes  and 

Reflections    .    .    , 14 

Holmes'  Surgery 20 

Holmes' System  of  Surgery  .  .  20 
Horner's  Anatomy  and  Histology  6 

Hudson  on  Fever 13 

Hutchinson  on  Syphilis     .    .   '25,  30 

Hyde  on  the  Skin 26 

Jackson  on  the  Skin  .  .  .  26 
Jamieson  on  the  Skin  ....  26 
Jones  on  Nervous  Disorders  .  17 
Juler's  Ophthalmic  Science  and 

Practice 23 

King's  Manual  of  Obstetrics  .    .    29 

Klein's  Histology 18,30 

Landis  on  Labor 29 

La  Roche  on  Pneumonia,  Mala- 
ria, exf-.  .    .        ....    17 

La  Roche  on  Yellow  Fever   .    .    13 
Laurence  and  Moon's  Ophthal- 
mic Surger-? 23 

Lawson  on  the  Eye 23 

Lea's  Auricular  Confession  and 

Indulgences 31 

Lea's  Chapters  from  Religious 

History  of  Spain 31 

Lea's  Formulary  of  the  Papal 

Penitentiary .31 

Lea's  Sacerdotal  Celibacy  ...  31 
Lea's  Studies  in  Church  History  31 
Lea's  Superstition  and  Force    .    31 

Lee  on  Syphilis 25 

Lehmanh  s  Chemical  Physiology  7 
Leishman's  Midwifery   ....    29 
Lucas  on  the  Urethra     ....    30 
Ludlow's  Manual  of  Examina- 
tions   30 

Luff's  Manual  of  Chemistry  .  9,  30 
Lyman's  Practice  of  Medicine     14 

Lyons  on  Fe\  er 13 

Maisch's  Organic  Materia  Medica  12 
Mackenzie  on  Nose  and  Throat  17 
Marsh  on  the  Joints  ...  20,  30 
May  on  Diseases  of  Women    .    .    28 

Medical  News 1 

Medical  News  Physicians'  Ledger  2 
Medical  News  Visiting  List  .  .  2 
Miller's  Practice  of  Surgery  .  .  20 
Miller's  Principles  of  Surgery  20 
Mitchell  on  Nerve  Injuries  .  18 
Morris  on  the  Kidney  .  .  .  23,30 
Morris  on  the  Skin  .....  26 
Musser's  Medical  Diagnosis  .  .  15 
National  Dispensatory  .  .  .11 
National  Medical  Dictionary  .  4 
Nettleship  on  the  Eye  .  23 
Norris  and  Oliver  on  the  Eye  .  '23 
Owen  on  Diseases  of  Children  .  30 
Parry  on  Extra-Uterine  Preg- 
nancy      30 

Parvin's  Obstetrics 29 

Pavy  on  Digestive  Disorders  .  16 
Payne's  General  Pathology    .    .    19 


Pepper's  Forensic  Medicine  .  30 
Pepper's  Surgical  Pathology    18,  30 
Pepper's  System  of  Medicine    .  14 
Pick  on  Fractures  and  Disloca- 
tions      21,  30 

Pirrie's  System  of  Surgery  .  20 
Playfair  on  Nerve  Prostration 

and  Hvsterla    .......  17 

Playfair's  Midwifery 29 

Politzer  on  the  Ear  .  .  .  .  24 
Power's  Human  Physiology  .  7,  30 
Purdy  on  Bright's  Disease  and 

Allied  Atfecuoos 24 

Pye-Smith  on  the  Skin      ...  26 

Quiz  Series   .        3 

Ralfe's  Clinical  Chemistry    .    10,  30 

Ramsbotham  on  Parturition     .  29 

Reichert's  Physiology     ....  7 

Remsen's  Theoretical  Chemistry  10 

Reynolds'  S.ystem  of  Medicine  .  14 

Richardson's  Preventive  Bled.  16 

Roberts  on  Urinary  Diseases     .  24 

Roberts'  Compend"  of  Anatomy  7 

Roberts'  Surgery 20 

Robertson's  Physiological  Phys- 
ics   7,30 

Ross  on  Nervous  Diseases  .  .  17 
Savage  on  Insanity,  Including 

Hvsterla 17, 30 

Schafer's  Histology 19 

Schofield's  Physiology    ....  8 

Schreiber  on  Massage  ....  16 
Seller  on  the  Throat,  Nose  and 

Naso-Fharynx 17 

Senn's  Surgical  Bacteriology     .  19 

Series  of  Clinical  Manuals      .    .  30 

Simon's  Manual  of  Chemistry  9 

Slade  on  Diphtheria 17 

Smith  (Edw.)  on  Consumption  17 

Smith  (J.  Lewis)  on  Children    .  30 

Smith's  Operative  Surgery     .    .  21 

Stille  on  Cholera 16 

Stilie  &  Maisch's  National  Dis- 
pensatory        11 

Sting's  Therapeutics  and  Mate- 
ria Medica 12 

Stimson  on  Fractures  and  Dis- 
locations      22 

Stimson's  Operative  Surgery  .  22 
Students'  Quiz  Series  ....  3 
Students'  Series  of  Manuals  .  .  30 
Sturges'  Clinical  Medicine  .  .  14 
Sutton  on  the  Ovaries  and  Fal- 
lopian Tubes 28 

Sutton  on  Tumors 28 

Tail's  Diseases  of  Woraen  and 

Abdominal  Surgery    ....  27 
Tanner  on  Signs  and  Diseases 

of  Pregnancy 29 

Tanner's    Manual   of    Clinical 

Medicine 14 

Taj'lor's  Atlas  of  Venereal  and 

Skin  Dieases 26 

Taylor's  Index  of  Medicine  .    .  15 

Taylor  on  Poisons 31 

Taylor  on  Venereal  Diseases  .  25 
Taylor's  Medical  Jurisprudence  31 
Thomas  &  Munde  on  Women  .  28 
Thompson  on  Stricture  ....  23 
Thompson  on  Urinary  Organs  .  23 
Todd  on  Acute  Diseases  ...  14 
Treves' Manual  of  Surgery  .21,30 
Treves  on  Intestinal  Obstruc- 
tion   21,30 

Treves'  Operative  Surgery  .  .  21 
Treves'  Student's  Handbook  of 

Surgical  Operations      .    .    .    ,  21 
Treves'  Surgical  Applied  Anat- 
omy     6,  30 

Tuke  on  the  Influence  of  the 

Mind  on  the  Body 17 

Vaughan  &  Novy  on  Ptomaines 

and  Leucomaine.-< 10 

Visiting  List,  The  Medical  News  2 

Walshe  on  the  Heart 14 

Watson's  Practice  of  Physic  .    .  14 

Wells  on  the  Eye 23 

West  on  Diseases  of  Women     .  27 
West  on  Nervous  Disorders  in 

Childhood      ....         ...  30 

Wharton's  Minor  Surgery  and 

Bandaging 21 

Whitla's   Dictionary  of  Treat- 
ment        15 

Williams  on  Consumption   .    .  17 
Wilson's  Handbook  of  Cutane- 
ous Medicine 26 

Wilson's  Human  Anatomy  .  .  6 
Winckel  on    Pathology   and 

Treatment  of  Childbed    ...  30 

Wohler's  Organic  Chemistry  .  7 
Year-Books   of  Treatment  for 

'86, 'H7. '91, 'fi2, 'fl3,'95 14 

Yeo's  Medical  Treatment ...  16 
Yeo   on    Food   in  Health  and 

Disease  16,30 

Young's  Orthopedic  Surgery    .  20 


